In the UK, all parents are offered the newborn infant physical examination (NIPE) for their baby as part of the Child Health Promotion Programme (Department of Health (DH), 2004; National Institute for Health and Care Excellence (NICE), 2015). This head-to-toe physical examination is carried out twice, once before 72 hours of age, and again at around 6–8 weeks. The check screens for problems or anomalies and specific screening elements include examination of the baby's eyes, heart, hips and testes. The aim is to confirm normality (Hall, 1999; Hall and Elliman, 2006) or identify abnormalities or conditions that contribute to long-term illness (DH, 2007). It is thought to have the potential to influence health choices and optimise maternal and newborn infant health by providing health education, advice and reassurance to parents (Mitchell, 2002; DH, 2007; Tappero and Honeyfield, 2010), which is consistent with the public health role of the midwife (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010).
The NIPE is not without criticism, owing to limited evidence supporting its use, its timing and the question of who should perform it. A central tenet of Western medicine and midwifery care is that scientifically derived knowledge is essential for the provision of evidence-based care and treatment (Hicks, 1996). Evidence-based care means that individual clinical expertise is integrated with the use of the best evidence—preferably that obtained by systematic research, with the randomised controlled trial (RCT) being the preferred research method for a clinical trial (Parahoo, 2006). Evidence is considered to have rigour if it is of a high standard, with potential pitfalls identified and reduced (Hicks, 1996; Rees, 2011). In the absence of such evidence, conclusions can be drawn from smaller-scale work, or consensus on good practice (Belsey, 2009).
However, although it is recommended that the NIPE is conducted at less than 72 hours (NHS England, 2013), there is actually no minimum time limit to identify all possible neonatal anomalies, nor an optimal time limit to perform the NIPE, particularly as the neonate could still be experiencing physiological changes, predominantly of the cardiovascular system (McDonald, 2013). Moreover, clinical examination for defects in hips, vision, hearing and other congenital abnormalities is not based on robust evidence (Glazener et al, 1999). If what is ‘normal’ is uncertain, then it must be questioned how midwives can confirm this expectation of normal. Nevertheless, the UK National Screening Committee (UK NSC) concludes that, based on best practice and current evidence, the NIPE is an essential examination, and the overall risks associated with babies going unscreened are greater than if babies are examined early. The UK NSC recommends that, ideally, the NIPE should be performed within the first 24 hours, and before 72 hours post-birth, and that all babies should be offered the NIPE before discharge from hospital even if this is at or before 6 hours, unless there is a comprehensive service in the community (NHS England, 2013).
Evidence base for the NIPE
The seminal EMREN study (Townsend et al, 2004) addressed some of the issues around the NIPE in the UK, discussing the timing of the examination and how this relates to who performs it. It examined whether midwives (as an extension of their role) or doctors were best placed to perform the NIPE. The study included a prospective RCT with mother and baby dyads randomised to either senior house officers (SHOs) or midwives for the routine NIPE. It also included videos of midwives and SHOs performing the examination, which were then rated by an independent consultant and senior midwife. It used extensive interviews, surveys, consultations and assessments to gauge opinions from both professionals and parents. This triangulation of research (Cowan, 2009), including the gold-standard RCT, means that credibility is attached to the study, because combining different methods is increasingly important in order to answer complex questions in increasingly complex systems. It appears to be a good quality study, albeit dated now—which is of concern, as it is imperative for research to be as current as possible (Cowan, 2009).
One of the study's conclusions was that there were benefits, or at least no significant barriers, to suitably qualified, trained midwives performing the NIPE. This would mean that expertise is maintained by midwives, rather than transferred with SHO rotations, which is important because inappropriate timing of the NIPE, or examiner inexperience, may result in errors (Lomax and Evans, 2005). There exists the potential for oversight of risk factors. Developmental dysplasia of the hip is one example, but errors are especially found with cardiac murmurs. Retrospective studies reporting congenital heart disease detection rates found less than 50% in a cohort of 1590 newborns in the UK between 1987–94 (Wren et al, 1999) and 26.2% in a Swedish cohort of 259 newborns between 1993–2001 (Mellander and Sunnegårdh, 2006). Midwives undertaking the examination will continue to improve detection rates as their skills develop with experience following completion of training (Lomax and Evans, 2005). Additionally, a more holistic, family-centred approach was taken by midwives, who were twice as likely as SHOs (65% versus 32%) to take opportunities for discussion of relevant health issues such as feeding and jaundice (Townsend et al, 2004), which is in keeping with the midwife's public health role (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010).
It may be questioned, however, whether the EMREN study's main purpose was actually to consider the cost-effectiveness of midwives completing the NIPE, and then to prove that midwives could do it. This would suit organisations needing to consider the structure of maternity care and a reduction in junior doctors' hours, and moves to better utilise the skills and expertise of all health professionals. Nevertheless, the research has been well received and the NIPE is universally accepted as good practice.
Preparation, history-taking and environment
All names and other identifiable details used in this case report have been changed to protect confidentiality, as per the Nursing and Midwifery Council Code (NMC, 2015). Consent was given by the woman for anonymised details of her case and her baby to be published.
The NIPE was conducted in a home setting with support from a NIPE-qualified midwife mentor. The woman, Sarah, had been given information about the examination antenatally, and prior to the NIPE, in line with national guidance (UK NSC, 2008). This ensures adherence to the principle of informed consent (NMC, 2015) now recognised in legislation (Napley, 2015). The midwife, MB, explained to Sarah that the examination has limitations as some conditions do not become evident until the baby is older; therefore, this exam would be followed by another comprehensive neonatal examination at 6–8 weeks.
Being in Sarah's home had benefits; for example, the history-taking was unhurried, which is important as this is an essential part of the examination. A detailed history is needed regarding the woman's health, pregnancy and birth (NHS Quality Improvement Scotland, 2008; UK NSC 2008; Tappero and Honeyfield, 2010; NICE, 2015). During history-taking, parents can raise any concerns, and practitioners may use the opportunity to provide general and public health information, and to support and reassure parents. Parents should always be asked to verify any information gained from notes, as details of relevant history are often missing from records (Mitchell, 2002). It is important that any problems or risk factors relating to antenatal or previous obstetric history are identified prior to the NIPE, because previous neonatal death or certain conditions may be significant and contribute to a current plan of care (Lomax, 2011).
Midwives should also ensure that the environment is conducive to effective and safe examination (UK NSC, 2008). A benefit of the home environment is that it removed some of the barriers that can exist regarding lack of time and adverse environments. This can be a challenge in hospital environments, even if there is a designated space or room for the NIPE (Lomax, 2011). The environment in this case was warm, with a consistent temperature (Michaelides, 2011) and it ensured privacy and confidentiality. It was well-lit and a firm surface was available (changing mat on carpet) to examine the infant's hips. MB washed her hands and equipment prior to starting the NIPE (UK NSC, 2008).
Case history
Sarah's history revealed that her pregnancy was ‘low risk’, with no personal or family medical history of note. Sarah's blood type was O positive. Her anomaly scan was normal. There were no antenatal concerns until 36 weeks, when a high vaginal swab—undertaken by Sarah's GP when she presented with a thick vaginal discharge—revealed that Sarah was colonised with Streptococcus agalactiae, otherwise known as Group B strep (Box 1).
Sarah and her midwife discussed the evidence to assist Sarah in reaching an informed decision about whether to continue with her homebirth plans, or attend hospital to receive antibiotics. Sarah decided to birth at home and, along with a supervisor of midwives, MB and Sarah formulated a care plan.
Sarah spontaneously laboured at 40 weeks' gestation. Her observations throughout labour were normal, with membranes spontaneously rupturing an hour before birth. The liquor was clear. Sarah, now para 2, gave birth in a birth pool. Her daughter, Kitty, had good Apgar scores, required no resuscitation and weighed 3500 g. At the time of the NIPE she was 26 hours old. Sarah had experienced no concerns about Kitty's health or wellbeing since birth.
MB's employer organisation's guidance advised that within 1 hour of birth, the midwife should perform a set of neonatal observations (heart rate, respiration rate, temperature), and repeat these prior to leaving the home and again the next day. The midwife should document the observations that may give evidence of infection, if present, and ensure that parents are aware of the need to routinely assess their baby for signs of infection and report any deviations from normal to the midwife immediately. This advice from the midwife's employer is consistent with evidence that standardised physical examination plus lab tests offers no advantage over physical examination alone (Cantoni et al, 2013). It is currently recommended that infants without clinical signs, but with risk factors, should be observed closely for such signs over the first 24 hours after birth (although screening nationally ranges from observations of the neonate's condition for a certain period of time, to blood tests for C-reactive protein levels (which indicate inflammation) (Royal College of Obstetricians and Gynaecologists (RCOG), 2012). There is no high-quality evidence for or against the use of prophylactic antibiotics for a neonate (Ungerer et al, 2004).
The employer organisation's guidance stated that, owing to the increased risk of neonatal infection, any baby found to have any symptoms should be referred for immediate paediatric opinion at the local hospital Trust, where immediate care can be expedited if necessary. This would be facilitated by phoning the local hospital with children's services and speaking to the on-call paediatrician. A baby thought to be affected by GBS disease would be commenced on a treatment pathway as soon as possible, which includes intravenous antibiotics (RCOG, 2012).
The NIPE examination
Throughout the NIPE, MB explained the findings and provided health information to offer reassurance to Sarah. Using both lay and professional terms ensured that Sarah understood and remained engaged (Schott and Priest, 2002). Townsend et al (2004) found that women appreciated this type of communication.
MB had already observed Kitty crying normally and she was subsequently breastfed. A high-pitched or irritable cry may signify neurological disturbances, metabolic abnormalities or drug withdrawal, and lack of feeding may be a sign of illness. However, Kitty had breastfed well, allowing MB to observe the sucking, rooting and swallowing reflexes, and to note that the baby seemed to display normal cardiac and respiratory function. When Kitty finished feeding, MB carefully undressed her, intending to perform the NIPE in a systematic manner, while remaining flexible enough to alter the approach as required by the baby's needs.
As Kitty was 26 hours old at this point, she was past the most likely period in which early-onset GBS would manifest. Nothing abnormal had been found by her midwife in checks at birth, 3 hours old or 23 hours old.
Sarah's normal birth history indicated minimal other risk factors for infection. Intrapartum care was as per NICE guidelines and the Trust's guidance, which states that, to reduce any risk of vertical transmission, no routine vaginal examinations should be undertaken.
As Sarah had chosen not to have any vaginal examinations and had given birth at home in a birth pool, the risk of neonatal infection from vertical transmission may have been reduced. An international multicentre RCT examining significant predictors of neonatal infection in infants born to women with premature rupture of the membranes found that infection increased with the amount of vaginal examinations experienced (Seaward et al, 1998). Additionally a prospective study of 213 women who birthed in water, with a control group of 261 women who spent the first stage of labour in water but birthed in a traditional birth environment, found that infants born in water were less frequently colonised with GBS (Zanetti-Dällenbach et al, 2006).
An infant with sepsis may present with cardiac, circulatory or respiratory failure, leading to arterial restriction, reduced blood flow to the skin, and a white appearance (Kenner and Wright Lott, 2007; Lomax, 2011). Additionally, the infant may present with pathological jaundice (NICE, 2016). Kitty displayed none of these signs and appeared centrally pink and well perfused with no cyanosis. MB applied gentle pressure to Kitty's skin over the sternum, observing that her capillary refill time was < 2 seconds, meaning her blood flow was normal (NICE, 2016).
To confirm correct anatomical placement of the heart, MB palpated the heart's apex beat, which was detectable in the fifth intercostal space, with no heaves or thrills palpable. MB auscultated Kitty's heart sounds, listening to the apex, left sternal edge, pulmonary, aortic and tricuspid areas. A strong and regular rhythm was evident, the first and second heart sounds were clearly audible and no murmurs were apparent. The baby's heart rate was normal at 144 beats per minute. Her femoral pulses, at the midpoint between the anterior iliac spine and the pubic ramus on the inguinal crease, were gently palpated and confirmed as present. This was a good indication that there was no narrowing of the aorta, and that the ductus arteriosus had closed normally in the transition to extrauterine life (Lomax, 2011). Routine pulse oximetry has helped to detect GBS in a number of neonates with low oxygen saturations but no other cardiac abnormalities (Gnanalingham et al, 2001; Knowles et al, 2005). MB did not possess pulse oximetry equipment and this was not mandatory as part of the screening process, but may be implemented in the future as it is an inexpensive and simple method of detecting cardiac abnormalities (Ewer et al, 2012; Thangaratinam et al, 2012). As Kitty's cardiac function appeared normal, the NIPE process map indicates she should be routinely re-examined at 6–8 weeks of age (Public Health England, 2015).
With the stethoscope bell, MB auscultated Kitty's respiration rate, which was normal at 36 breaths per minute. MB auscultated Kitty's chest bilaterally and at the upper, mid and lower areas. Inspiratory and expiratory breaths were clear and similar in pitch and duration. The baby's chest movements were symmetrical and she displayed no nasal flaring, expiratory grunting or chest recession, which also may indicate infection (Lumsden, 2010).
Neurological assessment throughout the examination indicated normal central nervous system function. Kitty responded to MB's voice and touch; she had fed well, displaying normal reflexes, and had also passed urine and meconium. Her appearance showed characteristics of a normal neonate, having a symmetrical appearance and being flexed with good tone and equal mobility of the limbs (Lomax, 2011). She spontaneously displayed the moro reflex, and MB stimulated the grasp reflex, Babinski and stepping reflexes. There was no sign of jitteriness, seizures, tonic or clonic movements (Lumsden, 2010).
Owing to Kitty's risk of infection, MB also assessed her axillary temperature, which—at 36.7°C—was within the thermal neutral range (Lomax, 2011). Additionally, the baby's fontanelles, if bulging, could indicate raised intracranial pressure and infection; but these felt normal, giving reassurance that sepsis was not present.
MB was able to confirm normality during Kitty's head-to-toe systematic NIPE examination. MB documented the findings in both Sarah's electronic notes and Kitty's personal health record. Good record-keeping is a fundamental part of midwifery practice and is critical to safe and effective care (NMC, 2015). There was no need to refer on to any further health services using the pathways previously identified, including admission to acute services via paediatrician for suspected infection. If any anomaly had been identified, MB would have discussed this with Sarah and advised onward referral for advice or treatment, as per professional rules and standards (NMC, 2015). MB was mindful that if Sarah had declined treatment for Kitty, this decision must be respected, but it would also be necessary to consider the best interests of the child; in some circumstances, court orders have been sought for treatment (Birthrights, 2013). MB ensured that Sarah was aware that infection or any anomalies, such as cardiac conditions (Wren et al, 1999), could still present in the future.
Reflection
This examination was performed in a systematic manner, under guidance from a qualified mentor. As the midwife, I was confident in my history-taking and identification of risk factors, and consolidated my knowledge of further signs of infection beyond the basic observations.
A comprehensive care plan for Sarah and Kitty, and clear documentation from their caseloading midwife, greatly assisted the examination; however, I feel that in a different model of care the formulation of this care plan may be challenging—for example, in environments where holistic care is the aim but is not always implemented. Caseloading midwifery is acknowledged as the gold standard of care, and it is accepted that midwives become more thorough owing to their perceived duties to the woman (Hatem et al, 2008). This may not be apparent in traditional care settings when another professional may see the woman, and any issues or questions then become someone else's responsibility (Finlay and Sandall, 2009). Additionally, a lack of continuity, responsibility and advocacy may mean that, at times, women are denied information and their choices are not guaranteed, especially when they clash with widely held professional views and when professional power is exercised (Finlay and Sandall, 2009).
Conclusion
Women and families will have a wide variety of different perceptions regarding the choices they make and the risks they may choose to take. They should, therefore, be assisted to become more aware of the choices available to them regarding the management of GBS and the risk of having a baby affected by early-onset GBS disease.
The NIPE is an imperfect screening tool, but it provides an opportunity for public health education and to screen all neonates for abnormality. However, there are no specific guidelines to assist examiners in determining the best time to perform this or which health professionals are best placed to perform this examination. Research on these issues is still needed, but until then reliance on what is considered to be best practice will ensure the continuance of the NIPE, and there is a strong argument for suitably trained midwives to perform it.