Examination of the Newborn

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The purpose of this assignment is to explore the issue surrounding screening and examination of the new born from birth. The article will look at why we perform this examination following birth and will pay particular attention to the examination of the eye. It is documented that the purpose of the first examination of the new born is to confirm normality and to provide reassurance to the parents (MacKeith, 1995, Hall, 1999) and also to identify any apparent physical abnormality (Buston and Durward 2001).

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However the question that we may wish to consider is ‘what is normal in a neonatal who is undergoing major physiological adaptations to extra uterine life (Blackburn and Loper, 1993) ? How as midwives can we fulfil this expectation of norm, when there is, as Hall (1999) suggests no confirmation of normality available ?

Nevertheless a thorough search of the literature suggests that the neonatal examination is universally accepted as ‘good practice’, and any deviation from this practice could perhaps, potentiate negligence when subjected to the Bolam test (Sherratt, A, 2001).

This test is often used as a benchmark to measure any negligence by, and examines if another professional of same standing would act in the same manner. This area will be explored in more detail later in the essay, when looking at the legal and ethical aspects of the new born examination firstly I would like to examine what is the examination of the new born, why we should do it and who us best placed to undertake the procedure ? The examination forms part of a range of post delivery screening opportunities, which include; * A midwife check immediately after birth

* Neonatal blood spot test
* Hearing test
* Eight week physical examination, usually performed by a GP.

It could also be argued that it is an extension of antenatal screening tests from the beginning of the pregnancy when the mother is offered various scans and blood tests to try to ensure a safe outcome of the pregnancy. NICE (2006) outlines the content of the neonatal examination regardless of who the practitioner may be undertaking the examination. In essence this is a top to toe physical examination of the baby that involves auscultation of the heart and lungs , palpation of the abdomen and assessment of the hips, a detailed examination of the eye and assessment of the genitalia and anus. As the content of the examination is quite extensive this has been included in the index of the article for further reference. NIPE (2008) in their standards and competences document suggest that “parents should be offered information antenatally at around 28 weeks both in written and verbally and this should be repeated prior to the new born examination being offered.

The information should cover the rationals for the new born physical examination as well as its limitations. The assessment of the new born being a continuing process with the parents continuing to assess their baby once they have taken it home. Therefore the examination provides a valuable opportunity to promote health and provide parents with knowledge about what to expect from their baby (Townsend et al, 2004) (Walker, 1999). The NSC (2004) increasingly presents screening as a ‘risk reduction’ and states that ‘it is not a fool proof process.’ In other words it can reduce the risk of developing a condition/complications, but it is unable to offer an absolute guarantee. Knowles et al (2005) in systematic review of the literature regarding detection and outcomes of children with congenital heart defects, shared that only half were detected.

However, often screening methods such as the use of pulse oximeter may improve this (Mahle et al 2009). The examination of the new born also offers an opportunity to detect congenitally displaced hips. Gerscovich (1997) tells us that “early detection leads to early treatment, which results in complete resolution in most cases.” The current strategy being to screen all neonates using the physical examination and only to refer for sonography if the infant is deemed to be high risk. Mahon et al (2009) suggest in cases of “breech presentation or known family history.” This highlights the need for the examiner to be fully aware of their own local trust guidelines and policies. As well as the importance of good history taking and methodical reading of the medical notes in order to identify risk factors that may require referral or simply make the examination outside the midwives role.

Dezateux and Rosendahl (2007) stipulate that the overall effectiveness, harm and benefits of the examination remain controversial. Furthermore the view of the UK National Screening Committee is that if the introduction of screening for developmental dysplasia of the hip were considered now it “would probably not be accepted.” However it is difficult to obtain clear evidence about the effectiveness of the examination of the new born as it is deemed unethical to conduct a randomised controlled trial in which are group of babies do not receive an examination (Townsend et al, 2004). However the fact that babies are examined in the immediate new born period is “universally accepted as good practice” and supported by national guidance such as NICE routine postnatal care guidelines (2006), child health promotion programme (DH 2008) and the UK National Screening Committee (2008) in its standards and competencies for practice. With this in mind the next area of consideration is the timing of the examination.

Almost immediately after birth the baby will be examined by the midwife to rule out any signs of gross physical abnormality but what appears to vary is the timing of next examination. Townsend (2004) suggests that “for most services the timing of discharge dictates the timing of examination, with most services preferring not to do the examination before 6 hours of age”. It could well be argued that if only one examination is being performed, this should be after 24 hours to allow the maximum length of time for ductus close and pulmonary vascular resistance to start to fall, therefore increasing the chances of detecting congenital heart disease (Patton C, 2006). Lock (1999) believes that “earlier examination may lead to earlier discharge, leading to congenital anomalies and feeding presenting in the community”.

This may hold cause for concern as any such occurrence would be at a time when health professionals were not around. However in contrast it could be argued that earlier examination may allow abnormalities to be dealt with before symptomsdevelop and in a planned way without discharge being delayed (Green K, Oddies, 2008). Timing of the examination is an issue with approximately 60% of those who screened positive during the first examination being normal by one week of age (Townsend et al, 2004). Hall and Elliman (2006) suggest that the examination be performed ideally within the first 24 hours of birth and certainly within 72 hours. The examination should of course be repeated between 6 – 8 weeks of age and is usually undertaken by the GP in primary care. The UK National Screening Committee (2008) support these timings as there is not currently any definite time in which to detect all abnormalities (Sherratt, 2001).

My experience in clinical practice is that discharge and availability of practitioner dictate when the examination takes place. Physiologically it seems to make sense to perform the examination at around 24 hours of age, giving time for the ductus to close. However with the push for early discharge to the community the examination is often done at 6 hours of age due to lack of qualified practitioners in the community. Parents are often reluctant to come back into hospital so soon after discharge home and may potentially have to wait for same considerable length of time on the postnatal ward before the paediatrician may be free. The current timing of examination within the maternity unit that I work in being dictated by service provision.

However women want choice regarding discharge and it does not offer prudent to prevent early discharge to primary care of an otherwise fit and healthy mother and baby. Therefore allowing the examination to be as late as is practically achievable seems to make sense. Traditionally the examination of the new born has been undertaken by the paediatric team and primarily by a senior house officer (MacKeith, 1995, Michaeldies, 1995, 1997, Seymour 1995). This routine neonatal examination has been an essential part of child health surveillance in the UK since the 1960’s, and primarily been undertaken by medical staff. With a reduction in junior doctors working hours and training (DOM 1991), which suggest a philosophy of person-centred care offering choice in maternity care.

Enabling midwives to undertake post registration training in the form of the N96 course helps to fulfil the need of allowing early discharge to the community, whilst balancing the physiological advantages of performing the examination after 6 hours but within 72 hours post delivery. It is suggested that midwives are well placed to examine the new born. This viewpoint is supported by the white paper ‘Making a difference’ which supports the breaking down of rigid demarcation of role boundaries (DH, 1999). Lomax (2001) believes the “midwife is the most appropriate health professional to provide holistic care to women and their babies”. Lomax (2001) goes onto suggest that “midwives who conduct the examination of the new born will be supporting the strategies set out in the National Health Service Plan (DH, 2000) and the vision of the Royal College of Midwives (RCM) by increasing midwifery autonomy (RCN, 2000).

However just training more midwives to perform the examination is only part of the ‘solution’ as this may put additional demands on the busy midwife and her existing role. Certainly one of the main benefits for both mothers and midwives is ensuring continuity of care. Within my own role as a community midwife this enables me to care for a woman antenatally, intraportum and postnatally and I perceive this as an extension of care into the postpartum period. The EMREN study (2004) showed that “mothers were more satisfied with a midwife rather than a trainee doctor performing the new born examination, because midwives were more likely to discuss healthcare issues such as feeding, sleeping and skin care, and were able to provide continuity of care”.

Certainly from my own experience health education seems to come naturally to midwives and opportunity during the examination to discuss issues such as feeding, BCG vaccination, jaundice and SIDS advice for example is also supported by the UK NSC 2008 in their NIPE standards and competencies. The EMREN study (2004) also showed us that “midwives” examinations were judged to be of high quality than the doctors in terms of both technical and communication skill. This is an important finding as we need to ensure that we are at least as equally competent as our medical colleagues. NIACE (1989) tells us that “competence is an outcome: it describes what someone can do. In order to measure reliably someone’s ability to do something, there must be clearly defined and widely accessible standards through which performance is measured and accredited”.

In 2008 the UK national Screening Committee (NSC) published standards and competencies for the new born and physical examination. These competencies are divided into 6 parts, each competency is broken down further into benchmarks and examples of knowledge and skills accompany them. This helps to provide consistency and transferability of skill and should be applied to all practitioners that undertake the examination. They serve as a useful way in which to audit our practice as this should ensure standardisation with all practitioners performing the examination in the same way across all units in the UK. Hall and Elliman (2006) tell us that the “professional qualification of the person delivering various aspects of this screening programme is less important than the quality of their initial training and continuing training, audit and self- monitoring”.

The NIPE (2008) programme of National Competencies and Standards aims to have a national database whereby each examination is documented electronically to provide a method of auditing from the initial examination to referral and outcome of referral appointments. Logistically this may be difficult as it relies on not just the midwife in putting the data at the initial examination but also the busy orthopaedic consultant working in the outpatient department. Time constraints may make this difficult but it should provide us with ways in which we can audit our own practice. A search of the literature suggests that although midwives have increasingly been trained through a formal process of education such as the N96 course, many are not utilising their skills on completion. Townsend and colleagues (2004) state that “44% of midwifery units have midwifery staff who are able to discharge new born babies, however only 2% of babies in England have the examination performed by a midwife”. This seems to be an astonishingly low figure.

However these findings are supported by Mayes et al (2003) who identified that only 2 % of babies in England are examined by midwives. So what is it that is stopping us as midwives in fulfilling our role ? Mayes et al (2003) raised several questions regarding what factors inhibited midwives from practicing their new skills, as well as what factors actually enabled them to practice ? One of the findings suggested that “midwives who felt unsupported by their manager were more likely to worry about their role, feared losing their skills and cited lack of confidence” as a reson for not practicing.

This does seem like a vicious circle as the longer the midwife leaves it before performing the examination the more this is likely to affect her confidence and in turn become less likely to practice. Mayes et al (2003) looked at the attitudes of midwives colleagues towards their new role. Some midwives stated “that they would not undertake the N96 course because there was no financial reward for learning new skills”, yet a shift in attitude occurred when addenda for change was published (DH 2003).

More midwives in the study went onto state that “role conflict demonstrates a lack of understanding of inter-professional working”. Midwives who felt unsupported by their manager tended to be more likely to worry about their role. Midwifery managers therefore have a vital role in supporting midwives and ensuring their skills are maintained following completion of the course. McDonald (2008) showed in her audit of 65 practitioners that overwhelmingly felt that the extension to their role had;

* Increased job satisfaction
* Improved continuity of care
* Improved maternal satisfaction

Future developments may see midwifery training extended to encompass the examination of the new born as part of pre-registration training. Members of the Royal College interviewed as part of the EMREN study (2004) were generally supportive of this. Sharon McDonald (2008) also found that midwives were overall supportive of the idea of including this as a part of midwifery training. This may lead to more midwives practicing a completion of their training, as this would be seen as part of providing care in ‘normality’. This course will be available from 2010 and will be an optional module in the undergraduate course at Anglia Ruskin University. What is essential is that the initial education and skill development should be supported by a comprehensive programme of updates and audit of practice. Currently midwives may find it difficult to audit their own practice unless they keep their own records of examinations and follow them through by refilling their medical notes.

The NIPE (2008) vision of a computer database of all examinations performed and outcomes from follow up referals will make this much easier. Midwives are fully aware of their midwives rules and standards (NMC 2004) which stipulate “a midwife is responsible for maintaining and developing her own competence and must ensure she becomes competent in any new skills required for her practice”. The NMC (2008 a:7) also stipulates within the professional code: “you must recognise and work within the limits of your competence”. Certainly PREP requirements NMC (2008 b) outline the need for 35 hour of relevant learning in every 3 years registration period and 450 hours of clinical practice. Therefore it is central to practice that midwives remain updated in their practice, if a lapse in practice occurs then the midwife must acknowledge the limitations of their own competence.

This should not mean the need to refrain from practice but to recognise the need for supervised practice, to ensure that the clinical skill required to maintain the competencies and standards of neonatal examination are maintained. The midwife should be supported in the expansion of her role by locally agreed policy and guidelines. Clearly set out ‘what’ group of patients the midwife can examine and outline the need for referral to member of the medical team when guidance is required. Each midwife undertaking the examination of the new born should ensure they are fully conversant with and work within their local trust guidelines. The NMC (2008 a) also stipulate that “referral for advice and support when an abnormality is suspected or detected is not a weakness but a professional requirement”.

Certainly Leonard et al (2004) tell us that “multidisciplinary team work is vital in the provision of effective, high quality care for the family unit”. Knowing when and how to refer is a pivotal part of the midwives role. Midwives also have the benefit of 24 hour access to a supervisor of midwives who can offer advice and support, regular meetings with a supervisor of midwives can allow the midwife to reflect on professional or practical issues of practice, within what should be a supportive environment. Midwives are also guided in their professional behaviours by the code, standards of conduct, performance and ethics for nurses and midwives (NMC 2008).

This document states that “as a professional you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions”. Midwives involved in the care of patients have a legal duty to care for them well. This means to the standard of a reasonable, competent member of their own profession, this is known as the Bolan test. In a case of ‘duty of care’ has occurred. Buston and Durward (2010) outline how a midwife could be in breach of her duty of care if she failed to detect a neonatal abnormality:

1) She did not gain informed consent from the parents
2) She failed to take steps to identify it
3) She was not using commonly accepted techniques to examine the baby
4) A colleague of equivalent status would have been expected to detect it
5) She failed to act on a suspicion of abnormality
6) She did not document her findings
7) She did not communicate her findings to the parents
8) She did not follow up investigations required

It is evident that there are many ways that the midwife could breach her duty of care even if she was clinically competent. However as Baston and Durward (2010) inform us “failure to detect an abnormality that a colleague of equivelant status would also have missed does not constitute negligence”. However it may well be different if the breach is seen as foreseeable. Baston and Durwood (2010) explain that if a practitioner did not document her findings such as a heart murmur and communicate then to an appropriate colleague the baby may be harmed by not receiving prompt referral and treatment ? In achieving and maintaining best practice the midwife should ensure that she has gained clear consent prior to undertaking the examination. In line with recent policy set out in Maternity Matters (DOH 2007) services increasingly aiming to offer ‘choices’ to women regarding the care they receive.

As outlined by Baston and Durwood (2010) to make choices women need to accss relevant, unbiased information in order to make decisions. Parents will need to know who you are, the options available, what you are going to do within the check, and the advantages and disadvantages of the procedures. Status is important as patients may mistakingly think that you are a doctor, particularly as many midwives are out of clinical uniform these days. Martin (1997) tells us that this could make the consent invalid if the procedure is undertaken by a midwife when the patient is expecting it to be a doctor. Dawling et al (1996) tell us that it is also important to inform parents that you have undertaken further education and training to perform this role.

Otherwise they may think you are acting outside of your clinical role. The use of a patient information leaflet that could be discussed with the mother at around 28 weeks pregnant may also be a useful way of explaining what the examination of the new born entails, its limitations and purpose. However consent should be always be gained immediately prior to the examination as well, and clearly documented in the notes. Documentation of the findings of the neonatal examination are also crucial as this is a way in which we communicate with other members of the multidisciplinary team, as well as serving as evidence that a task has been performed.

It provides a paper trail to identify if abnormality has been seen and what has been done as a result of it. Nurses and midwives can seek guidance in record keeping from the NMC (2009) document “Record Keeping: Guidance for Nurses and Midwives”. Peer review of documentation can be a way to promote ‘best practice’ and help with finding ways in which to improve it. Midwives must also remain mindful of their ethical as well as legal responsibilities when offering women screening tests and when supporting them with their decisions. The laws of society as well as the professional codes within wich we work as midwives open us up to look at ethical principles underpinning decision making.