OSCE neonatal examination Flashcards
- Introduction
How would you begin and conduct your visit? (3)
Hi there, it’s nice to meet you and congratulations. My name is Ayesha, and I am the student midwife. I’m going to be undertaking the daily examination of your new-born if that is okay.
I would make sure to include both parents during the examination of their new born, explaining the procedure to them and my findings to them. Stefanie and James, this will be a full head to toe examination of your baby, and it will involve undressing Alfie. I will also be looking for any deviations from the norm. Once I have explained the procedure to them and answered any questions they may have about the procedure, I would want to make sure I have their informed consent before conducting the examination. I would also want to make sure this is an appropriate time, for example Alfie may be disturbed and needing a feed before I can do the examination. This could be an opportunity to provide breastfeeding support and ensure Alfie is feeding well.
- What is the purpose of the daily newborn examination? (5)
To ensure neonatal wellbeing and to detect any deviations from the norm. Where I find any deviations from the norm, I would want to refer this to the appropriate person and provide the appropriate evidence-based information and support to Stefanie and James so that they are reassured.
I would also want to monitor weight gain or loss and I would monitor this in line with the local guidance.
It’s purpose is also to support the parents navigating this new life with their baby and to answer any questions they may have.
What would be your initial observations on entering the home? (3)
Initially I would want to observe how the parents are doing, if they look tired or if there’s anything in their presentation that would cause me concern. I would also observe how they are handling Alfie such as holding him or putting him down to sleep. This could be an opportunity to provide information or advice such as safe sleeping.
I would also observe the environmental factors such as any pets that are loose, the temperature, smoke exposure, or anything that may affect my safety as a lone worker.
Whilst making these observations I would want to be careful not to intrude on their privacy or do anything that would make them feel as though I am judging them.
- What would you wish to discuss with Stefanie and James regarding baby Alfie? (9)
Prior to examining baby, I would want to ask Stefanie and James about Alfie’s behaviour, so if he often upset or often rested. I would also tell them that it is okay to walk away from Alfie if he is just not settling and they feel they are losing patience. I would also want to discuss Alfie’s sleeping pattern and ask how they are getting on with feeding as well as frequency of feeds. I would ask to observe a feed if possible so that I can provide any advice or support with positioning and attachment so that Alfie is getting the most out of his feeds. If he was formula feeding, I would give different advice.
I would then go on to ask about elimination. As Alfie is 3 days old, we would expect to see between 5 and 6 wet nappies, and these should become heavier. I would also tell Stefanie and James to expect to see a change in the colour of Alfie’s stool, it will start to become lighter and eventually yellow and as they are breastfeeding it will develop a seedy consistency. We would expect to see a minimum of 2 dirty nappies the size of a 2 pound coin. The volume that Alfie eliminates will link to how much volume he is taking in.
I would also want to discuss safe sleeping as this reduces the risk of cot death. Stefanie and James should be putting Alfie’s feet at the bottom of the cot, he would not have a hat on inside as he could become overheated and there should not be any other toys or objects in the cot with Alfie.
I would also want to discuss worsening symptoms and signs of infection for Alfie and ensure they know who to contact if this happens. I would also want to discuss the structure of postnatal community care and when they will be discharged over to the care of the health visitor. I’d also want to discuss registering baby Alfie with the GP, registering his birth, and arranging mum and baby’s 6 week check with the GP.
- How would you prepare for the daily physical examination of the baby? (8)
I would want to make sure the environment is warm enough as the examination requires me to undress Alfie. If it was not warm enough, I would try to only expose Alfie where and when necessary. I would also want there to be good lighting as this can affect observing for signs of jaundice etc.
I would wash my hands using the WHO seven steps of hand washing in the 5 moments of hand hygiene. This will reduce the risk of cross infection as Alfie is particularly vulnerable as a newborn. If my hands were visibly unclean, I could use the alcohol gel but if they were not then I would have to wash my hands. I would make sure my hands are warm and would wear non sterile gloves an apron.
I would also want to make sure this is a good time for Alfie to be examined as he may be needing a feed or distressed which would make it difficult to carry out the examination.
- Observing the baby before fully undressing it can reveal several potential problems. How would you undertake the general observation of the baby? (10)
Before undressing Alfie, I could observe his face first to check for symptoms of jaundice. I would be mindful that this may be harder to notice on darker skin tones and so I would want to check the baby’s eyes for a yellow tone instead.
I would also check his respiration rate. The normal respiration rate for a newborn baby is between 30 and 40 breaths per minute. However, this could be increased to 60 breaths per minute if Alfie was distressed or crying.
I am observing Alfie’s head and looking for any signs of moulding or caput, bruising or scarring so looking all around the head. There could be puncture sites from the birth or any trauma from forceps if they were used. I would also feel for the indentations where the fontanelles would be; the anterior and posterior fontanelle should not be expanded or extended. If there was any moulding, I would want to reassure Stephanie and James that this is normal.
Moving on from the head I will examine Alfie’s eyes. I am looking for a clear sclera and any signs of bloodshot from the labour; if there is signs of bloodshot I will reassure Stephanie and James that this is normal and nothing to be worried about. I am also looking for any signs of infection such as discharge, but there are no problems here with Alfie today. Moving on to the nose, I would want to make sure there is no excessive respiratory effort or swelling of the nose. Again, there is no concerns here. I am now going to look inside the mouth by gently opening it with my thumb. I’m going to visualise the tongue and the roof of the mouth. I am looking for any signs of infection or trauma. I have often found with breastfeeding babies they may have a thin layer of milk on their tongue, and this can often make parents worried about thrush etc. I would reassure Stefanie and James and ask any questions they may have.
I am then going to examine his neck, making sure to look between the skin creases. I am looking for any signs of infection as vernix can build up increased areas and cause infections. I would want to turn him around and examine the back of his neck aswell as there may be vomit leaked to the back here. This could be an opportunity to speak to Stefanie and James about the hygiene of their baby.
- Explain how you would perform the physical examination, explaining in detail what you would do and why. (25)
I would like to take a systematic approach to this examination, so working from head to toe to ensure I am covering each factor of the examination.
Whilst undressing Alfie I could observe how he reacts to this, such as being disturbed or beginning to move his limbs. This would be a good sign of Alfie being reactive and alert. I would observe Alfie’s movements, whether they look floppy, and I would want to make sure all four of his limbs are moving. I would also be able to notice his skin tone, whether this looks blue or grey at all. Again, being mindful that we may not see a pink baby for babies with darker skin tones, but this is not a sign of an unhealthy baby.
After undressing Alfie for the physical examination, I would like to firstly observe his chest movements as it is important to ensure Alfie’s respiration rate is normal. His chest movement should be symmetrical, there should be no nasal flaring and his chest should not be drawing in at breaths. If any of these were the case, these would indicate that Alfie is working too hard for his air intake.
I will also take a moment to weigh Alfie and keeping the local guidelines in mind. Generally, it is normal for babies to initially lose between 5-10% off their birthweight and then gain weight, becoming closer to their birthweight by around 2 weeks.
I would then want to measure Alfie’s temperature. I’m going to use the thermometer to do an axillary temperature on Alfie and the normal temperature will be between 36.5 degrees and 37.5 degrees.
For the examination, I will have Alfie on my laps and make sure he is secure and safe.
I will then observe his skin for any birthmarks or trauma and make sure the birthmark is documented. I am looking for good peripheral perfusion, making sure there are no signs of any challenges for his circulatory system. His skin should not have a white or blue tinge to it a this could suggest cyanosis. If Alfie had darker skin, I could look at his tongue, gums or eyes for signs of jaundice or cyanosis. I am also looking for any signs of bruising or rashes or spots. Alfie may have a new born rash and if so I would want to reassure Stephanie and James that this is normal as his skin is readjusting to the new environment as opposed to when he was in your womb Stephanie.
I would then look at his arms, legs, hands, and feet, making sure he has all 5 fingers on each hand and all 5 toes on each leg. I would also want to make sure there are no hairs stuck between his fingers or toes. I would want to check between skin creases for any signs of infection. I will turn Alfie over and look at his spine and this is all normal.
I’m then going to look at the umbilicus to look for any signs of separation or infection. This looks fine here, and I am also going to give the parents advice about hygiene and keeping the area clean and dry. I’m now going to look at Alfie’s groin from the front and both sides. This all looks fine. I am then going to look at his bottom so just lifting his legs to be able to do this. I am looking for any signs of thrush or a nappy rash. Again, this would be a good opportunity to provide advice on hygiene and provide information on whatever I find in the nappy, reassuring Stefanie and James that what I see is normal. I will then offer to put a clean nappy on Alfie if necessary, however Stefanie and James may want to redress Alfie themselves.
- Newborn babies have higher levels of uric acid which is a by- product of nucleotide breakdown. Explain how this may present and what information would you provide to the parent(s). (2)
I would also ask the parents if there were any signs of uric acid in the dirty nappies and the wet nappies.
Uric acid is a by-product of nucleotide breakdown. This is a normal process in new born babies and can present itself as a red or orange powder or crystal formation in the nappy. I would want to answer any questions the parents have about this and reassure them that this is a normal process. It is not blood in their nappy and this is not painful for them.
- Following the routine examination of the newborn what will your actions be? (5)
I would ensure Alfie is comfortable and dressed. I will then wash my hands and remove my ppe and dispose of any single use equipment. I’m now going to discuss findings with parents and reassure them that Alfie is well and listen to any questions they may have. I will also think about any referrals that I may need to make, however Alfie raised no concerns today. I would ensure Stephanie and James have any relevant contact numbers and know when and why to use them. Lastly, I will plan my next visit and ensure this is an okay time for Stephanie and James before saying goodbye and telling them to take care.
9.a What findings from the routine examination of the newborn would you document? (14)
- Alfie is well and reactive.
- Alfie has good skin tone.
- Alfie raised no concerns today.
- Alfie’s weight
- Alfie’s temperature
- Alfie’s feeding and sleeping pattern.
- The topics that I discussed with Stefanie and James and the information that I provided them with.
- Number of wet and dirty nappies
- Colour of stool
- Any birthmark that I observed.
- Any rashes, caput, or moulding
- Any concerns about parent’s wellbeing and the safety of the environment.
- The time and date of next visit
- Date time and sign.
- Summarise the role and responsibilities of the midwife when performing the routine examination of the newborn. (8)
- Handling Alfie gently and appropriately
- Communicated well with parents regarding my findings.
- Providing reassurance and evidence-based information and advice
- Allow time and listening to Stephanie and James questions.
- Used postnatal care as an opportunity for promoting health and wellbeing of baby, childcare.
