This edition first published 2018
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Since the early 1990s, midwives have been able to access further training in order to become Newborn and Infant Physical Examination (NIPE) practitioners and incorporate the examination of the newborn into their daily practice. Not all midwives have yet undertaken the course, but in recent years a growing number of higher education institutions have started to incorporate the course into their pre-registration midwifery programmes. This action not only aligns with one of the key points highlighted within the document Midwifery 2020 (Department of Health, 2010), but also enables midwifery students to conduct solo NIPEs at the point of registration as a qualified midwife.
However, this book is not for the sole use of midwives or student midwives, as there have been a growing number of neonatal intensive care nurses who also access the course. Therefore, the content of this book seeks to give both students and those already qualified as NIPE practitioners an ‘at-a-glance’ understanding of the key elements that relate to this valuable skill. For some, this will be the first step in their journey to become NIPE practitioners, for others this book will provide a revision aid or an opportunity to update professional knowledge and understanding.
We strongly believe that the examination is an important part of normal, holistic, woman-centred care. The content of this book covers the main conditions and issues relating to physical examination of the newborn. We have also provided some crosswords and multiple choice questions to enable the reader to undertake a short self-test.
We hope the reader finds this book a useful aid to learning and professional practice.
Department of Health. (2010). Midwifery 2020: Delivering Expectations. London: The Stationery Office. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216029/dh_119470.pdf (accessed 23 October 2017).
Chapters
Section 1 Professionalism
Section 2 Communication skills
Chapters
Section 3 Adaptation
Section 4 Emergency management
Section 5 Jaundice
Section 6 Disorders
Section 7 Birth complications
Chapters
Section 8 Routine care
Section 9 Screening
Chapters
Section 10 Preparation
Section 11 History awareness
Chapters
Section 12 Broad assessment
Section 13 Head and neck
Section 14 Upper body
Section 15 Pelvis and lower body
Chapters
Section 16 Revision
Section 17 Self-assessment
Public Health England (PHE) is an operationally autonomous executive agency of the Department of Health. The prime role of PHE is to reduce health inequality and protect and improve the health and well-being of the nation’s individuals. The National Health Service (NHS) national population screening programmes are developed and implemented on the advice given by the National Screening Committee (NSC) in the United Kingdon (UK). The NSC provides evidence-based recommendations to government ministers in all four UK countries.
PHE supports its activities by drawing evidence from world class research and by promoting advocacy and collaborative partnerships, all of which assist the delivery of specialist public health services. It is also in close liaison with the Screening Quality Assurance Service who, by investigating whether national standards are met, can verify if screening programmes are safe and effective. In relation to the NHS Newborn and Infant Physical Examination (NIPE) Screening Programme, both the NIPE Handbook 2016/2017 and the NIPE Screening Programme Standards 2016/2017 were published to inform and support best clinical practice. These texts will subsequently be updated and amended to reflect the available evidence and therefore it is important that practitioners refer to the latest edition. It is also important that the Service specification 2016/2017 (No. 21) (Public Health England, 2016a) is also referred to in the same manner.
Population screening is a way of identifying healthy people who may be at increased risk of a disease or condition. When an individual is highlighted as being at a higher risk of developing the disease or condition in question, then they can receive further information, investigations or treatment. The provision of screening aims to reduce the risks or complications associated with a disease or condition.
Screening is not a diagnostic process. Without further investigation, a screening process cannot usually provide confirmation that an individual has a specific disease or condition. However, newborn blood spot screening does merge these two processes, as screening is offered for all babies so there will be some babies in whom a specific condition is confirmed and so subsequent treatment and management of the condition can be offered.
In relation to NIPE, there are four main screening elements that are assessed: eyes, heart, hips and testes. This is not because examining the baby for other conditions is not important (including a full top-to-toe), but because these four elements can be systematically measured and therefore, standards relating to good practice and timescales can be set accordingly.
The NSC requires that all eligible babies should be offered the NIPE within 72 hours of birth (Figure 1.1). A second NIPE is offered again at 6–8 weeks of age by the family’s general practitioner (GP). However, it is the responsibility of the birth unit to identify all eligible babies (including those who move into the area), which will continue until the 72-hour NIPE is completed or responsibility for this is transferred to another acute care provider. The responsibility for following up on referrals after the 6-week examination rests with the GP, who should check the care pathway for progression in relation to referrals or results of action taken.
The main aim of the NIPE programme is to detect any congenital abnormalities of the eyes, heart, hips and testes, where these are detectable within the first 72 hours after birth. The examination at 6–8 weeks provides a second opportunity to detect these abnormalities at the end of the neonatal period. The ending of the neonatal period is when most of the physiological changes that occur after birth have been completed. Most babies will have made the transition from fetal to neonatal life and conditions arising after this time will not necessarily be congenital in origin. However, if an abnormality is undetected or masked by another condition or illness, then it may still be first recognised because of parental concern or because the baby exhibits signs and symptoms of the condition. It is a salient point to note that parental concerns should be taken seriously – they know their child and changes in behaviour or ability will often be clear to them.
All parents should be given information relating to the NIPE, in terms of what it is, why it is offered and when it is performed and by whom. During the antenatal period and before the NIPE is conducted, a leaflet and discussion should take place, so that questions can be answered and to give the parents time to think about any family history that the practitioner may not be aware of.
Verbal consent should be obtained from the parents prior to conducting the examination. During the examination, the ability of the baby should be mentioned and any concerns that the parents have should be addressed. The findings of the examination should be discussed with them prior to completing a comprehensive record (see Chapter 3). They should also be informed who to contact if they have concerns about their baby’s health and that the second main examination for their baby will be when he/she is 6–8 weeks of age when any queries remaining from the 72-hour NIPE should be addressed. For example, the baby may have had unilateral undescended testes at the 72-hour examination and the parents will need to know if this has now resolved. The documentation should reflect the fact that previous findings have been noted, the findings of the 6–8 week examination plus any further actions that may be required.
NIPE recommends that the 72-hour examination should be undertaken for all babies prior to discharge home. This maximises the likelihood that the examination will be completed in a timely manner. It is also advantageous to the parents, as some will not want to return to the hospital after being discharged home. There will also be some who will choose not to return and not to take part in screening when they are no longer in an environment where it is easily accessed.
If an examination must be performed early in neonatal life when auscultating for heart murmurs is more likely, it is preferential to do so rather than the examination not be conducted and therefore at risk of a heart murmur being missed. As with a baby of any point in the first 72-hours, there is always the possibility of hearing a heart murmur and therefore the information given in relation to signs of ill health is no less or more important for one baby during this time, than any other.
If a baby has been admitted to a neonatal intensive care unit (NICU) or special care baby unit (SCBU), then all practitioners in contact with the baby should ensure that the key elements of the NIPE are assessed when practicable to do so. If a baby has been discharged home from NICU or SCBU, then practitioners in the community such as the midwife, health visitor or GP need to investigate if the NIPE has been comprehensively completed, as sometimes this can be missed.
As with any programme, the completion of its component parts is paramount and NIPE SMART will assist in highlighting errors or omissions. However, the process of completion will still only be as good as the attention to detail of the professionals involved.
NHS Trusts utilise a systematic approach to maintain and improve the quality of patient care whilst reducing risk. To achieve these aims, robust processes are put in place to facilitate the audit of areas such as clinical effectiveness, education and training, risk management and transparency in relation to investigation and policy. In effect, quality assurance provides a process that enables continuous audit of progress, standard of practice and/or activity and the identification of issues that require improvement. Quality assurance assists in assessing if the standards set are not only being met, but are also appropriate and feasible.
Each of the NHS national screening programmes has its own clearly defined set of standards. However, in order that the process of quality assurance is robust and comprehensive, several factors should be considered. First, a screening programme is developed and overseen by a committee who have experience and knowledge in that specific field of expertise or who have first-hand knowledge (professionals and service users). The facilitation of a quality review of the service includes diverse participants such as those involved in commissioning or providing screening services as well as those who use the service.
The committee assists in the development of national quality standards. This involves setting up processes that can monitor how the service meets (or not) the standards set. In the event of adverse incidents, the committee also provides access to expert screening advice to allow for effective incident management.
Quality assurance is all-encompassing and covers the screening process from start to finish. This process commences with the premise that the screening programme is justifiable; it decides who will be offered screening; assesses the quality throughout the screening activity and continues through to referral when this is required. In relation to the Newborn and Infant Physiological Examination (NIPE), the main aim is to provide a screening service that is accessible to all women and their babies and that a minimum standard is maintained in order to minimise harm whilst maximising the benefit derived from screening.
A consistent driver within quality assurance is the need to maintain a high-quality service. Collaboration with local screening programmes through involvement of local teams is important. Effective team working necessitates that professionals, commissioners and the screening committee work towards risk reduction and ensure that audit trails are working effectively. A process that works well should be able to respond appropriately to incidents and allow productive inter-professional communication to take place if the issue is to be resolved and to promote the sharing of good practices.
Quality assurance is inevitably a formal process and each local screening programme is responsible for its own effectiveness. This is monitored by statistical review, regional meetings or even informal visits. The NIPE standards give a parameter to work towards, which is feasible and allows for the very slight local differences that occur from region to region.
Key performance indicators (KPIs) were introduced into NHS screening programmes to assist in the measurement of performance within specific areas. They act as a tool to govern and assess performance, by helping to identify potential or actual problems. Highlighting issues is important if the root cause is to be uncovered and a solution found to remedy the situation. The NIPE screening programme currently has two KPIs (NP1 and NP2), which can be viewed in the NIPE Screening Programme Handbook (Public Health England, 2016a) and the NIPE Screening Programme Standards 2016/2017 (Public Health England, 2016b).
It is good practice for NHS Trusts to maintain a list of NIPE practitioners to detail when a practitioner qualified, if they conduct NIPEs regularly (this is a Trust, not a Public Health England parameter) and when the practitioner last attended an updating course. No arena of professional practice stands still for long and both the Nursing and Midwifery Council and the General Medical Council require practitioners to update and maintain a high level of professional knowledge and skill as well as recognise when care has not been in keeping with the standards set. The use of the NIPE SMART system enables data to be collected that identify areas of shortfall, near misses or those areas where clinical performance is exemplary. Those Trust sites where NIPE SMART is not yet operational have had to put in place their own methods of auditing the standards.
Figures 2.1 and 2.2 show a visual representation of the standards and guidelines set; in this instance, developmental dysplasia of the hip (DDH) is used as an example. These standards and guidelines reflect the serious consequences for the baby if further investigation or treatment is delayed. In this example, late detection of DDH not only has implications for the baby in terms of discomfort, reduced mobility and the prospect of increasing the level of trauma, but it also highlights the future impact on the individual (see Chapter 44). Woodacre et al. (2014) pointed out that the cost of treating DDH early not only clearly reduces the level of impact to the individual, but greatly reduces the cost incurred of treating DDH at a later stage. Treating the condition later often becomes more complex and the need for surgical intervention is higher. The psychological impact on the child and parents can also be higher with later diagnosis.
Therefore, it can be demonstrated that if the available literature points to the need for early treatment to prevent or reduce the impact of a dislocated hip, then it is sensible to assess the available services, in terms of training and referral pathways, as well as produce publications relating to expected professional activity and the standards and guidelines that should reflect best practice.
All NIPE practitioners should keep a record of babies that they have referred in order to check on outcomes. This assists with learning, as it encourages self-reflection in terms of one’s knowledge base and awareness of the condition and appropriate referral processes, as well as the discussion that took place with the parents and the accuracy of information given. The standards and guidelines may not appear directly related to such activity, but it is inevitable that professional practice and how it is carried out has a strong part to play in meeting the thresholds set for each NIPE standard.
In relation to the Trust site, the guidelines clearly pinpoint the levels that are considered ‘acceptable’ and ‘achievable’. If these thresholds are not being met, then the Trust is obliged to investigate where the problem lies. For example, it is possible that there are too few experienced NIPE practitioners available to help support those who are newer to the role, or it could be that data are missing. Some issues can be resolved and therefore it is important that they are highlighted. It is important to take into account factors that cannot be easily resolved, at least making the issue known.