The value of clinical mnemonics
Tom McEwan, midwifery lecturer and honorary advanced neonatal nurse practitioner, offers some aids for supporting staff and students to perform the newborn and infant physical examination
In the final article of my series exploring neonatal topics relevant to the midwife, I'd like to explore the newborn and infant physical examination (NIPE), and share some aids I have created to support health professionals and student midwives to undertake this screening examination.
National guidance suggests this examination should be conducted within the first 72 hours of life and then repeated at 6-8 weeks of age. However, the national standards for this examination only apply to the newborn screening as there is currently no mechanism to measure, monitor or report the quality of this examination when performed at 6-8 weeks (Public Health England [PHE], 2019). The specific screening elements of this examination relate to the heart, hips, eyes and testes but these are incorporated within a thorough and systematic assessment of the entire newborn or infant, including consideration of relevant history and any concerns raised by the parents or carer (PHE, 2016).
For the purposes of this article, I will focus upon the newborn examination. In terms of who conducts this examination, there will be some variance across the UK. It will either be conducted by member of medical staff, a suitably trained midwife or an advanced neonatal nurse practitioner. Within Scotland, the ‘Best start: five-year plan for maternity and neonatal care’ (Scottish Government, 2017) recommends that in most cases, appropriately trained midwives, with audit and governance structures in place, should conduct this examination. Currently in Scotland, the preparation for qualified midwives to undertake this examination has been successfully facilitated by the ‘Scottish multiprofessional maternity development programme’ with their ‘Routine examination of the newborn’ course (https://www.scottishmaternity.org/scottish-routine-examination-of-the-newborn.htm), which was developed as a result of the national best practice statement for this examination, originally published in 2004 and revised a few years later (Quality Improvement Scotland, 2008).
In other parts of the UK, dedicated NIPE courses are available for health professionals to be trained to perform this examination, as well as this being incorporated within many pre-registration midwifery programmes. My institution, the University of the West of Scotland, is the first in Scotland to include it within their pre-registration midwifery programme. Although this has been challenging to introduce, most notably in ensuring students are supervised and supported to develop this skill during their practice learning experiences, it has allowed me to develop some additional teaching resources that may be of use to others; a selection of clinical mnemonics for components of the examination.
Mnemonics are a well-established tool for assisting health professionals to recall prior learning when providing care (Putnam, 2015; Woodfin et al, 2018). Obviously, these mnemonics in themselves are no substitute for the specialist knowledge required but they may serve as a useful adjunct when conducting the examination. Furthermore, it should be remembered that this examination is part of range of screening activities for the newborn, the purpose of which is to detect deviations from normal and make an appropriate referral, not to diagnose a condition and determine an appropriate treatment. While with further experience and knowledge the midwife examining may be able to identify the type of cardiac lesion a murmur may represent, there is no expectation that they perform as a mini-cardiologist, mini-ophthalmologist or mini-orthopaedic surgeon! The mnemonics below are designed to be an aide-memoire and not a specific list of items that indicate an abnormal finding or need for referral. Practitioners must refer to the national guidance, current evidence and their local policies in relation to what constitutes a positive finding or criterion for referral.
The examination of the heart is often a component that can cause considerable anxiety, especially for midwives. Worries of ‘what if I miss a murmur’ are common, with stories of babies being readmitted in poor condition days after discharge, adding to their concerns. With an overall incidence of congenital heart disease ranging between 6–12 per 1 000 live births (PHE, 2019), it is important that the examination is conducted methodically. To aid this, I suggest BEATS (see Table 1).
|B||Background: family history, pregnancy information, parental concerns|
|E||External: inspection of general tone/activity, features/size/shape of the chest|
|A||Airway: inspect colour, respiratory rate, symmetry of chest wall movement, signs of respiratory distress|
|T||Touch: position of apex, perfusion (capillary refill), presence of thrills/heaves, palpation of liver (exclude hepatomegaly), femoral/brachial pulses|
|S||Sounds: auscultate over the five key regions, identifying rate and rhythm, and listening for presence of a murmur|
This aligns with the general principles of any clinical examination which midwives will be familiar with for abdominal examination-inspection, palpation and auscultation. In addition to this, I also recall being taught a mnemonic to remember the order by which to listen to the five key regions of the heart: ‘Must Try Picking Apples Myself’ (see Table 2). Unfortunately, I'm not sure to whom the credit for this should rest but I find it very useful in my teaching and clinical practice.
|Try||Tricuspid: lower left sternal border in the 4th intercostal space|
|Picking||Pulmonary: second intercostal spaces adjacent to the sternum (left side)|
|Apples||Aortic: second intercostal spaces adjacent to the sternum (right side)|
|Myself||Mid-scapulae: coarctation area|
The examination of the hips is another important aspect of this screening opportunity as failure to identify any early abnormality or developmental dysplasia of the hip may lead to significant long-term complications, often requiring surgical intervention. However, with prompt referral for ultrasound screening or more senior review on the basis of established risk factors or abnormal clinical findings, these outcomes can be improved for the one or two babies per 1000 with a hip problem requiring treatment (PHE, 2019). I developed the following HIPS mnemonic (see Table 3) as an aid for this examination for new practitioners. Although the observation of skin creases for symmetry is no longer considered a part of the NIPE screening (PHE, 2019), I believe it remains a useful component of the overall examination.
|H||History: assessment of risk eg breech, 1st degree relative with dysplasia of the hip/early hip problem etc|
|I||Inspection: observe the resting tone of lower limbs, any features of moulding, symmetry of leg length/knee height/buttock creases|
|P||Palpation: initial simple abduction test to exclude fixed hip dislocation|
|S||Stability: undertake Barlow's and Ortolani's manoeuvres separately on each hip|
My final offering relates to a non-NIPE screening element but an important aspect nonetheless. The careful examination of the palate is essential to exclude the delayed detection of a cleft. The prevalence of this delayed detection beyond 24 hours remains stubbornly around 30% and resulted in the publication of robust, multi-professional guidance by the Royal College of Paediatrics and Child Health ([RCPCH], 2014). This recommended that a careful visual inspection of the entire palate is the preferred method for this examination, recommending the use of a tongue depressor for this purpose. The historically entrenched ‘finger sweep’ as the method of palate examination is no longer acceptable, as the practitioner can easily miss a cleft of the soft palate by failing to reach far enough back in the mouth. However, there remains value in a digital examination of the palate to exclude a sub-mucosal cleft following the visual inspection. To this end, I created PALATE (see Table 4) with a former colleague to emphasise the best practice recommendations from the RCPCH (McEwan and Hannah, 2015) which was shared with cleft nurse specialist colleagues in NHS Greater Glasgow and Clyde for their modified use in the training of staff.
|L||Look: visualise entire palate and uvula|
|T||Touch: digital examination (illicit gag to ensure soft palate felt)|
In closing, the NIPE is an important screening examination with key elements that require a focussed and structured approach to ensure consistency and quality. I hope that these mnemonics are useful and provide some support to student midwives and other health professionals as they conduct this examination in the future.