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Examination of the Newborn on the Postnatal Ward UHL Neonatal Guideline Author: J. Behrsin, E Boyle, J Foxon Contact: S Mittal, Neonatal Guidelines lead Approved by: Neonatal Guidelines Meeting Guideline Register No: C98/2008 NB: Paper copies of guidelines may not represent the most recent version. The definitive version is held on BadgerNet and in the Policy and Guidelines Library.

of 9 Written: August 2008 Last Review November 2019 Next Review: November 2020

1. Introduction and who the guideline applies to:

This guideline applies to clinicians undertaking the full examination of the newborn on the postnatal ward within the hospital setting.

Associated UHL Guidelines

Breastfeeding strategy

Child Protection - Safeguarding Children

Weighing of well term babies

Prevention and management of symptomatic or significant hypoglycaemia in neonates Thermal protection of the newborn

Consent to examination or treatment

Hand hygiene

Maternity records

Guidelines for midwives performing the neonatal examination Neonatal Guidelines for the Postnatal Ward (Postnatal Ward Book)

Purpose:

The purpose of the neonatal examination is to:

1. Undertake a safe, systematic approach to screen for abnormalities as part of the on-going programme of child health surveillance.

2. To provide advice, information and reassurance to parents (Townsend et al 2005).

Examination of the Newborn on the Postnatal Ward UHL Neonatal

Guideline

University Hospitals of Leicester

NHS Trust Nov 2019 – Nov 2020

Trust Ref C98/2008

NHS



Staff able to perform the examination.

Staff performing the examination must be Paediatricians/Advanced Neonatal Nurse practitioners (ANNPs) trained in neonatal examination or Midwives undertaking the neonatal examination as part of their extended role following completion of a recognised examination of the newborn course (See Guidelines for midwives performing the neonatal examination).

Timing of the Examination

The timing of the examination should reflect the physiological adaptations the neonate makes to extra uterine life. The exact timing will in part be determined by the time of birth and the parent’s wishes regarding discharge home if in hospital. It is ideal to ensure that the check is done prior to discharge home if possible. The clinician should use professional discretion when determining the exact timing of the examination which would normally occur within 72 hours following the birth (UK NSC handbook 2016/17). Routine checks will be done between 09:00 and 17:00 when there are designated medical staff to cover the postnatal ward.

If an appropriately trained clinician is not available for the examination or an early discharge home occurs, the midwife responsible for the discharge must advise the parents on contacting the GP.

Review of records/history:

Obtain maternal history regarding past medical history, pregnancy, labour and birth.

Check for fetal alerts. Where an alert exists a management plan should be documented in the medical notes postnatally.

Check for administration of vitamin K to ascertain if it has been given and if any further doses are required

Obtain family history and particular sibling history

Explain that the examination is purely a screening examination and cannot always predict or exclude severe congenital abnormalities (particularly cardiac)

Obtain maternal consent for examination of her baby

Discuss with parents how they perceive the baby is progressing e.g. feeding pattern, urination, passing of meconium, and any concerns.

Both parents should be encouraged to be present where possible (DOH, 2005).

The examination is completed with regard to thermal protection of the baby and cross infection (see related guidelines).



An examination of the 4 main screening elements (NIPE standards, NSC 2019) undertaken: (see National Screening Committee NIPE Handbook)

NIPE handbook

Eyes: General examination and elicit the red reflex

Cardiovascular system including heart sounds and femoral, brachial pulses and capillary refill time.

Musculoskeletal system: Hips including Ortolani’s and Barlow’s test, limbs and digits

Genitalia: In male infants check the position of the urethra and note whether the testes are descended. Ensure the infant has passed urine (and the nature of the stream in a boy).

In addition to this a systematic examination of the following is also undertaken:

Observe the baby for posture, movement, tone, colour, cry, and obvious deviations from the norm, such as dysmorphic features

Respiratory system - Rate and noise, symmetry of movement, use of diaphragm and abdominal muscles

Head: Head circumference, anterior fontanelle, sutures, structural anomalies, mouth to exclude cleft lip and palate, symmetry and position of ears, nose and neck

Clavicles to exclude fracture

Abdominal examination: Palpate for masses/organomegaly, condition of the umbilical cord

Anus: Check for patency and the passage of meconium

Spine: Check for bony structures and integrity of the skin

Neurological system: posture, tone and reflexes

Skin: Check for colour, texture, lesions, birth marks and rashes. Document these on a body map in the hospital records and red book.

The examiner should be alert to the risk factors and signs of child abuse and follow UHL Safeguarding Children guideline (2019) if suspected.

Documentation:

Record all findings in the NIPE smart system and print a copy for the Personal Child Health Record booklet (PCHR or red book). Retain a copy for the maternal records and document findings in postnatal notes. Record any deviations from normal, the subsequent actions taken and the discussions with parents. It would also be good practice to indicate any significant birthmarks or skin marks / lesions on the appropriate page of the Child Health Record (Body Map – see appendix 4 below).

Examples of referral letters (printable from the NIPE smart system) are shown in the appendices below. The postnatal ward handbook contains useful summaries of many common conditions encountered

https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-programme-handbook/newborn-and-infant-physical-examination-screening-programme-handbook



Communication:

Communicate findings to Parents including any potential problems identified and recommended action.

Explain problems such as jaundice that may not be observable in the newborn but could be significant a few days later. If there have been concerns about jaundice in the newborn period it is good practice to document the details of this in the free text area of the NIPE smart examination sheet so that the GP and community midwife have a record.

Advise on health education as appropriate e.g. infant feeding, baby care, baby’s social capabilities and reducing the risk of sudden infant death syndrome.

Advise on continuing programme of child surveillance including newborn blood spot screening test, hearing screen, 6-8 week postnatal check.

Ensure findings are communicated to those providing future health care to the family i.e. Midwives, GP, Health Visitor

References

1. Department of Health (2005) National Service Framework for Children, young people and maternity services. Standard 11:Maternity service 10.2

2. National Institute for Clinical Excellence (2006) guideline 37 Routine postnatal care of women and their babies. NICE. London

3. Nursing and Midwifery Council (2002) Code of professional conduct. London, NMC

4. Nursing and Midwifery Council (2005) Guidelines for records and record keeping. London NMC

5. Nursing and Midwifery Council (2004) Midwives rules and standards. London, NMC

6. Nursing and Midwifery Council (2004) The PREP handbook. London, NMC 7. Townsend et al (2004) Routine examination of the newborn: The EMREN

study. An evaluation of an extension of the midwife’s role including a randomized controlled trial of appropriately trained midwives and paediatric SHOs. Health Technology Assessment vol 18 no 14

8. UK National Screening Programme Committee (2008) Guidelines for newborn blood spot sampling.

9. Wolke D, Dave S, Hayes J et al (2002) Routine examination of the newborn and maternal satisfaction: A randomised controlled trial. Archives of Diseases in childhood, fetal and neonatal edition.

10. Newborn and Infant Physical Examination Screening Programme Handbook 2016/17 (National screening committee)



Monitoring

Process for monitoring: Retrospective review of NIPE smart

How often will monitoring take place:

Annually

Population: 1% of all health records of newborns

Person responsible for monitoring:

Senior midwives for Intrapartum Services Matron for Neonatal Services

Auditable standards:

All babies undergoing the neonatal examination on the postnatal ward in hospital, where there are suspected deviations from the norm, are referred to the appropriate specialist for further assessment, investigation or treatment.

Results reported to: Maternity Governance Group Neonatal Governance Group

Action plan to be signed off by:

Neonatal Governance Group

Person responsible for completion of action plan:

Senior midwives for Intrapartum Services Matron for Neonatal Services

Action plan to be monitored by:

Neonatal Governance Group

How will learning take place: in one or more of the following fora

Newsletter Team meetings Unit meetings

Guideline development:

Aug 2008 Original Guideline E Boyle, Consultant Neonatologist, and J Foxon, Neonatal Modern Matron

Sept 2011 Review by E Boyle, Consultant Neonatologist, and J Foxon, Neonatal Modern Matron

May 2016 Review by J Behrsin Consultant Neonatologist - amendments made (including the addition of NIPE smart system information)

Jun 2016 Neonatal guidelines meeting (ratified)

Oct 2019 Neonatal Guideline meeting ( Minor amendments )

Nov 2019 Neonatal Governance Meeting

Examination of the Newborn on the Postnatal Ward Author: J. Behrsin, E Boyle, J Foxon Contact: Neonatal Guidelines lead Approved by: Neonatal Guidelines Meeting Guideline Register No: C98/2008

NB: Paper copies of guidelines may not represent the most recent version. The definitive version is held on BadgerNet and SharePoint.

of 9 Written: August 2008

Last Review June 2016 Next Review: June 2019

Appendix 1: Example Eye referral letter printable from the NIPE smart system





Appendix 2: Example Heart referral letter printable from the NIPE smart system





Appendix 3: Example Hips referral letter printable from the NIPE smart system





Appendix 4: Personal Child Health Record Body Map

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