routine exam newborn

7/29/2019 Routine Exam Newborn

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Version: 1

Job Title of Responsible Manager: AGM Women and Childrens Services

Job Title of Executive Sponsor: Director of Operations and Nursing

Ward / Department: Maternity unit and community midwives

Replacing Document: N/A

Approving Committee / Group: Clinical Practices group

Date Approved: May 2009

Date for Review: May 2012

Relevant Standard(s): CNST 5.7

SfBH C5C6,D2,C7,C9,C11,C14, C16, D10.

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Maternity

Routine Examination ofthe Newborn-Guideline

SWH 00063


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Routine Examination of the Newborn Guideline

Version 1May 2009 Page 2 of 18 Printed on 08/02/10

Table of Contents

1. INTRODUCTION.........................................................................................................4

2. PURPOSE...................................................................................................................4

3. AUDIENCE..................................................................................................................4

4. RESPONSIBILITIES / DUTIES...................................................................................4

5. ROUTINE EXAMINATION OF THE NEWBORN ........................................................5

5.1 Prior to the Examination .......................................................... ........................................................... ............. 55.2 During the Examination.................................................. ........................................................... ....................... 55.3 Detailed Physical Examination (Antenatal and Newborn Screening Programme 2008) .................65.4 Following the Examination ...................................................... ........................................................... ............. 75.5 Documentation ....................................................... ........................................................... ................................. 76. TRAINING...................................................................................................................7

7. MONITORING COMPLIANCE AND EFFECTIVENESS.............................................8

8. AUTHORS...................................................................................................................8

9. CONTRIBUTORS .......................................................................................................8

10. EQUALITY IMPACT ASSESSMENT TOOL...............................................................8

11.

REFERENCES............................................................................................................9

12. APPENDICES.............................................................................................................9

13. APPENDIX A DEVELOPMENTAL DYSPLASIA OF THE HIPS (DDH) ..................10

14. APPENDIX B ANTENATAL RENAL PELVIS DILATATION ON ULTRA SOUNDSCAN (USS) ............................................................................................................11

15. APPENDIX C TALIPIES EQUINO VARUS (CLUB FOOT).....................................12

16. APPENDIX D UNDESCENDED TESTES................................................................13


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17. APPENDIX E EYE EXAMINATION .........................................................................14

18. APPENDIX F CONGENITAL HEART DEFECTS ....................................................15

19. APPENDIX G MONITORING COMPLIANCE AND EFFECTIVENESS OF SWH 00063 ROUTINE EXAMINATION OF THE NEWBORN ...........................................16

20. APPENDIX H DISSEMINATING SWH 00063 ROUTINE EXAMINATION OF THENEWBORN FORM....................................................................................................17

21. APPENDIX I APPROVING CHECKLIST FOR SWH 00063 ROUTINEEXAMINATION OF THE NEWBORN GUIDELINE...................................................18


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1. IntroductionThe assessment of the newborn is a continuing process during which health professionals

and parents work together to assess the baby. Evidence points to parents being moresatisfied with care characterised by continuity and opportunities to ask questions (Wolke etal2002)

An initial examination of the newborn is carried out within an hour of birth, followed by amore detailed examination. It is established as good practice to carry out the detailedexamination of a baby within 24 hours of birth (Hall & Elliman 2006) and certainly within 72hours as part of the core health programme for under 5s. (DH, 2007)During these routineexaminations problems can be identified. If appropriate, full discussion with the parentscan take place prior to referral for investigation, specialist assessment and treatment (NHSbest practice statement 2008).

The aim of the newborn physical examination is to detect less obvious adverse conditionsor abnormalities. It includes screening for congenital cardiac defects, developmentaldysplasia of the hips, some ocular disorders, and undescended testes as well as a generalphysical examination. A daily assessment of the baby feeding, colour, behaviour andgeneral well-being will be carried out as routine post natal care.

2. PurposeTo aid health care practitioners in the understanding of the relevance of the examination,to identify normality, recognise abnormality and refer appropriately.

3. AudienceThis document is aimed at:

Paediatricians, working within the maternity unit

Midwives working both in the hospital and the community, who have received trainingand achieved a level 3 qualification in carrying out the routine examination of thenewborn

Midwives working towards this qualification, working within a framework of professional

supervision to maintain their competencies

For midwives to maintain this competency a minimum of 30 examinations a year must becarried out (SHW - 000159, 2009).

4. Responsibilities / DutiesAll staff involved in the care of the newborn must:

Ensure that parents are given written information about the examination in the antenatal period

Highlight the need for an interpreter prior to the examination Ensure the examination has been carried out or inform a paediatrician or

appropriately trained midwife of the need for an examination within the 24 hr timeframe


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Ensure standardisation of the examination

Inform the parents of findings, and make any appropriate referrals

5. Routine Examination of the Newborn

The detailed examination of the newborn may only be carried out by a paediatrician oran appropriately trained midwife. The midwife can carry out this examination on anywell baby, regardless of family, antenatal or labour history, ensuring that relevantreferrals are made, to the appropriate health professionals if concerns are highlighted

Any baby that is admitted to the Special Care baby Unit, or if any concerns have beenraised at the initial examination must be reviewed, and the detailed examination carriedout by a paediatrician within 72 hours of birth

5.1 Prior to the Examination

All health care professionals who carry out detailed examinations of the newborn must:

Ensure that the parents have received information regarding the examination, bothverbally and written via the NHS screening programme leaflet (Screening test for youand your baby NHS 2008)

Make sure that family history, ante natal (including screening) and labour problems areidentified. Also the findings of the initial examination, including type of delivery,gestation, apgar score and weight are recorded. Any identified risk factors may requirea management plan and follow-up

Ensure parental health issues such as depression, domestic violence, substanceabuse, learning difficulties or known mental health problems, are identified and takeninto account

Obtain consent from parent to carry out the examination at a time that is mutuallyconvenient for the health professional, parents and baby (COR - 0068, 2007)

Inform parents what the routine examination of their baby can assess, the benefitssuch as early referral and the limitations such as the inability to diagnose someconditions due to ongoing circulatory changes. Also the effects of maternal hormoneson joints and muscles

Use interpreters where necessary to facilitate communication between parents andhealth care professional

Assess the condition of the baby since birth to include:

o Feeding

o Passage of meconium

o Urine including stream in male infants

o Discuss these points with the parents and other health professionals involved

5.2 During the Examination

Wash hands as per Trust policy (SWH - 00013)

The examination must be carried out in appropriate well-lit, warm and private area. It


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will be carried out by one person

The examination must take place between 6 and 72 hours of life, best practice shouldbe within 24 hours of birth, or at least following one feed

The healthcare professional will discuss:

o Baby care

o Feeding

o Vitamin K

o Reducing the risk of Sudden Infant Death Syndrome (SIDS)

o Any other matter relevant to the individual baby or of concern to the parents

Problems not apparent in the newborn, but may be significant later such as jaundice,

must be explained to the parents, and the significance highlighted, including theimportance of informing a health professional

If the baby becomes unduly upset during the examination, or the examination couldnot be completed; the examination should be repeated when the baby is calmer, anddocumented in the babys Health Care Record and Red Book

If findings were ambiguous the examination must be repeated by a senior clinician

5.3 Detailed Physical Examination (Antenatal and Newborn Screening Programme2008)

The person carrying out the examination, must document the following, both in the RedBook and the babys Health Care Record.

Observe the babys appearance including colour, breathing, behaviour, activity andposture

Examination of the fontanelle(s), face, nose, mouth including palate, ears, neck andgeneral symmetry of head, vault, sutures and facial features

Measurement of the head circumference

Checking of the eyes opacities and red-reflex

Examination of clavicles, limbs, hands, feet and digits

Assessment of cardiovascular system, heart rate, rhythm and sounds, murmurs andfemoral pulse volume

Assessment of respiratory system, effort, rate, and lung sounds

Assessment of abdomen shape, palpate to identify any organomegaly. Checkcondition of umbilical cord

Genitalia and anus - check anus for patency. Check genitalia for form andundescended testicles in males

Observe if passed urine and meconium (usually passed within 24hrs)

Spine inspection and palpatation of bony structures and integrity of skin

Observe colour and texture of the skin, including birthmarks and rashes


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Central Nervous System - including Moro and Grasp reflex

Hips - check symmetry of the limbs and skin folds. Perform Barlow and Ortolanis

manoeuvres Cry - observe sound of babys cry

5.4 Following the Examination

If any concerns have been highlighted further advice must be sought from a seniorclinician. The name and grade of the professional must be recorded in the Health CareRecord, along with the time and date of referral. A review of the findings must bediscussed with the parents, in an empathetic manner; this must include the reasons forrequesting a further opinion.

If a senior clinician review has been requested they will be responsible for discussing theirfindings and any suggested referrals.

Appendixes A-F show the care pathways for the most common deviations from the normwhich may become apparent during the detailed examination of the newborn. Appropriatereferrals must be made, using these appendices as a guide, relevant to the findings of theexamination or family/antenatal history.

5.5 Documentation

All staff involved in the care of the newborn must :

Complete all relevant documentation including recording delivery details in the HealthCare Record

Ensure that any entries are signed, timed and dated, the surname is printed and theNMC or GMC numbers are recorded Bleep numbers must not be used

Record the findings of the detailed examination of the newborn in the babys Red Book,and in the hand held post natal records prior to transfer to community care

Ensure that any follow up plans and/or referrals are made and documented

All incidences and follow up of non-consent for examination or refused referrals must becommunicated to the Health Visitor and GP and Paediatric Consultant and documented inthe appropriate health care record.

6. TrainingStaff training needs will be assessed by a peer review system using the benchmarkstandards set out by the National Screening Committee 2008 (SWH-00159, SWH-00160,2009). In the absence of external structured study days training will be provided by aPaediatrician on a one to one basis.


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7. Monitoring Compliance

A record will be made on the post natal ward, of time of birth and the time the

examination takes place and by whom, in the newborn examination book A record will be kept on the post natal ward, of any referrals made, to whom and the

time scale for the appointment, also in the newborn examination book

Problems will be reported via the clinical incident reporting system

Compliance to the document will be monitored six monthly through audit and reportedto the Labour Ward Forum. This will include whether the newborn examination bookhas been completed

8. Authors

Jan Phipps Midwife Lecturer Practitioner, Supervisor of Midwives

9. Contributors

Jane Allen Post Natal Core Team Midwife.

Dr Acharya Consultant Paediatrician

Sheila Clayton Paediatric Physiotherapist

Paediatric Audit meeting

Labour Ward Forum

Maternity editorial group

10. Equality Impact Assessment ToolPlease see Procedural Document (including Policies) Policy on how to complete this table.

Has an Equality Impact assessment been carried out?

YES

Preliminary Stage 1 Equality Impact Assessment (must be completed if required*)

What date was Stage 1 completed and published?

January 6th 2009

Has a Full Assessment Stage 2 Equality Impact Assessment Tool been undertaken*?

NO

If yes, what was the date of assessment and publication of Stage 2 and action plan?


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11. References

Department of Health (DH) 2007. The child Health Programme Delivery Standard.

Pregnancy and the first five years of life.Hall DMB, & Elliman D. (ed). Health for all children. 4th edition. Oxford. Oxford UniversityPress; 2003.

National Institute for Health and Clinical Excellence. (2007). Intrapartum Care: care ofhealthy women and babies during childbirth. Clinical guideline 55. London .NICE.

NHS 2007, Screening tests for you and your baby. Antenatal and Newborn ScreeningProgramme. UK National Screening Committee. Oxford.

NHS Quality Improvement Scotland. (2008) Best practice StatementRoutine examinationof the Newborn.

South Warwickshire General Hospitals NHS Trust: (2003) Guideline for the Managementof the Newborn Immediately after Birth. MID-0022.

South Warwickshire General Hospitals NHS Trust: (2008) Hand Hygiene Procedure.SWH-00013.

South Warwickshire General Hospitals NHS Trust: (2007) Policy for Consent toExamination and Treatment. COR-0068

South Warwickshire General Hospitals NHS Trust: (2009) Maternity UnitTraining NeedsAnalysisSWH-00160

South Warwickshire General Hospitals NHS Trust (2009) Maternity UnitTraining Needs

PolicySWH-00159

Wolke D., Dave S.,Hayes J., Tomlin M. Routine examination of the newborn and maternalsatisfaction :a randomized controlled trial. Archives of Disease in childhood Fetal NeonatalEd. 2002;86(3):F155-60.

12. AppendicesAppendix A - Developmental Dysplasia of the hipsAppendix B - Dilated Renal PelvisAppendix C - Talipies

Appendix D - Undescended testesAppendix E- Eye ExaminationAppendix F- Congenital Heart DefectsAppendix H - Dissemination FormAppendix I - Approving Documentation checklist.


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13. Appendix A Developmental Dysplasia of the Hips (DDH)(http://www.pediatric-orthopedics.com)This condition was once termed congenital dysplasia of the hip because it was thoughtthat all these problems began prior to birth. Recently, the term developmental dysplasia ofthe hip was coined because it was realised that some hips were normal at birth andgradually became dysplastic or malformed later.

Newborn physical examination.Barlows/Ortolani

Positive Clickconfirmedbyexperiencedpractitioner

Normal,But identified risk

factorsBreech.

ECVFamily historyor skeletal limb

anomalies notedon examination

Inconclusive

Inconclusive

To be confirmed byexperiencedpractitioner

Positive

Hip scan at 6 weeksPaediatric follow up at 8

weeks

Refer the sameday to

Orthopaedicsurgeon at

University HospitalCoventry

Via the paediatricsecretar

GP reviewat 6 weeks


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14. Appendix B Antenatal Renal Pelvis Dilatation on Ultra SoundScan (USS)

Dilated Renal Pelvis more than 5mmon 32 week Ultra Sound Scan

Unilateral more than10mm

Bilateral 5-10mmUnilateral 5-10mm

Ensure passedurine within 24hours of birth (notestream if possiblein boys)

ProphylacticTrimethoprim

Inform Consultant Renal USS 48-72

hours of birth

Ensure Passedurine prior totransfer into thecommunity

ProphylacticTrimethoprim to beprescribed by thepaediatricianfollowing birth

Renal USS in 6-8

weeks Paediatric follow

up 8 weeks


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15. Appendix C Talipies Equino Varus (Club Foot)

Talipies can be seen in newborn babies as a result of their postion in utero. It is easilycorrectable and may resolve without treatment within a few days of life (positionalTalipies). But some babies may have a structural talipies, where it is not possible to easilycorrect the foot position and the foot is very tight.

Talipies on examination

Not correctableDifficult to correct

Easily correctable

Refer toPaediatric/Orthopaedi

c Surgeon atUniversity Hospital

CoventryPaediatrician.

At the earliest possibleopportunity

Explain to parents. Show how to

gently stretch footback into correctposition

Health visitor to referto paediatric

physiotherapist at 2weeks if not resolved


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16. Appendix D Undescended Testes

Bilateral Undescended testes Unilateral Undescendedtestes in an otherwise normal

baby

Paediatric review by seniorpractitioner

GP review at 6 weeks


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17. Appendix E Eye Examination

Absence of RedReflex in the eye

Opacities

Checked byexperienced

ractitioner

No concernsConfirmed absentreflex

GP follow up at 6weeks

Opthalmologyreferral as soon as

ossible


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18. Appendix F Congenital Heart Defects

Abnormal Cardiac sounds on Auscultation

Examined byexperienced practitioner

No abnormalitydetected

Confirmed by discussionwith On Call Consultant

See GP at 6 weeks

Referral toCardiologist and

PaediatricConsultant Clinic as

necessary


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19. Appendix G Monitoring Compliance SWH 00063 RoutineExamination of the Newborn

Title of Document SWH 00063 Routine Examination of theNewborn Guideline

Date 31/3/09

Standards for Better Health (SfBH)relating to this document (if any)

C5C6,D2,C7,C9,C11,C14, C16, D10.

NHSLA Standard related to thisdocument (if any)

1.5.7 2.5.7

YESDoes the document fulfil thecriterion of NHSLA and SfBH

(please circle as appropriate) If not, why not:

Audit KPI ReviewOther, please

specify;_______________

1. How will the documentbe monitored?(please circle as appropriate)

Methodology:Auditing the newborn examination record book on thepost natal ward, for .

A record of the time scale in which the examinationwas carried out, any referrals made, to whom and

the time scale for the appointment. Staff training needs will be assessed, in the absence

of structured study days by a peer review system.Using the benchmark standards set out by theNational screening committee 2008.

2. What is the process forreviewing results ofmonitoring?

Compliance to the document will be fed back to LabourWard forum and the Maternity risk Management Groupon a quarterly basis.

Group / Committee Individual3. Who is responsible for

conducting themonitoring?(please circle as appropriate)

Name / Title (also include position of individuals):Audit Midwife.

Monthly 6 Monthly YearlyOther, please

specify;_______________

4. How often will thedocument bemonitored?(please circle as appropriate) Comments:

Through a spot check system of the record book on thepost natal ward, and 5 sets of notes.


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20. Appendix H Disseminating SWH 00063 Routine Examination ofthe Newborn Form

Plan for Dissemination of Document

Title of Document Routine Examination of the Newborn

Date finalised 02/04/2009

Review Committee Clinical practices group

Dissemination lead(Author)(Print name and contact details)

Jan Phipps ex 8251

[email protected]

Previous Documentalready being used?

No

(please delete as appropriate)

If, yes in what formatand where?

No

What action will be usedto retrieve out-of-datecopies of the document:

Dissemination Process

Receiver (area /ward / unit)

Process Responsible TimelineFormat

(paper or electronic)

All staff working

within the maternityunit

Send email with

Document attached

Governance Midwife By 21/07/09 Electronic

Labour ward Hard Copy Governance Midwife By 21/07/09 Paper

Post Natal Ward Hard Copy Governance Midwife By 21/07/09 Paper

Special Care BabyUnit

Hard Copy Governance Midwife By 21/07/09 Paper

________________________________________________________________________________________________

Record of Dissemination of DocumentComplete this section of the form once the document has been approved by the

appropriate committee.Date of approval of the document

Date of review of the document

Receiver (area/ ward / unit)

Contact (area/ ward / unit)

Number ofcopies sent

Datecomplete

Comments

e.g. Castle Ward Joe Bloggs #1111 10 17/07/08 Emailed Joe, on leave - forwardedto John Citizen, in Joes absence


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21. Appendix I Approving Checklist for SWH 00063 RoutineExamination of the Newborn Guideline

Title of Document Routine Examination of the Newborn guideline

Author Jan Phipps

Ratifying Committee / Group Clinical Practices

Date of Submission 3rd April 2009

Item Complete(YES / NO)

1 Has the Procedural Documents Policy and its associated documentsbeen consulted during the development of this document?

Yes

2 Has the appropriate template been used? Yes

Has the South Warwickshire General Hospital NHS Trust Style Guidebeen used to develop this document?

Yes

3 Have the appropriate committees / groups / individuals been consultedas to the appropriateness of the content of this document?

Yes

3a Please list these committees / groups / individuals:Paediatric Audit Group

Labour ward forumMaternity Editorial group

4 Has the Plan for Dissemination of a Documentsform been completedand attached?

Yes

5 Has a Equality Impact Assessmentbeen undertaken? Yes

6 Has the procedural document been attached? Yes

7 Has the Monitoring Compliance with and Effectiveness of DocumentFormbeen attached?

Yes

Author (sign off)I declare that the information above is a true and accurate record

Name Position SignatureJan Phipps Midwife Lecturer Practitioner J.R.Phipps

Appropriate Manager for Subject (sign off)

I declare that I have overseen that development of this document and believe all appropriatematters have been addressed

Name Position Signature