The Student Guide to the Newborn Infant Physical Examination

Tracey Jones

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138086395
• eBook ISBN: 9781351617772
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

This concise guide offers a comprehensive step-by-step framework for midwifery students to learn about all aspects of the newborn infant physical examination (NIPE), a screening assessment completed on all babies between 6 and 72 hours of age.

The Student Guide to the Newborn Infant Physical Examination encourages the reader to approach the examination in a system-based format, with case studies and practice tips to support learning.

The book offers:

• Evidence-based, well-illustrated assessment tools, which take into account the national screening committee standards, and is written by authors with both academic and clinical experience;

• A clear direction on how to perform the NIPE in practice while exploring the wider context of screening in healthcare today;

• Coverage of the changing role of the midwife, and the importance of understanding the whole context of the mother's care, health promotion and starting the practitioner-parent conversation.

The Student Guide to the Newborn Infant Physical Examination is a core text for all pre-registration midwifery students and a useful resource for qualified midwives, neonatal nurses and practice nurses.

1 The newborn infant physical examination

Tracey Jones

Introduction

This chapter will help you to understand the background of how the newborn infant physical examination (NIPE) has become part of the midwifery and neonatal nursing, role and why there is a need for more practitioners to actively take on this extended role. The total number of births in England has fluctuated since declining to a low in 1977. In 2014 there were 664,543 births in England, compared with 566,735 in 2017. There were 679,106 live births in England and Wales in 2017, a decrease of 2.5% from 2016 and the lowest number of live births since 2006. In 2017, the total fertility rate (TFR) declined for the fifth consecutive year to 1.76 children per woman, from 1.81 in 2016 (Office for National Statistics (ONS), 2017). By 2020 the number of births will have increased by 3% to 691, 038, although by 2030 it will have begun to fall and is projected to be 686,142 (NHS England, 2016). Despite the fluctuations in birth rates all babies born in the UK are required to have a NIPE to confirm that the baby has made a successful adaptation to extrauterine life as part of the Public Health England screening; the aim of the NIPE is to:

identify and refer all babies born with congenital abnormalities of the heart, hips, eyes or testes, where these are detectable, within 72 hours of birth.

(Public Health England, 2018, Section 1)

This requires a significant number of skilled practitioners to be available. To understand why it is important for midwives and nurses to train to become NIPE practitioners, it is relevant to understand how the NIPE came about. The aim of this chapter is to explore the history of how the newborn physical examination has evolved over time to be recognised today as the NIPE.

The antenatal and newborn screening programmes should be seen as an integrated programme. It is important that the woman’s journey through her pregnancy, birth and immediate postnatal period is regarded as a single, cohesive passage, and that information about mother, father and child is also incorporated, so that all the family history can be reviewed to avoid any missed early intervention.

As part of the education of students embarking on the NIPE journey, it is important to recognise that all practitioners, whether midwives or neonatal nurses, must have an understanding of the importance of the maternal documentation and the information that can be gathered from it to enable that journey to be smooth (see Chapter 5). The reasons for newborn examination are, first, to offer reassurance to anxious parents who look to the professional caring for their infant to give them assurance that there are no concerns and that their baby is healthy. To successfully achieve this it is important to recognise the limitations of the examination and have a full understanding of its benefits. It is important to remember that the NIPE is a screening process whereby your aim as a practitioner is to highlight any abnormality that requires a referral and not to make a diagnosis.

Midwives have been successfully performing examinations of the term infant as an extended aspect of their role since the first post-qualifying course was established in 1995 (Michaelides, 1995). However, there have always been specific examinations that the midwife/nurse, in accordance with organisation guidance, does not have as part of their scope of practice. There are some examinations that should be carried out by a medical practitioner and this is explored later.

THINK POINT

Take a moment to consider what has changed in the arena of childbirth over the past decade

The changing arena of childbirth

To recognise why there has been an increase in the need for more midwives and nurses being trained to complete the NIPE, it is important also to examine how the arena of maternity services and social dynamics has evolved. The factors that influence childbirth have altered. The physical act of childbirth has not changed over the years, but other aspects that might influence both the safety and the risk of childbirth, such as where babies are born and how long women stay in hospital, have altered significantly. The increase in women accessing assisted reproductive technology for childbirth has exposed the NIPE practitioner to further considerations. Areas that might need to be explored when examining the maternal history include previous in vitro fertilisation (IVF) attempts and if the pregnancy was a multiple birth (Davies et al., 2017), and the increasing age demographic of mothers:

Fertility rates decreased for every age group in 2017, except for women aged 40 years and over, where the rate increased by 1.3% to 16.1 births per 1000 women in that age group, reaching the highest level since 1949.The average age of mothers in 2017 increased to 30.5 years, from 30.4 years in 2016 and 26.4 years in 1975.

(ONS, 2017)

All of these factors require consideration by the NIPE practitioner.

The NIPE is clearly guided in that it should be performed within 72 hours of birth to highlight any abnormality at the earliest possible stage (Public Health England, 2018). Considerations such as home delivery and a speedy discharge from the acute setting need to be contemplated not only for monitoring of completion of the NIPE and reporting of the key performance indicators, but also to ensure that skilled practitioners are available to carry out the examination.

In addition to the evolving speed of maternal discharge, there are other factors that the NIPE practitioner must consider such as the age demographic of women giving birth. Childbearing at an older age has risen considerably and is becoming more common (Fitzpatrick et al., 2016). With this alteration, there is an increase in the potential problems that the NIPE practitioner must consider as more women choose to have their babies later in life. There has been a steady increase in the average age of first-time mothers from 27.2 years in 1982 to 30.2 years in 2014 to 30.4 years in 2016, a factor clearly outlined as a consideration in the ‘Better Births’ document (NHS England, 2016) which suggests that as a service the NHS must consider the implications on the risk to these women. According to the ONS (2017) women aged 30–34 years currently have the highest fertility rate of any age group since 2004; before this, women aged 25–29 years had the highest fertility rate, indicating that women are progressively delaying childbearing to older ages. With this increase in age comes added health considerations, and as the NIPE practitioner it is important to have an understanding of any maternal factors that might influence the NIPE. It might be that the mother is anxious or unwell, Was there assisted conception? There might be added pressures for the family or additional maternal medical conditions to consider. By examining the maternal notes in depth before embarking on the examination, this offers additional preparation, before the start of the communication process (NHS England, 2017; see also Chapter 5).

In addition to the consideration of the increased age demographic of women giving birth in the UK it is also important to recognise teenage pregnancy. Teenage pregnancies are continuing to fall and are currently at their lowest since the data first started to be gathered (ONC, 2017); however, there are certain parts of the country where this continues to be a significant consideration so it might be that you work within an area where there is a high number of teenage births. Baston and Durward (2017) highlight that teenage pregnancies have a probable rate of increasing due to the rapid age of maturity in young women, resulting in the first sexual encounter happening at a younger age. It is important for the NIPE practitioner not to make assumptions that all teenage births are a mistake; it is important that communication is a priority and that time is made available for discussion. Every mother will have her specific needs and it is important to be able to communicate effectively to ensure that full understanding of the NIPE has been made before consent is given. Public Health England (2017) clearly document in their standards for newborn infant physical examination that obtaining consent for screening is a professional obligation and a matter of respect between health professionals and the parent. The NIPE practitioner carrying out the screening is ultimately responsible for ensuring that the parent has an understanding of the examination and has given verbal consent. The decision to agree or decline the offer of NIPE screening should be clearly documented by the NIPE practitioner. As the NIPE practitioner, you will be required to verbalise to the parents any referrals being made and to ensure that all questions have been answered appropriately; this is in further depth in Chapter 3. There may be occasions when parents do not fully understand this information and refuse the examination. In this event first it is important to understand why this is the case. Do they understand what the aim of the NIPE is? Do they understand how the examination is carried out? If, after further discussion, the parents still refuse the examination and consent is declined, then it is important to be clear about your trust’s policy because it might be that this situation requires you to seek support from a more senior colleague. Later in the book you will learn more about data monitoring systems such as the NIPE Screening Management and Reporting Tool (SMART), if after, further discussion, the parents continue to refuse for their baby to have the NIPE, it is the responsibility of the NIPE practitioner to clearly document on the data monitoring system the reasons for refusal, and in some cases there may be a need for a written declaration signed by the parents.

CLINICAL TIP

Explore what your trust’s NIPE guideline directs in the event that a parent refuses to give consent for the NIPE screening. Being aware of this process will prepare you in the event that in the future you are the lead professional involved in such a situation.

Data evidences that the birth rate in the UK is seen to be decreasing, although the admission rates to neonatal units are in fact increasing (Royal College of Paediatrics and Child Health, 2017). This highlights an increased need for neonatal nurses to be skilled in performing the NIPE, which is evident in the increase in neonatal nurses accessing NIPE education. The (NNAP, 2017) has continued to highlight that a large number of babies born at term are separated from their mothers due to admissions to neonatal care, so speedy discharge is just as important from a neonatal unit as it is from a postnatal ward. As a result of the increased admission rate to neonatal units, there have been resources and learning platforms made available for all practitioners caring for the newborn. These learning tools assist the practitioner to develop skills to recognise and manage compromised newborns with the aim of reducing the number of term infants admitted to neonatal units (see Further resources at the end of this chapter).

THINK POINT

Consider what you understand by the term ‘health screening’?

Health screening

Health screening programmes are commissioned by NHS England, Public Health England and the Department of Health. Health screening is not just a test. A test on its own will not improve outcome. All components of a care pathway need to be in place for screening to be effective. The key steps are:

• Identifying the individuals eligible for screening

• Inviting eligible individuals for screening

• Giving information and facilitating uptake

• Undertaking the screening test and making sure it is accurate

• Acting on screening results: referral, diagnosis, intervention and treatment

• Providing support and follow up

• Optimising health outcomes

(Public Health England, 2017)

The way the NHS approaches screening is constantly evolving as further evidence becomes available; embracing new technology offers the programmes further assurance. The pilot for the introduction of routine pulse oximetry has been completed by Public Health England and it is anticipated that this may be a recommendation as part of the cardiac examination because many trusts are actively including this as part of the NIPE; this is covered in depth in Chapter 6. The benefits of maternal antenatal ultrasound have increased the information that the NIPE practitioner can access before performing the examination, again offering further information to predate potential problems. This is an important note to make because practitioners can at times find themselves under pressure to complete the NIPE in a speedy manner. The reasons might be linked to assisting with faster discharges or succinct bed management; however, it is always important to review the maternal notes before performing the NIPE and that time is allocated and protected. Chapter 5 covers in detail some of the information that might be established from examination of the maternal history.

The NIPE role

THINK POINT

Consider why midwives and nurses have additional qualities to bring to the NIPE role. What other health-promotion strategies can be discussed with the parents during the allocated NIPE time?

The NIPE provides an opportunity for providing general health information, support and encouragement because this is often an interaction with parents when specific time has been allocated to that set of parents and baby. Jones (2014) suggests that the midwife, having influenced healthy choices in pregnancy, can now provide information relating to neonatal health during the examination. Feeding, nutrition, smoking, sudden infant death and immunisations can be openly discussed in this non-threatening environment, where mothers can be congratulated and praised at the same time as the NIPE is carried out. However, the challenges to maternity services are also well documented and it is no doubt that midwives can find themselves with heavy workloads (Royal College of Midwifery, 2016). Jones (2014) recognised that some practitioners have stated that lack of time and equipment and increased responsibility have been major barriers for performing the NIPE. Some services have recognised this and the importance of succinct NIPE completion, and ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures
• List of tables
• Notes on contributors
• Acknowledgements
• Introduction
• 1 The newborn infant physical examination
• 2 The changing role of the practitioner caring for the newborn
• 3 Communication skills in healthcare
• 4 Maternal factors that influence fetal development
• 5 Why the maternal history is important for the NIPE practitioner in performing a safe and thorough examination
• 6 The physical examination: a step-by-step approach
• 7 Congenital abnormalities
• 8 Overview of the NIPE and appropriate and timely referral pathways
• 9 Clinical competence and professional responsibility
• 10 The second examination
• Index