NIPE 1 Flashcards
1
Q
what are the first steps of NIPE?
A
Identify significant factors
2
Q
what are the significant factors such should be identified in the first steps of NIPE?
A
- Any personal or family history which may be significant
- Any pregnancy information which may be significant
- Any significant risk factors from antenatal, intrapartum, postnatal
periods - If mum has any concerns with baby
- What feeding method and if baby has been feeding well
If baby has passed urine or bowel motions
3
Q
what should be noted from the family history when performing a NIPE?
A
- Cardiac
- Hip problems
- Congenital cataracts
- Renal conditions
- Haemoglobinopathies (blood disorders)
- Cleft lip and/or palate
- Hearing problems
4
Q
what should be noted about the mothers health during a NIPE?
A
- Endocrine (diabetes, hypo/hyperthyroidism)
- Cardiac
- Hypertension
- Haematological (anaemia, DIC (abnormal blood clotting), Sickle Cell, Thalassemia)
- Mental health
- Connective tissue disorders
- Medications ( prescribed medication e.g. labetalol - baby requires blood sugars) which then requires to check is blood sugars have been stable, if observations are stable and if baby has been feeding well.
- Social circumstances - substance misuse, child protection concerns)
- Smoking
- Infection
5
Q
what should be noted about mothers pregnancy when performing a NIPE?
A
- Past obstetric history and children’s health
- Relate antenatal history to stage or fetal development and predict outcome in baby
- Results of antenatal screening (e.g. syndrome screening)
Gestational accuracy
6
Q
what should be noted about the mothers obstetric history when performing a NIPE?
A
- Reduced fetal movements - tells us there might have been a lack of oxygen that’s why it was reduced
- Abruption
- Fetal distress
- PROM
- Meconium stained liquor - baby may be grunting, breathing recessions, nasal flaring, which could be due to meconium aspiration and there can be an infection developing.
- Maternal opiates - analgesia in labour and impact on neonatal sedation
- Neonatal resuscitation
7
Q
what additional sources of fetal compromise should be noted when performing a NIPE?
A
- Smoking
- Alcohol
- Drugs - prescribed medication - recreational drug misuse
Infection - such as sepsis, GBS, PROM
8
Q
what is the risks of smoking in pregnancy?
A
- Carbon monoxide reduces oxygen carrying capacity of mother and fetus
- Low birthweight (fetal hypoxia)
- Increased risk of glue ear - where the empty middle part of the ear canal fills up with fluid. This can cause temporary hearing loss.
- Increased risk of asthma
- Increased risk of orofacial cleft
Increased risk of NEC - Necrotizing enterocolitis (NEC) is the death of tissue in the intestine. It occurs most often in premature or sick babies
9
Q
what is FAS?
A
FAS - Fetal Alcohol Syndrome
- Variable fetal effects depending on quantities of alcohol. - Microcephaly - small head - Small eyes - Hearing disorders - Large eyes - Shallow philtrum - Intrauterine growth restriction - Thin upper lip - Congenital abnormalities - cleft lip, palpate, heart defects
10
Q
what congenital infections should be noted when performing a NIPE?
A
- Group b Streptococcus
- Cytomegalovirus (CMV)
- Rubella
- Toxoplasmosis
- Varicella Zoster (chicken pox)
- Listeria - food positioning
- Hepatitis B, C
- HIV
Herpes - genital warts
11
Q
what information around the mode of birth should be noted when performing a NIPE?
A
- Posture and compression effects
- Birth injuries
- Effect of hypoxia
- Effects of maternal medication
12
Q
what does the history review of a NIPE involve?
A
Be prepared
Understand the history of the pregnancy, birth, adaptation to birth and family history - review maternity notes
Appreciate and understand the pregnancy and birth journey
13
Q
how do you display sensitive communication when performing a NIPE?
A
Demonstrate - respectful, sensitive, communication with clear and understandable explanations towards NIPE.
Ask - of any concerns and listen to parental concerns
Seek and obtain - verbal consent for screening from parents, which should be documented in notes.
Every - woman will be going through a different journey - don’t assume
Choose - words carefully, be aware of non-verbal cues such as body language and eye contact.
Compassion - and non-judgemental approach makes a different. Non-verbal cues are extremely important.
14
Q
how does the interdisplinary team work in relation to NIPE?
A
- NIPE trained midwife
- ANNP - Advance neonatal Practioners - any concerns refer to ANNP
- Neonatal team - liaise very close with ANNP
Specialist team for referral - if concern is redeem as significant it is then referred to specialist team
15
Q
how do you feedback a negative NIPE result?
A
- parents should be informed of the results in a clear and understandable manner.
- parents should be informed that the NIPE will be undertaken in the primary care setting at 6-8 weeks as some conditions can develop later.
16
Q
how do you feedback a positive NIPE result?
A
- the parent should be informed of the result and any referral process that may be required, including expected appointment timescales.
- if baby is in a treatment pathway for one of the screening elements. inform the parents the NIPE 6-8 weeks will still be required to be completed for the remaining screening elements.
17
Q
How do you record keep NIPE?
A
- Verbal consent from parents should be documented
- Record screening result
- Record referrals following screen positive result
- Each health board could record different on badger and have differing referral procedures
Have awareness of local arrangements to ensure all babies with screen positive results are referred and seen in line with national standards.
18
Q
What is the purpose of the NIPE?
A
One of the main reasons for conducting the routine examination of the newborn is to screen for health problems and this may result in a referral
- Full systematic check of the newborn to screen for potential abnormalities. - Offered to parents and completed within 6-72 hours after birth - Similar to examination of the baby at birth but includes additional screening elements: Hips, Heart, Eyes, Genatalia, Palate, Pulses RECOGNISE AND REFER
19
Q
what are the standards of the NIPE examination?
A
- Determines the relationship between antenatal (before birth) and intrapartum (occurring during labour and delivery) events that may impact on the newborn’s health status, and subsequent events that may impact on the 6- to 8-week infant
- Ensures that the environment is conducive to effective and safe examination
- Facilitates effective informed decision-making
- Utilises a holistic, systematic approach, to comprehensively examine the neonate/infant effectively and sensitively
- Records and communicates findings to parents and relevant professionals
- Maintains and further develops professional competence in examination of the newborn/6to 8-week infant
20
Q
what should the examiner bare in mind in relation to labour and birth?
A
- Was the pregnancy prolonged?
- Was the labour induced or accelerated and, if so, why?
- How long were the fetal membranes ruptured prior to birth?
- Were there any anomalies of the fetal heart rate during labour?
- Was the liquor meconium stained?
- What were the methods of pain relief used during the labour and birth?
- What was the presenting part of the fetus during labour?
- What was the mode of birth?
- Did the baby require any resuscitation at birth?
Were any injuries or abnormalities noted at the birth?
21
Q
what are the limitations to nipe?
A
- Only a snapshot in time
- Things change!
Repeated by the GP at 6-8 weeks.
- Things change!
22
Q
what is the structure to the NIPE examination?
A
- Preparation
- Observation and Discussion
- Examination
- Explanation
- Documentation
23
Q
what does the preparation to the NIPE involve?
A
- Review family, maternal and full perinatal history in notes.
- Gather and check equipment (ophthalmoscope, pen torch, tongue depressor, tape, stethoscope, pulse oximetry, thermometer.)
- Introduce yourself to parents, name and role. Offer congratulations.
- Briefly explain the procedure including limitations.
- Confirm with mum any significant history or clarify anything identified from notes.
- Confirm baby name and date of birth
- Seek and gain consent to complete NIPE
24
Q
what is the equipment required for NIPE?
A
ophthalmoscope, pen torch, tongue depressor, tape, stethoscope, pulse oximetry, thermometer
25
what does the observation and discussion involve in NIPE?
- Ascertain any carers anxieties and observe interaction with the baby
- Observe baby’s general condition while settled and undisturbed: colour, breathing, behaviour, activity, tone and cry
- Confirm urine and stool output (if it is 6 hours in and no meconium this is okay)
- Establish feeding method and any concerns
- Perform hand hygiene and don PPE if appropriate
26
what is the stool output expected and colour?
1- 2 day - 1 meconium
6 hours - 0-1 meconium
3-4 2 and changing to greenish/yellow
27
what is the urine output expected?
1 day 1-2 wet
3-4 day 2-4 heavier
28
what does it mean by baby's colour?
should be pink in colour
check for cynosis, jaundice, any marks etc
29
what does it mean by check baby's breathing?
check there is no recession - chest sinks in
check that theres not extra effort breathing
30
what does it mean by checking babys behaviour?
baby alert, sleeping etc
31
what does it mean by checking babys tone?
baby should not feel floppy when held
32
what does it mean by checking babys activity?
ss
33
what does it mean by checking baby's cry?
does the cry sound normal, not high pitched etc
34
what do you asses wen you are checking the skin?
Colour - no jaundice etc.
integrity - no cuts, breakages etc
birthmarks - blue spot etc
trauma - birth trauma e.g. forceps
35
what is the skins role?
Important role in temperature regulation, barrier to infection, balances electrolytes and stores fat.
36
what is the advice of using products on baby's skin?
- Baby products along with exposure to urine or faeces could disrupt this protective barrier ‘Parents should be advised that cleansing agents should not be added to a baby’s bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild non-perfumed soap.’ (NICE, 2015)
baby skin is really healthy and new things like vernix can be rubbed in and moisturiser. baby's tend to not need any moisturiser.
37
Baby's all of ethnicities should have what colour of mucus membranes?
Baby's all of ethnicities should have pink mucus membranes
38
why should vernix be left to be absorbed?
Vernix caseosa should be left to absorb as an antibacterial and antifungal skin barrier.
39
what else should you view/ look out for when assessing the skin?
- View oral mucus membranes, gums and tongue, especially when a baby has a darker skin tone.
Lanugo – downy hair present is much more present in premature babies, however term babies also have variable amount of lanugo.
40
what skin findings should you note?
- Port wine stains
- Mongolian blue spot
- Cradle cap
- Desquamation
- Erythema toxicum
- Milia
- Acne
- Naevus simplex (“stork bite”)
- Moles
41
what is this a picture of?
Cyanosis is the blue discolouration of the skin and mucous membranes caused by deoxygenated haemoglobin.
42
what is the difference between central and peripheral cyanosis?
Central Cyanosis - this condition produces a bluish discolouration, specially noticed on the mucous membranes of the lips, tongue, fingers and toes. Peripheral Cyanosis - this condition affects the fingers, toes and skin surrounding the lips, is not noticed around mucous membranes.
43
what is peripheral cyanosis associated with?
In neonates peripheral cyanosis is common in the first 24 hours of life and is not considered pathological if the baby is generally well.
44
what is central cyanosis associated with?
Central cyanosis is associated with pathology and can indicate respiratory, cardiovascular or haematological abnormalities. Therefore, it is essential that midwives are able to detect signs of cyanosis in neonates.
45
what should the examination of the skin also involve?
It should always involve examination of the lips and mucous membrane in the mouth and tongue because these are areas where there is thin epidermis and a good blood supply in all skin colours and therefore sites that are reliable indicators of central cyanosis.
46
what is this?
Erythema Toxicum Neonatorum (commonly called Newborn Rash) can look alarming but it is an insignificant, transient rash present in approximately half of babies in the first few weeks of life
47
what is this?
Neonatal pustular melanosis resolves spontaneously but similarly it can be very concerning for parents, particularly as the small pustules develop and then turn into flat, brown lesions
48
what is dermal melanocytiosis?
we strongly recommend using the correct name: dermal melanocytosis or simply blue spot. Inability to accurately recognise blue spot has led to this being confused with bruising.
They are always non-tender with no associated swelling or redness. Bruises may be tender with associated inflammation. They can be blue/grey but they are less uniform in colour and the colour also changes as the bruise ages; sometimes purple and yellow tones can be seen.
49
what is jaundice?
Jaundice is the yellow colouration of skin and sclera caused by raised bilirubin
jaundice in the first 24 hour is always pathological
physiological jaundice that spontaneously resolves without treatment. Less commonly, jaundice is pathological and can be life-threatening. require referral is an important part of neonatal care
A full visual assessment should be made in good light and particular attention should be paid to inspecting the whites of the eyes (sclera), gums, palms of the hands and small areas of skin temporarily ‘blanched’ by light digital pressure.
50
is this normal?
piterkea - infection
51
is this normal?
mottling not normal
52
is this normal?
no
53
what is this?
stork bites - normal
54
what is this?
strawberry mark normal
55
what does the head and face examination involve?
head and scalp
eyes
nose
mouth
ears
neck and clavicles
56
what things should you be looking our for when examining the head?
shape, size, sutures, head circumference (32cm-36cm), fontanelles (should not be raised - bleeding trauma, or sunken - dehydration), injury (birth injury - FSE Marker make sure they aren't infected), caput - can press down on it, crosses suture lines. Cephalhematoma - hard feeling, does not cross suture lines, worry about jaundice, can get worse, refer to paeds.
57
what things should you be looking our for when examining the eyes?
Eyes - shape, symmetry, position, spacing/folds discharge, sclera and red reflexes. epicanthic folds can indicate Down’s, purulent discharge could indicate infection, fissures, keyhole - if part of the pupils leak into eyes - concerning. Using the ophthalmoscope away from eye then look at eye away from eye then look at eye. White red reflexes may be sign of cataracts.
58
what things should you be looking our for when examining the nose?
patency (size of the nostrils), philtrum - having a shallow philtrum may be sign of syndromes.
59
what things should you be looking our for when examining the mouth?
visualising and digital inspection of the hard and soft palate to uvula, tongue and gums, presence of suck reflex, jaw
60
what things should you be looking our for when examining the ears?
size, shape, position, level, abnormalities, hearing test
61
what are you checking for when palpating the vault of the skull?
Palpating the vault of the skull to check the degree of moulding by the amount of overriding bones at the sutures and fontanelles. The shape of a baby’s head as a result of moulding gives an indication of the presentation in utero. Parents can be reassured that moulding usually resolves within a few days.
62
what is caput?
oedematous swelling, caput may be noted over the presenting part as a result of pressure of the cervical os and disappears within 24hrs.
- Soft tissue oedema with poorly defined outline
- Present at birth, does not increase in size
- Swelling crosses suture lines
- Disappears within hours to several days
63
what is this?
caput
64
why must the neck be examination in relation to the head?
- The neck must be examined to exclude presence of swellings and that rotation and flexion of head are possible.
65
during NIPE what should you measure?
- Head circumference of the occipitofrontal diameter should be 32-36cm for a term baby
66
what is important about the fontanelles?
- The anterior fontanelle remains present and palpable for up to 18 months, while the posterior fontanelle should be closed by 6 weeks following birth
- Examination of the fontanelles should be when the baby is at rest and should neither be raised or sunken.
rasied - trauma
sunken - dehydration
67
what should the head in examined for in relation to birth?
The head should be examined for any trauma in the form of abrasions or bruising resulting from intrapartum experiences, e.g artificial rupture of membranes or assisted birth. It should be clearly explained to parents with clear documentation.
68
what can bruises increase the chance of?
- Also note that any bruising increases the chance of the newborn developing jaundice due to excessive blood collection in the bruised area and the need for breakdown and excretion.
69
what is this?
cephalohematoma
70
what is a cephalohematoma?
- Soft, fluctuant, localized swelling with well-defined outline
- Appears after birth, increase in size for 2-3 days
- Can get worse
- Worry about jaundice due to this
- Swelling does not cross suture lines
Disappears from several weeks to even months after birth
71
where are the frontal bones?
72
where are the parietal bones?
73
where is the occipital bone?
74
where s the metopic suture?
75
where is coronal suture?
76
what is the sagittal suture?
77
what is the lamboid suture?
78
where is the anterior and posterior fontanelle?
79
what are we looking for in relation to symmetry in the eyes?
symmetry is assessed in relation to other features such as eyelids and brows and slant of the palpebral fissures.
80
what can the space between the eyes and epicanthic folds indicate?
Extremely wide or narrow spaced eyes are abnormal and may indicate a syndrome as may epicanthic folds, however this can be a normal feature of some ethic groups, so caution is required.
81
what should be noted about sclera?
jaundice
- sclera should be white, however take note of any conjunctival hemorrhages around the iris or sclera. These can be normal due to the pressure at birth, especially if the birth was rapid. Parents should be reassured that they will not affect the newborn but may take weeks to resolve fully.
82
what should be noted about sclera?
jaundice
- sclera should be white, however take note of any conjunctival hemorrhages around the iris or sclera. These can be normal due to the pressure at birth, especially if the birth was rapid. Parents should be reassured that they will not affect the newborn but may take weeks to resolve fully.
83
what should be noted about the iris?
The iris should be blue and circular in shape with a round pupil in the centre.
84
how do you check the red reflexes?
Normal reflection of white light from the back of the eye which is seen as a red glow in the pupil on ophthalmoscopy
- Dim lights if necessary and make sure baby is settles
- Hold to eyepiece of the ophthalmoscope up to their eye, at arms length from the baby’s face
- Direct the circle of white light towards the baby’s eye, gently parting the eyelids, if necessary
- View the red reflex through the ophthalmoscope eyepiece – the colour, brightness and presence of any shadows on the red reflex is noted in each eye
White babies have an orange -red reflex. The reflex can be less bright and appear magnolia in colour in black, Asian or minority ethic babies. White reflex may be a sign of cataracts.
85
what are the risk factors for eye issues?
• genetic syndromes e.g Noonans, trisomy 21
• pre-natal infection e.g CMV, rubella
• sensorineural hearing loss/neurodevelopmental issues
• 1st degree family history of an eye condition with onset in infancy or early childhood.
• prematurity
86
where the palpebral fissure length?
87
where is the inner canthal distance?
88
where is the epicanthic fold?
89
what should you inspect about a baby's ear?
- Inspected noting their size, shape, position, abnormalities and surrounding anomalies, for example skin tags or dimples.
90
what are ear abnormalities associated with?
- Ear abnormalities can be associated with chromosomal anomalies and syndromes and should be reported to neonatal staff.
91
what should the position of the ears be?
- The position of the ears should be similar on both side with the upper part in line with the outer canthus of the eyes. (top of the eye should meet the outer corner of eye)
92
what is a pit at the ear?
Pit at the ear (may look like a small hole) can be normal or can mean there is a hearing issue.
93
what else should you make sure about with the ears?
- Hearing test - make sure this is being organised.
if their are risk factors refer to audiology
94
which one of the is normal and which one is abnormal?
95
what external aspects of the mouth should you check?
Jaw size
Lips, philtrum (bit of skin between nose and mouth)
96
what should you ask the parents before examining the mouth?
consent
97
how do you inspect the palate?
- Use torch between to inspect
- Uvula will tell you if palate is intact but not always, if a uvula is present then it is likely the palate is complete as you can see it.
- It may be usually to turn yourself around so that your eyes are in line with baby's mouth.
- To inspect you should sweep your finger side to side, I will know I am doing this right if the baby gags.
3. A torch and method of depressing the tongue should be used to visualise the whole palate.
4. Parents should be informed if the whole palate (including the full length of the soft palate)
has not been visualised during the newborn examination.
5. If the whole palate is not able to be visually inspected at first attempt then a further
attempt at visual examination should be made within 24 hours
98
what internal aspects of the mouth you should apart from palate be examining?
- Tongue. Shape, size and position - tongue tie? Issues with feeding cos of this?
- Presence of teeth - if teeth are lose then they will need to be removed as this is a choking hazard.
- Reflexes – suck, swallow, rooting
99
ow can you check the suck, swallow root reflex?
You can test a baby’s sucking reflex by placing a nipple (breast or bottle), clean finger, or pacifier inside the baby’s mouth. If the reflex has fully developed, the baby should place their lips around the item and then rhythmically squeeze it between their tongue and palate.
Stroke your baby’s cheek near the corner of her mouth, and she’ll turn her head, open her mouth, and thrust out her tongue or make sucking noises
100
to ensure the baby has not got cleft palate what do you need to do during the examination?
You must visualise the whole palate, and see the central uvula to ensure it is intact. You cannot rely on palpation to exclude a cleft.
101
what is cleft lip?
Cleft lip is a congenital condition where there is a split or open section of the upper lip. This opening can occur at any point along the top lip, and can extend as high as the nose.
102
what is cleft palate?
Cleft palate is where a defect exists in the hard or soft palate at the roof of the mouth. This leaves an opening between the mouth and the nasal cavity. Cleft lip and cleft palate can occur together or on their own.
103
what is the management of cleft lip or palate?
The definitive treatment is to surgically correct the cleft lip or palate. This leaves a subtle scar, but is generally very successful, giving full functionality to the child. Cleft lip surgery is usually performed at 3 months, whilst cleft palate surgery done at 6 – 12 months.
Neck and clavicles The first priority is to ensure the baby can eat and drink. This may involve specially shaped bottles and teats. The specialist nurse will follow the child up through surgery and beyond to ensure good development.
104
what is the complications of cleft?
Cleft lip or cleft palate is not life threatening, although it can lead to significant problems with feeding, swallowing and speech. It can also have significant psycho-social implications, including affecting bonding between mother and child. Surgery generally resolves these problems. Children with cleft palates can be more prone to hearing problems, ear infections and glue ear.
105
what do you palate the neck for?
tumors, skin tags and skin folds (there should be creases but no extra folds)
106
what do you palpate the clavicles for?
Palpate across clavicle line to detect trauma - if it doesn’t feel smooth this may indicate fracture
107
what should you be checking for with upper limbs?
- movement - check for erbs palsy
- Proportion
- symmetry
- Brachial pulses - creases of elbows should be equal
- palmer creases – 2 present?
- Digits - Digits should be counted and separated to ensure no webbing or extra digits
- The axillae, elbows, groin should also be inspected for abnormalities.
Palmar grab reflex - closing hand around palm
108
what should you look out for in relation to upper limbs?
erbs palsy, waiter tip
109
where is the brachial pulses check for?
creases of elbows where you take blood.
it should be equal in al aspects
110
what do you examine for with the chest?
- Chest and abdominal movement should be synchronous. (rising and falling equally on both sides no recession)
- Should be checked under arm pit, at babies sides
- Respiration rate – 40-60bpm
- Auditory assessment of breathing - Should be no crackling just smooth
- Nipples
Extra work of breathing?
111
what are you checking for with the heart?
- Observation
- Capillary refill – on chest press for 2 seconds and should refill less than 3 seconds
- heart auscultation x5
- Heaves & thrills - (thrill vibration like a phone, heaves hand over sternum should feel heart beat as such)
pulse oximetry
112
what three things are you listening for with the heart?
- heart rate - 120-160bpm
- heart rhythm - LUB DUB noise (no ectopic beats - missed beats, any extra or difference is murmur)
heart sound - LUB DUB
You don’t need to name the murmur just know where you heard it.
113
what is the first sound the LUB caused by?
The first heart sound (S1) is caused by the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles.
114
what is the second sound the DUB caused by?
The second heart sound (S2) is caused by the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete.
115
what are the five areas of listening into with the heart?
MARY TRIES PICKING APPLES MID SEPTEMBER
Mitral, Tricuspid, Pulmonary, Aortic, Mid Scapulae
116
how do you check the aortic value?
Aortic valve (upper right sternal border) second intercostal space - listen using the diaphragm side (big side) stethoscope for one minute
117
how do you check the pulmonary valve?
Pulmonary valve (upper left sternal border) second intercostal space - listen using the diaphragm side (big side) stethoscope for one minute
118
how do you check the tricuspid valve?
- Tricuspid valve(lower left sternal border) fourth intercostal space on left side of sternal edge. - listen using the diaphragm side (big side) stethoscope for one minute
119
how do you check the mitral valve?
Mitral valve (the apex) below the nipple on the mid clavicular line in the fourth or fifth intercostal spaces - listen using the diaphragm side (big side) stethoscope for one minute and use the bell side (small side) of stethoscope for one minute) as murmurs in this area can be quite hard to hear due to frequency.
120
how do you check the miscapulae?
midscapulae (coarctation area) (on the back between the shoulder blades)- listen using the diaphragm side (big side) stethoscope for one minute
121
Why do we screen for Congenital Heart Disease?
• Early identification of congenital heart problems before heart failure or hypoxia develop
Prevention of irreversible damage
122
What are the risk factors for congenital heart disease?
• Family history of CHD (first degree relative)
• Fetal trisomy 21 or other trisomy diagnosed (these babies have high risk of cardiac defects and require continued surveillance)
• Cardiac abnormality suspected from the antenatal scan
• Maternal exposure to viruses e.g Rubella
• Maternal conditions such as Type1 diabetes, Lupus
Maternal medications - Sodium Valproate (used for epilepsy)
123
what are the sign and symptoms of congenital heart disease?
• Tachypnoea at rest
• Intercostal, sub-costal, sternal or supra-sternal recession, nasal flaring
• Central cyanosis (this is never normal)
• Visible pulsations of the heart muscle – heaves or thrills
• Absent or weak femoral pulses
Presences of cardiac murmurs/extra heart sounds
124
what are suspicious heart sounds?
• murmurs may represent an abnormality are usually loud, heard over a wide area, have a harsh quality and are associated with other abnormal findings e.g heaves/thrills/cyanosis
• Benign murmurs are typically short, Soft and localised to the left sternal border. Many babies will have a cardiac murmur in the first 24 hours of life and usually linked to physiological changes at birth. However, remember cardiac murmurs may be absent in babies with a significant cardiac defect
125
Why do we measure femoral pulses?
Although it might be easy to link pulses with the hips, femoral pulses is part of the heart examination. Absent or diminished pulses are a sign of the serious heart condition coarctation of the aorta - a narrowing of the aorta, the major blood vessel that carries blood away from the heart to the body. If there is any question of the strength or rhythm of the femoral pulse then this must be simultaneously assessed with the brachial pulse.
126
how do you test blood oxygen sats in a baby?
right hand and either foot
127
what are pre and post ductal sats?
- pre- and the post-ductal saturations are both arterial saturations
128
what does pre-ductal sats measure?
arterial oxygen saturation in vessels originating from the aorta – the right hand
Pre-ductal saturations are measured in the baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus.
129
what does post ductal sats measure?
post-ductal sats are measured in the foot
Post-ductal saturations are measured in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus.
130
how do we tell there is mixing of bloood?
- Post-ductal saturations become lower than pre-ductal when there is mixing of pulmonary blood through the duct, i.e. in congenital heart defects that are duct dependent
- In severe coarcations or transpositions of the great arteries typically have lower postductalsat´s.
131
what should the oxygen sats readings be?
95% and above no more than 2% difference
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what should you examine when checking the abdomen?
- General visual inspection – distended? Sunken?
- palpate through four corners shallow then deeper
- Kidneys/liver/spleen/bladder
- Roll hands from lower corner up to see if anything is enlarged. You may feel tip of the liver or baby's right side but nothing more than a finger length. You shouldn’t feel the baby's spleen.
- Press just above baby's pubic, bone you should not feel the bladder.
- umbilical cord – check for signs of infection
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what should you and shouldn't you feel during a baby's abdominal palpation?
You may feel tip of the liver or baby's right side but nothing more than a finger length. You shouldn’t feel the baby's spleen.
134
what can a oncave abdomen in a newborn mean?
oncave abdomen may indicate diaphragmatic hernia with abdominal contents in the chest
135
what side of the body is a baby's liver and spleen?
liver - right spleen - left
136
what are the general things you are looking at with the genitalia and anus?
- appearance (swollen - excess hormones)
- positioning
- completeness
Patency - open
- Check if it is in proportion - abnormal size to be reviewed
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what are you looking for when examining the male genitalia?
Male – Penis size, penis shape, testes x 2 in scrotum. If not felt may be still undescended.
penis, urinary meatus at the tip of the penis, no curvature, urinary stream has happened, normal scrotum with 2 testes and patent anus in the correct position
138
what is a hydrocele?
If you feel a hydrocele/swollen tests check if it is fluid it is normal. This is checked by shinning the torch and it should glow and it should be able to be moved) if not then refer.
• Firm or fluctuant?
• Will trans-illuminate
• Non tender
Most resolve spontaneously
139
what happens if you can only feel one teste?
If you can't feel one of the teste descended then you may feel it at the groin. Wait for 6-8 week GP check before action. Give it time. DOCUMENT.
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is a hernia a normal finding when checking male genitalia?
• Common
• May be reducible
• Irreducible may strangulate
Early referral for paediatric surgery
141
what do you check when checking female genitalia?
- Female – clitoris, labia, vaginal opening. May be discharge, bleeding (pseudo menstruation)
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swollen clitoris?
Relatively larger in preterm or IUGR infants.
143
are skin tags normal to find when inspecting female genitalia?
• Common
No action required
144
what is pseudo-menstruation?
• Normal
• Withdrawal of maternal hormones
Resolves 48 hours to 6 days
145
is testicular torsion normal?
• Uncommon
• treatment required within 6 hrs for testis to remain viable
• Hard, tender testis sometimes have bluish discolouration
• Most neonatal cases testis is already necrotic
URGENT surgical referral
teste is twisted
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what is the care plan for hypospades?
• Ventral urethral meatus
• Palpate carefully for testes with hypospades
• 3 per 1000 babies
• Surgical correction < 2 years
Avoid circumcision
where the tip of the urethra isnt as the top of the penis
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what is penis chordee?
• Tethering of penis
• Problems with erection
Surgical referral sometimes needed
penis is bent downwards
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what do you do if there is ambiguity regarding genitalia?
If there is any ambiguity regarding the genitalia, the midwife should be positive and honest and does not assign a gender to the baby. A multi -disciplinary approach with paediatricians, urologists, geneticist and endocrinologists will investigate prior to gender being assigned.
•Distressing to parents
•Sensitive communication with the parents is important
•Delay in assigning sex adds complexities and anxieties
•Urgent referral is needed
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what are you checking when examining the lower limbs?
- Femoral pulses – present and equal - groin - two index finger gentle press. Absents can indicate heart abnormalities.
- Symmetry
- movement
- tone
- length
- plantar creases - shouldn’t be very deep - this may indicate syndromes
- Digits - checking webbing also.
reflex - run finger up feet and toes should curl or press feet and toes should curl
150
what's the difference between club foot and talipes?
Club foot - fixed into position, refer
Talipes - can be fixed with positioning.
151
what do you check when doing a hip examination?
- Leg height position – equal? - check this with soles of feet on table (if not equal may be joint is not in place)
- leg/buttock creases
- Barlow’s test – will detect an easily dislocatable hip
- Ortolani’s test – will detect a congenital dislocatable hip
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how do you perform a hip exam?
- Fingers in line with leg (trigger fingers) straight down leg and apply pressure and go out
- Stabilised baby's pelvis with hand at gentilia, thumb at the front and fingers at the back.
- If there is no issue you shouldn’t feel anything - smooth motion
- Clicking means it is just a clicky hip
- Clunk noise and feeling is not normal as it has went back into place
- If hips come all the way out it is not normal.
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why do we do hip exams?
early identification of a dislocated or a dislocatable hip(s)
identification of sonographic pathological hip dysplasia through selective ultrasound scan (USS)
minimising the risk of long-term complications through:
- timely hip ultrasound scan
- further expert assessment
- early intervention
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if a unstable hip goes undetected what can this mean?
Undetected unstable hip(s) with delayed treatment may result in the need for complex surgery and, or longterm complications such as impaired mobility and pain osteoarthritis of the hip and back.
Early diagnosis and intervention should improve health outcomes and reduce the need for surgical intervention.
155
when is it better to catch an unstable hip for outcomes?
before 12 weeks of age
156
how common is a development dysplasia of the hip?
• Incidence of an abnormal hip at birth is 1 in 64
• Treatment rate is approximately 3-5 per 1000
• More common:- Left hip than right, Females more than males, 1st born female, post dates (can be second babies)
70% of babies with an abnormal hip have never been breech and have no family history
157
what is the NIPE hip risk factors?
• first-degree family history of hip problems in early life – this includes baby’s parents or siblings who have had a hip problem that started as a baby or young child that needed treatment with a splint, harness or operation
• breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at birth or mode of delivery – this includes babies who have had a successful external cephalic version (ECV)
breech presentation at the time of birth between 28 weeks gestation and term
- First degree family history
- Breech presentation from 36 weeks onwards
- Breech presentation at birth if 28 weeks onwards
- Multiple pregnancy
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what is the 5 point hip examination?
1. Cause of hip instability and babies ‘at risk’ - is the baby at risk of DDH? as above and extended breech presentation, oligohydramnios, first baby - often big, long and post dates, Family history of DDH - Mum or sibling treated
2. Resting posture - what is the babies resting posture like? Do legs sit naturally?
3. Range of abduction - do both hips flex and abduct? Is there any resistance?
4. Groin/buttock creases - are the deep groin creases, posterior crease and labia symmetrical?
5. Tests for instability - Barlow's and Ortilani's tests
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what is the hip exam screening for?
The Hip examination is screening for Congenital Hip Dysplasia. This is where the acetabulum (hip socket) is shallow or dysplastic (abnormally developing). As the baby moves it’s legs, the femoral head moves in and out of the shallow hip socket.
160
how do you diagnose DDH?
Where children are suspected of having DDH, ultrasound of the hips is the investigation of choice and can establish the diagnosis. All children with risk factors or examination findings suggestive of DDH should have an ultrasound.
161
what does clicking of the hip mean?
Clicking is a common examination finding and is usually due to soft tissue moving over bone. When this is the cause an ultrasound will be normal. Isolated clicking without any other features does not usually require an ultrasound unless there are other concerns. Clunking is more likely to indicate DDH and requires an ultrasound.
162
what is the management of DDH?
Treatment typically involves a Pavlik harness if the baby presents at less than 6 months of age. The Pavlik harness is fitted and kept on permanently, adjusting for the growth of the baby. The aim is to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape. This harness keeps the baby’s hips flexed and abducted. The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks.
Surgery is required when the harness fails or the diagnosis is made after 6 months of age. After surgery is performed, an hip spica cast is used to immobilises the hip for a prolonged period.
163
How are you examining the spine?
- Best examined by lying the baby face down with its abdomen and chest in the palm of one hand.
- The back and spine should be visualised and palpated. - should be straight
- Any abnormality of the skin, for example swelling, tuft of hair, birthmark should be noted.
- Any sacral dimple should be closed. - if you can visualise the base of the dimple that is an issue.
- Inspect skin and head again
- Buttock cleft
164
what final reflex do you do?
- With the next you hands should flare out then come back into the body.
- Sit baby up then lie in back into hand aka catch baby,
- Warn and be sensitive to parents.
- Moro
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summary of the reflexes in NIPE?
- Moro reflex: when rapidly tipped backwards the arms and legs will extend
- Suckling reflex: placing a finger in the mouth will prompt them to suck
- Rooting reflex: tickling the cheek will cause them to turn towards the stimulus
Grasp reflex: placing a finger in the palm will cause them to grasp
166
after doing the NIPE exam what do you do?
To finish:
- Dress and wrap baby
- Doff PPE if appropriate and perform hand hygiene
Explanation
- Communicate findings to parents, inform parents of future proposals or plans.
- Time given for questions.
Documentation
- Complete documentation - discuss no plan or care or what you think it could be. That is not your job
Complete referrals
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what is the NIPE exam in order?
skin
head
facial features and ears
neck and clavicles
upper limbs
chest
heart and sats
abdomen
genitalia
lower limbs
hips
spine
reflexes
