Maternity

Routine Examination of the Newborn-Guideline

SWH 00063

Version: Job Title of Responsible Manager: Job Title of Executive Sponsor: Ward / Department: Replacing Document: Approving Committee / Group: Date Approved: Date for Review: Relevant Standard(s):

1 AGM Women and Childrens Services Director of Operations and Nursing Maternity unit and community midwives N/A Clinical Practices group May 2009 May 2012 CNST 5.7 SfBH C5C6,D2,C7,C9,C11,C14, C16, D10.
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SWH 00063 Routine Examination of the Newborn Guideline

Table of Contents
1. 2. 3. 4. 5.
5.1 5.2 5.3 5.4 5.5

INTRODUCTION.........................................................................................................4 PURPOSE...................................................................................................................4 AUDIENCE..................................................................................................................4 RESPONSIBILITIES / DUTIES ...................................................................................4 ROUTINE EXAMINATION OF THE NEWBORN ........................................................5
Prior to the Examination .................................................................................................................................. 5 During the Examination.................................................................................................................................... 5 Detailed Physical Examination (Antenatal and Newborn Screening Programme 2008) ................. 6 Following the Examination.............................................................................................................................. 7 Documentation ................................................................................................................................................... 7

6. 7. 8. 9.

TRAINING ...................................................................................................................7 MONITORING COMPLIANCE AND EFFECTIVENESS .............................................8 AUTHORS...................................................................................................................8 CONTRIBUTORS .......................................................................................................8

10. EQUALITY IMPACT ASSESSMENT TOOL ...............................................................8 11. REFERENCES............................................................................................................9 12. APPENDICES .............................................................................................................9 13. APPENDIX A DEVELOPMENTAL DYSPLASIA OF THE HIPS (DDH) ..................10 14. APPENDIX B ANTENATAL RENAL PELVIS DILATATION ON ULTRA SOUND SCAN (USS) ............................................................................................................11 15. APPENDIX C TALIPIES EQUINO VARUS (CLUB FOOT).....................................12 16. APPENDIX D UNDESCENDED TESTES ................................................................13

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17. APPENDIX E EYE EXAMINATION .........................................................................14 18. APPENDIX F CONGENITAL HEART DEFECTS ....................................................15 19. APPENDIX G MONITORING COMPLIANCE AND EFFECTIVENESS OF SWH 00063 ROUTINE EXAMINATION OF THE NEWBORN ...........................................16 20. APPENDIX H DISSEMINATING SWH 00063 ROUTINE EXAMINATION OF THE NEWBORN FORM....................................................................................................17 21. APPENDIX I APPROVING CHECKLIST FOR SWH 00063 ROUTINE EXAMINATION OF THE NEWBORN GUIDELINE...................................................18

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1.

Introduction

The assessment of the newborn is a continuing process during which health professionals and parents work together to assess the baby. Evidence points to parents being more satisfied with care characterised by continuity and opportunities to ask questions (Wolke et al 2002) An initial examination of the newborn is carried out within an hour of birth, followed by a more detailed examination. It is established as good practice to carry out the detailed examination of a baby within 24 hours of birth (Hall & Elliman 2006) and certainly within 72 hours as part of the core health programme for under 5s. (DH, 2007)During these routine examinations problems can be identified. If appropriate, full discussion with the parents can take place prior to referral for investigation, specialist assessment and treatment (NHS best practice statement 2008). The aim of the newborn physical examination is to detect less obvious adverse conditions or abnormalities. It includes screening for congenital cardiac defects, developmental dysplasia of the hips, some ocular disorders, and undescended testes as well as a general physical examination. A daily assessment of the baby feeding, colour, behaviour and general well-being will be carried out as routine post natal care.

2.

Purpose

To aid health care practitioners in the understanding of the relevance of the examination, to identify normality, recognise abnormality and refer appropriately.

3.

Audience

This document is aimed at: Paediatricians, working within the maternity unit Midwives working both in the hospital and the community, who have received training and achieved a level 3 qualification in carrying out the routine examination of the newborn Midwives working towards this qualification, working within a framework of professional supervision to maintain their competencies

For midwives to maintain this competency a minimum of 30 examinations a year must be carried out (SHW - 000159, 2009).

4.

Responsibilities / Duties

All staff involved in the care of the newborn must: Ensure that parents are given written information about the examination in the ante natal period Highlight the need for an interpreter prior to the examination Ensure the examination has been carried out or inform a paediatrician or appropriately trained midwife of the need for an examination within the 24 hr time frame
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5.

Ensure standardisation of the examination Inform the parents of findings, and make any appropriate referrals

Routine Examination of the Newborn

The detailed examination of the newborn may only be carried out by a paediatrician or an appropriately trained midwife. The midwife can carry out this examination on any well baby, regardless of family, antenatal or labour history, ensuring that relevant referrals are made, to the appropriate health professionals if concerns are highlighted Any baby that is admitted to the Special Care baby Unit, or if any concerns have been raised at the initial examination must be reviewed, and the detailed examination carried out by a paediatrician within 72 hours of birth

5.1 Prior to the Examination All health care professionals who carry out detailed examinations of the newborn must: Ensure that the parents have received information regarding the examination, both verbally and written via the NHS screening programme leaflet (Screening test for you and your baby NHS 2008) Make sure that family history, ante natal (including screening) and labour problems are identified. Also the findings of the initial examination, including type of delivery, gestation, apgar score and weight are recorded. Any identified risk factors may require a management plan and follow-up Ensure parental health issues such as depression, domestic violence, substance abuse, learning difficulties or known mental health problems, are identified and taken into account Obtain consent from parent to carry out the examination at a time that is mutually convenient for the health professional, parents and baby (COR - 0068, 2007) Inform parents what the routine examination of their baby can assess, the benefits such as early referral and the limitations such as the inability to diagnose some conditions due to ongoing circulatory changes. Also the effects of maternal hormones on joints and muscles Use interpreters where necessary to facilitate communication between parents and health care professional Assess the condition of the baby since birth to include: o Feeding o Passage of meconium o Urine including stream in male infants o Discuss these points with the parents and other health professionals involved 5.2 During the Examination Wash hands as per Trust policy (SWH - 00013) The examination must be carried out in appropriate well-lit, warm and private area. It
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will be carried out by one person The examination must take place between 6 and 72 hours of life, best practice should be within 24 hours of birth, or at least following one feed The healthcare professional will discuss: o Baby care o Feeding o Vitamin K o Reducing the risk of Sudden Infant Death Syndrome (SIDS) o Any other matter relevant to the individual baby or of concern to the parents Problems not apparent in the newborn, but may be significant later such as jaundice, must be explained to the parents, and the significance highlighted, including the importance of informing a health professional If the baby becomes unduly upset during the examination, or the examination could not be completed; the examination should be repeated when the baby is calmer, and documented in the babys Health Care Record and Red Book If findings were ambiguous the examination must be repeated by a senior clinician

5.3

Detailed Physical Examination (Antenatal and Newborn Screening Programme 2008) The person carrying out the examination, must document the following, both in the Red Book and the babys Health Care Record. Observe the babys appearance including colour, breathing, behaviour, activity and posture Examination of the fontanelle(s), face, nose, mouth including palate, ears, neck and general symmetry of head, vault, sutures and facial features Measurement of the head circumference Checking of the eyes opacities and red-reflex Examination of clavicles, limbs, hands, feet and digits Assessment of cardiovascular system, heart rate, rhythm and sounds, murmurs and femoral pulse volume Assessment of respiratory system, effort, rate, and lung sounds Assessment of abdomen shape, palpate to identify any organomegaly. condition of umbilical cord Genitalia and anus - check anus for patency. undescended testicles in males Check

Check genitalia for form and

Observe if passed urine and meconium (usually passed within 24hrs) Spine inspection and palpatation of bony structures and integrity of skin Observe colour and texture of the skin, including birthmarks and rashes

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Central Nervous System - including Moro and Grasp reflex Hips - check symmetry of the limbs and skin folds. Perform Barlow and Ortolanis manoeuvres Cry - observe sound of babys cry

5.4 Following the Examination If any concerns have been highlighted further advice must be sought from a senior clinician. The name and grade of the professional must be recorded in the Health Care Record, along with the time and date of referral. A review of the findings must be discussed with the parents, in an empathetic manner; this must include the reasons for requesting a further opinion. If a senior clinician review has been requested they will be responsible for discussing their findings and any suggested referrals. Appendixes A-F show the care pathways for the most common deviations from the norm which may become apparent during the detailed examination of the newborn. Appropriate referrals must be made, using these appendices as a guide, relevant to the findings of the examination or family/antenatal history. 5.5 Documentation All staff involved in the care of the newborn must : Complete all relevant documentation including recording delivery details in the Health Care Record Ensure that any entries are signed, timed and dated, the surname is printed and the NMC or GMC numbers are recorded Bleep numbers must not be used Record the findings of the detailed examination of the newborn in the babys Red Book, and in the hand held post natal records prior to transfer to community care Ensure that any follow up plans and/or referrals are made and documented

All incidences and follow up of non-consent for examination or refused referrals must be communicated to the Health Visitor and GP and Paediatric Consultant and documented in the appropriate health care record.

6.

Training

Staff training needs will be assessed by a peer review system using the benchmark standards set out by the National Screening Committee 2008 (SWH-00159, SWH-00160, 2009). In the absence of external structured study days training will be provided by a Paediatrician on a one to one basis.

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7.

Monitoring Compliance
A record will be made on the post natal ward, of time of birth and the time the examination takes place and by whom, in the newborn examination book A record will be kept on the post natal ward, of any referrals made, to whom and the time scale for the appointment, also in the newborn examination book Problems will be reported via the clinical incident reporting system Compliance to the document will be monitored six monthly through audit and reported to the Labour Ward Forum. This will include whether the newborn examination book has been completed

8.

Authors
Jan Phipps Midwife Lecturer Practitioner, Supervisor of Midwives

9.

Contributors
Jane Allen Post Natal Core Team Midwife. Dr Acharya Consultant Paediatrician Sheila Clayton Paediatric Physiotherapist Paediatric Audit meeting Labour Ward Forum Maternity editorial group

10.

Equality Impact Assessment Tool

Please see Procedural Document (including Policies) Policy on how to complete this table. Has an Equality Impact assessment been carried out? YES Preliminary Stage 1 Equality Impact Assessment (must be completed if required*) What date was Stage 1 completed and published? January 6th 2009 Has a Full Assessment Stage 2 Equality Impact Assessment Tool been undertaken*? NO If yes, what was the date of assessment and publication of Stage 2 and action plan?

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11.

References

Department of Health (DH) 2007. The child Health Programme Delivery Standard. Pregnancy and the first five years of life. Hall DMB, & Elliman D. (ed). Health for all children. 4th edition. Oxford. Oxford University Press; 2003. National Institute for Health and Clinical Excellence. (2007). Intrapartum Care: care of healthy women and babies during childbirth. Clinical guideline 55. London .NICE. NHS 2007, Screening tests for you and your baby. Antenatal and Newborn Screening Programme. UK National Screening Committee. Oxford. NHS Quality Improvement Scotland. (2008) Best practice Statement Routine examination of the Newborn. South Warwickshire General Hospitals NHS Trust: (2003) Guideline for the Management of the Newborn Immediately after Birth. MID-0022. South Warwickshire General Hospitals NHS Trust: (2008) Hand Hygiene Procedure. SWH-00013. South Warwickshire General Hospitals NHS Trust: (2007) Policy for Consent to Examination and Treatment. COR-0068 South Warwickshire General Hospitals NHS Trust: (2009) Maternity Unit Training Needs Analysis SWH-00160 South Warwickshire General Hospitals NHS Trust (2009) Maternity Unit Training Needs Policy SWH-00159 Wolke D., Dave S.,Hayes J., Tomlin M. Routine examination of the newborn and maternal satisfaction :a randomized controlled trial. Archives of Disease in childhood Fetal Neonatal Ed. 2002;86(3):F155-60.

12.

Appendices

Appendix A - Developmental Dysplasia of the hips Appendix B - Dilated Renal Pelvis Appendix C - Talipies Appendix D - Undescended testes Appendix E- Eye Examination Appendix F- Congenital Heart Defects Appendix H - Dissemination Form Appendix I - Approving Documentation checklist.

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13.

Appendix A Developmental Dysplasia of the Hips (DDH)

(http://www.pediatric-orthopedics.com) This condition was once termed congenital dysplasia of the hip because it was thought that all these problems began prior to birth. Recently, the term developmental dysplasia of the hip was coined because it was realised that some hips were normal at birth and gradually became dysplastic or malformed later.

Newborn physical examination. Barlows/Ortolani

Positive

Inconclusive

Normal, But identified risk factors Breech. ECV Family history or skeletal limb anomalies noted on examination

Click confirmed by experienced practitioner

To be confirmed by experienced practitioner

Positive

Inconclusive

Hip scan at 6 weeks Paediatric follow up at 8 weeks Refer the same day to Orthopaedic surgeon at University Hospital Coventry Via the paediatric secretary GP review at 6 weeks

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14.

Appendix B Antenatal Renal Pelvis Dilatation on Ultra Sound Scan (USS)

Dilated Renal Pelvis more than 5mm on 32 week Ultra Sound Scan

Unilateral 5-10mm

Unilateral more than 10mm Bilateral 5-10mm

Ensure Passed urine prior to transfer into the community Prophylactic Trimethoprim to be prescribed by the paediatrician following birth Renal USS in 6-8 weeks Paediatric follow up 8 weeks

Ensure passed urine within 24 hours of birth (note stream if possible in boys) Prophylactic Trimethoprim Inform Consultant Renal USS 48-72 hours of birth

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15.

Appendix C Talipies Equino Varus (Club Foot)

Talipies can be seen in newborn babies as a result of their postion in utero. It is easily correctable and may resolve without treatment within a few days of life (positional Talipies). But some babies may have a structural talipies, where it is not possible to easily correct the foot position and the foot is very tight.

Talipies on examination

Easily correctable

Not correctable Difficult to correct

Explain to parents. Show how to gently stretch foot back into correct position

Refer to Paediatric/Orthopaedi c Surgeon at University Hospital Coventry Paediatrician. At the earliest possible opportunity

Health visitor to refer to paediatric physiotherapist at 2 weeks if not resolved

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16.

Appendix D Undescended Testes

Bilateral Undescended testes

Unilateral Undescended testes in an otherwise normal baby

Paediatric review by senior practitioner

GP review at 6 weeks

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17.

Appendix E Eye Examination

Absence of Red Reflex in the eye Opacities

Checked by experienced practitioner

Confirmed absent reflex

No concerns

Opthalmology referral as soon as possible

GP follow up at 6 weeks

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18.

Appendix F Congenital Heart Defects

Abnormal Cardiac sounds on Auscultation

Examined by experienced practitioner

Confirmed by discussion with On Call Consultant

No abnormality detected

Referral to Cardiologist and Paediatric Consultant Clinic as necessary

See GP at 6 weeks

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19.

Appendix G Monitoring Compliance SWH 00063 Routine Examination of the Newborn

SWH 00063 Routine Examination of the Newborn Guideline
31/3/09

Title of Document Date Standards for Better Health (SfBH) relating to this document (if any) NHSLA Standard related to this document (if any) Does the document fulfil the criterion of NHSLA and SfBH
(please circle as appropriate)

C5C6,D2,C7,C9,C11,C14, C16, D10. 1.5.7 2.5.7

YES If not, why not: Other, please specify; _______________

1.

How will the document be monitored?

(please circle as appropriate)

Audit

KPI

Review

2.

3.

Methodology: Auditing the newborn examination record book on the post natal ward, for . A record of the time scale in which the examination was carried out, any referrals made, to whom and the time scale for the appointment. Staff training needs will be assessed, in the absence of structured study days by a peer review system. Using the benchmark standards set out by the National screening committee 2008. What is the process for Compliance to the document will be fed back to Labour reviewing results of Ward forum and the Maternity risk Management Group monitoring? on a quarterly basis. Who is responsible for Group / Committee Individual conducting the monitoring? Name / Title (also include position of individuals): (please circle as appropriate) Audit Midwife. How often will the document be monitored?
(please circle as appropriate)

4.

Monthly

6 Monthly

Yearly

Other, please specify; _______________

Comments: Through a spot check system of the record book on the post natal ward, and 5 sets of notes.

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20.

Appendix H Disseminating SWH 00063 Routine Examination of the Newborn Form

Plan for Dissemination of Document Routine Examination of the Newborn 02/04/2009 Clinical practices group Jan Phipps ex 8251 Janet.Phipps@swh.nhs.uk No (please delete as appropriate) No

Title of Document Date finalised Review Committee Dissemination lead (Author)

(Print name and contact details)

Previous Document already being used? If, yes in what format and where? What action will be used to retrieve out-of-date copies of the document:

Dissemination Process Receiver (area / ward / unit)

All staff working within the maternity unit Labour ward Post Natal Ward Special Care Baby Unit

Process
Send email with Document attached Hard Copy Hard Copy Hard Copy

Responsible
Governance Midwife

Timeline
By 21/07/09

Format
(paper or electronic)

Electronic

Governance Midwife Governance Midwife Governance Midwife

By 21/07/09 By 21/07/09 By 21/07/09

Paper Paper Paper

________________________________________________________________________________________________

Record of Dissemination of Document Complete this section of the form once the document has been approved by the appropriate committee. Date of approval of the document Date of review of the document Receiver (area / ward / unit)
e.g. Castle Ward

Contact (area / ward / unit)

Joe Bloggs #1111

Number of Date copies sent complete

10 17/07/08

Comments
Emailed Joe, on leave - forwarded to John Citizen, in Joes absence

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21.

Appendix I Approving Checklist for SWH 00063 Routine Examination of the Newborn Guideline
Routine Examination of the Newborn guideline Jan Phipps Clinical Practices 3rd April 2009 Item Complete
(YES / NO)

Title of Document Author Ratifying Committee / Group Date of Submission

1 2

Has the Procedural Documents Policy and its associated documents been consulted during the development of this document? Has the appropriate template been used? Has the South Warwickshire General Hospital NHS Trust Style Guide been used to develop this document? Have the appropriate committees / groups / individuals been consulted as to the appropriateness of the content of this document? Please list these committees / groups / individuals: Paediatric Audit Group Labour ward forum Maternity Editorial group Has the Plan for Dissemination of a Documents form been completed and attached? Has a Equality Impact Assessment been undertaken? Has the procedural document been attached? Has the Monitoring Compliance with and Effectiveness of Document Form been attached?

Yes Yes Yes Yes

3 3a

4 5 6 7

Yes Yes Yes Yes

Author (sign off) I declare that the information above is a true and accurate record Name Position Signature Jan Phipps Midwife Lecturer Practitioner J.R.Phipps

Appropriate Manager for Subject (sign off) I declare that I have overseen that development of this document and believe all appropriate matters have been addressed Name Position Signature

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