A clinical assessment tool for midwives undertaking the Newborn Infant Physical Examination

The purpose of the Newborn and Infant Physical Examination (NIPE) is to identify and refer all children born with congenital abnormalities of the eyes, heart, hips, and testes, where these are detectable, within 72 hours of birth. A second physical examination is performed later to identify abnormalities that may become detectable by 6–8 weeks of age, thereby reducing morbidity and mortality. NIPE screening includes a holistic ‘top-to-toe’ physical examination of a newborn (UK National Screening Committee, 2008). Once the NIPE is completed, parents should be informed of the outcome of normality or any abnormality, including any explanation of the referral process if required. They should also be informed that the infant examination will be undertaken at 6–8 weeks of age, as some conditions can develop or become apparent later (Public Health England, 2016). The Public Health England standard (2016) clearly focuses on patient safety and the referral process. The UK National Screening Committee standards (2008), on the other hand, stipulate the practitioners' learning needs and clinical competency requirements. One could argue that both standards complement each other, but from an educator's standpoint the 2008 NIPE standards are more explicit in terms of training needs and competency requirements for NIPE trained professionals.

Ensuring that the clinical environment is primed for safe examinations is paramount to the assessment, the outcome of the NIPE, and neonatal stabilisation. A neutral thermal environment should be maintained with an axillary temperature of 36.5–37 .5ºC, depending on the gestational age of the baby (Resuscitation Council, 2015), and all equipment required should be gathered prior to conducting the NIPE. The issue of privacy is challenging, especially if there are no dedicated areas for performing examinations. Individual health Trusts must consider this to prevent breaches of confidentiality and a lack of sensitivity for individual families; however, some local Trusts have dedicated areas allocated for NIPEs. In order to facilitate an informed decision-making process, a practitioner must familiarise themselves with NIPE and NICE guidelines, as well as local guidelines and pathways.

Despite the success of NIPEs in the UK, a high number of infants or neonates develop problems whilst being cared for in low-risk postnatal settings. Early identification and management of these neonates may reduce neonatal morbidity and mortality rates (British Association of Perinatal Medicine, 2015). The Office for National Statistics (2015) recorded the annual number of live births in England and Wales in 2014 as 695 233, compared to 698 512 in 2013, a fall of 0.5%, with 9% of these infants requiring admission to a neonatal unit for their ongoing management.

Most midwives perform NIPEs on normal babies without any antenatal, labour, or postnatal complications, according to their local Trusts' protocol. A knowledge of what could go wrong and why is important. When faced with unusual cases, the use of the Newborn and Infant Assessment Tool (NIAT) may be helpful (Table 1). Originally designed for use by midwives performing NIPEs, it may also be used as a systematic assessment tool to facilitate group reflection or self-reflection when faced with an unexpected neonatal clinical scenario.

In order to facilitate the use of NIAT, a midwife is presented with a sample clinical scenario on how this tool could be applied (Box 1). The midwife is expected to assess the baby and differentiate between a compromised or non-compromised baby; a baby who is compromised will need urgent emergency intervention to establish their airway, breathing and circulation (Resuscitation Council UK, 2015). In an emergency, the midwifery professional is expected to call for help and initiate ABC management until the baby is stable or until help arrives.

Sample clinical scenario

Information is essential for accurate decision making, timely referrals and patient safety (Public Health England, 2016). Where possible, the physical examination of a newborn should be preceded by a thorough review of the mother's pregnancy, labour, and delivery. The mother's past obstetric history, intrapartum history, maternal medical history, and family and social histories should also be taken (Tappero and Honeyfield, 2003). The midwife or health professional should also be able to make reasonable links between this history and how the baby presents, though this process normally comes with practice and a period of consolidation. It is important to provide the rationale for any recommendations, investigations, or further management suggested by the midwife during the handover of a compromised baby to the receiving parties; SBAR—situation, background, assessment, and recommendation—is the recommended reporting tool. SBAR is a standardised communication tool which reduces communication variability, and enhances concise, objective, relevant reports (Benson et al, 2006). Once the handover is complete, all actions and interventions must be documented. It is important that parents are updated and health professionals must communicate in a sensitive manner, using plain English. Where necessary, the help of a language advocate must be organised.