There are many advantages in training midwives to carry out the neonatal examination, not least in reducing the time women must wait before being allowed home after delivery. An audit was undertaken to assess the clinical effectiveness of those midwives who are able to perform this procedure.
Authors: Amanda Williamson is lecturer in midwifery, Julie Mullet is an advanced neonatal nurse practitioner, Margaret Bunting is a practice development midwife and Julian Eason is a consultant neonatologist
Midwives magazine: March 2005
The objective of the pilot study was to test the appropriateness of an audit tool developed to determine the clinical effectiveness of midwives carrying out neonatal examination of the newborn. The audit was undertaken by reviewing retrospective data, collected from midwives' personal clinical records of neonates and the case records of the babies they had examined. The data was gathered over a period of 18 months, and included the records of 482 term babies. The setting was a district general hospital in the east of England. The participants were all midwives who had successfully completed the neurobehavioural examination of the newborn course, and practising at a local district general hospital. The findings of the study indicate that the audit tool was sufficiently robust to test the clinical effectiveness of midwives' detection of specific congenital abnormalities. Clinical effectiveness rates were reassuringly high. The study also began to highlight the positive impact on the improvement of the service available to women. A further study has been started to compare the clinical effectiveness rates between professional groups.
Audit, clinical effectiveness, midwives, neonatal examination
The neurobehavioural physiological assessment of the newborn course was started at a university in 2000 in collaboration with service colleagues. The aim of the course is to prepare midwives to undertake the holistic assessment of the newborn infant, including the examination done by paediatric medical staff. The examination is a `screening tool with a number of different components' (Bloomfield et al, 2003). These components include assessment of the cardiovascular and respiratory system, neurological assess- ment and examination of the eyes and hips. If midwives are to function competently as lead professionals, as recom- mended by Changing childbirth (Department of Health, 1993), they should be able to undertake the comprehensive, holistic assessment of the normal term baby following birth and make appropriate referrals should a problem be discov- ered. This is also reinforced in health policy in Making a difference (Department of Health, 1999) and the NHS Plan (Department of Health, 2000). It may also be seen to encourage the development of `midwifery-led service' as recommended by the House of Commons Health Committee in 2003. The RCM publication Vision 2000 asks midwives to act in response to initiatives that ensure evidence-based, cost-effective and quality care (RCM, 2000).Midwives trained to carry out the neonatal examina- tion may certainly be seen to be taking up this challenge. One of the perceived benefits to midwives undertaking the holistic neonatal examination may include the reduc- tion of waiting times for women wishing to go home four to six hours following delivery. These women would have previously had to wait for a paediatrician to be available. A further benefit may be as an aid to reducing junior doctors' workloads and hours, in keeping with the European Working Time Directive (2000). There have been several papers published that explored the midwife's role. Other papers have discussed maternal and professionals' perspectives of midwives undertaking the holistic assessment of the newborn (Bloomfield et al, 2003; Rogers et al, 2003;Wolke et al, 2002; Lee et al, 2001; Lomax, 2001; Robins, 2001;MacKeith, 1995). However, what is often lacking within the published literature is the clinical effectiveness of midwives' abilities to detect abnormalities when undertaking the routine neonatal examination. Therefore, the objective of this study was to test the appro- priateness of an audit tool determining this. This paper will discuss the rationale for screening and the basis of the project undertaken, and will go on to explore the expected clinical standards to be achieved. It should be noted that this has been done as a pilot study for further audits.
Holt (1974) described the criteria for a screening test as being `sensitive to and specific for a particular condition, capable of being performed quickly and cheaply, and providing a pass/fail result'. However, the neonatal exami- nation as it stands is unable to fulfil all of these criteria, as it does not provide a pass/fail result for all abnormalities with certainty. Naidoo et al (1996) suggest six criteria that should be met for screening to be effective. The test should: n Include a long preclinical phase (thus ensuring that screening will not miss signs) n Offer early treatment to improve outcomes n Be sensitive and able to detect all of those who have the diseasen Be easy and safe n Be cost-effective n Be specific. The neonatal examination is unable to fulfil all of these criteria due to lack of specificity and the inability to detect all of those with an abnormality.While acknowledging the limitations of the neonatal examination as a screening test, it is still generally accepted within the medical profession that it plays an essential role in the detection of abnormalities (MacKeith, 1995). Therefore, the objective of the study was to test the appropriateness of an audit tool to determine if midwives are as clinically effective as other professionals in detecting abnormalities in the newborn. This will also ensure they are practising to the acceptable legal standard defined in Bolam v Friern Hospital Management Committee (1957): `The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent. It is well-established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art.'One of the aims of the study was to define a standard against which midwives' practice could be audited.
The sample audited in the pilot project included all neonates examined by eight midwives working at a large district general hospital who had undertaken the neurobehavioural physiological assessment of the newborn course. Retrospective data, collected over a period of 18 months during 2000 to 2002, was used from midwives' personal clinical records of neonates they had examined. Retrospective data was used to allow time for congenital abnormalities to become apparent if not identified at the neonatal examination. This assured the robustness of the study. All midwives voluntarily gave their records to the collecting auditors. The records of 482 term neonates were audited and all neonates included in the study were given a separate identification number. The midwives' records were tracked against the baby's medical records, in order to determine if referrals had been appropriate. It was imperative that the audit team had a degree of common understanding of the definition of clinical effectiveness in this instance. Following extensive discussion and review of the literature, it was agreed to define clinical effectiveness as, `midwives' ability to detect relevant family history, congenital abnormalities and make appropriate referrals following the neonatal examination against agreed standards'. It was agreed that five aspects of the neonatal examination would be audited. A literature review was carried out to find research projects that had undertaken a review of care and found a prevailing detection rate among senior house officers (SHOs) or advanced neonatal nurse practitioners doing the neonatal examination. These findings formed the basis of the standard to be achieved by midwives undertaking the neonatal examination in three of the aspects audited. A further two (appropriate referrals) were audited against local NHS Trust guidelines. Cardiac Standard: midwives to detect and refer all neonates presenting at the newborn examination with an audible murmur, excluding neonates with previous diagnosis of a cardiac abnormality. A target figure of 50% to be detected and referred was set. This standard was based on a retrospective study of 7204 babies who had a neonatal examination undertaken by an SHO (Ainsworth et al, 1999). The study examined the clinical effectiveness of SHOs in relation to the cardiac component of the neonatal examination. The study concluded that the neonatal examination `detects only 44% of cardiac malformations, which present in infancy'. Dislocated or dislocatable hips Standard: midwives to detect and refer all neonates born with dislocated and/or dislocatable hips. A target figure of 74% to be detected and referred was set. This standard was based on a prospective study by Lee et al (2001) to compare the clinical effectiveness rates of SHOs and advanced neonatal nurse practitioners in undertaking the neonatal examination. The study reviewed the data of 527 babies. They concluded that SHOs had a clinical effectiveness rate of 74% in the detection of hip abnormalities. Family history of developmental dysplasia of the hip or breech delivery Standard: midwives to refer all neonates born with a family history of developmental dysplasia of the hip and/or breech deliveries as recorded on maternal notes. The target for referral was 100% as we would expect all midwives who have completed the neurobehavioural examination of the newborn course to undertake an appropriate review of family history for each baby. Congenital cataracts Standard: midwives to detect and refer all neonates born with congenital cataracts. A target figure of 35% to be detected and referred was set. This standard was based on a study undertaken by Rahi et al (1999). The objective was to determine the method of detection and the timing of ophthalmic assessment of children with congenital and infantile cataracts. The data of 235 children was reviewed and a clinical detection rate of congenital cataracts via the neonatal examination of 35% was found. All referrals All referrals were to be made appropriately. The target was 100% as per the appropriate local guideline. Data collection involved searching clinical records to ascertain if any baby who had a neonatal examination done by a midwife had returned to the district general hospital within any of the specialities defined above ± cardiac, orthopaedic or opthalmology. A baby with an outpatient appointment or admission to hospital had its records cross-checked with any of the above criteria.We also looked to see if a baby had been referred and if so the documentation was checked against local referral guidelines to ensure appropriateness and adherence to these.
All records of midwives undertaking the neonatal examination during this time were included. The auditing team reviewed data from 508 babies, of which 26 were lost to the audit. This was due to incorrect record-keeping by midwives undertaking the examination, thus it was not possible to track the baby by its own or its mother's record number (22 cases). An SHO signed two cases and two babies were less than 37-weeks' gestation. The records of 482 babies were audited. It is anticipated that some babies were lost to the study as not all those checked by the midwives were documented in their personal clinical records. Any baby that had moved away from the area could not be tracked via the hospital computer system, however, within the indigenous population there is only a small amount of movement. The results are shown in Table 1.
The findings of the study indicate that the audit tool was sufficiently robust to test the clinical effectiveness of midwives' detection of the specific congenital abnormalities. The rates were reassuringly high, although the number of midwives participating in the study was small. However, the actual number of neonatal examinations carried out by these midwives was sufficient to draw some inference. The clinical effectiveness rate in the detection of cardiac abnormalities was high (75% ± target was 50%). It could be argued that the remaining 25% would fall into the range of late diagnosed conditions, such as ventricular septal defects, which would not be expected to be detected at birth. No congenital cataracts were detected within the study. However, with the number of babies examined, this would be expected due to the small number of children presenting with detectable congenital cataracts. In the national surveillance study by Rahi et al (1999), of 248 children with newly-diagnosed cataracts, only 83 were detected at the neonatal examination. Only one baby was detected and referred with a dislocatable hip ± a larger number of neonatal examinations would be required, before a true clinical effectiveness rate could be concluded.
Limitations of study
This was a small-scale pilot study examining the data of one hospital for a period of 18 months. The records of only eight midwives were examined, but these were the only midwives qualified to undertake the neonatal examination at the hospital at that time.
A further prospective study has begun with the aim of including all babies who had a neonatal examination at the hospital to allow comparison between all healthcare professionals. There are now 12 midwives qualified to undertake the neonatal examination at the hospital. Following the study, an audit record was developed to allow easier tracking of babies. Cost-effectiveness was not considered in this audit as a study into this is taking place in Wessex (Lomax, 2001). However, we have included a question regarding whether the examination was done because of a delay in a paediatrician being able to attend. This will allow us to review whether midwives are having an impact on releasing beds that would otherwise be blocked. It is also intended to broaden the data to include other hospitals (two are interested in joining the audit).
This has been a local retrospective audit with some limitations. However, it offers reassuring evidence that midwives are clinically effective in detecting congenital abnormalities and making appropriate referrals. It is also beginning to highlight the positive impact, not only on the improvement of the service available to women, but also on helping to reduce junior doctors' working hours. This would enable junior doctors to undertake the neonatal examination as a learning experience rather than a service requirement.With ongoing audit, it is anticipated that if areas of clinical weakness are identified these can be addressed, and midwives' clinical effectiveness will continue to be proven.
The authors would like to thank all the midwives who allowed review of their personal records of neonatal examinations.
Ainsworth S,Wyllie J,Wren C. (1999) Prevalence and clinical significance of cardiac murmurs in neonates. Archives of Disease in Childhood ± fetal and neonatal edition 80: 43-5. Bloomfield L, Townsend J, Rogers C. (2003) A qualitative study exploring junior paediatricians', midwives', GPs' and mothers' experiences and views of the examination of the newborn baby. Midwifery 19: 37-45. Bolam v Friern Hospital Management Committee. (1957) 2 All ER 118. Department of Health. (1993) Changing childbirth: report of the expert maternity group (Cumberlege Report). HMSO: London. Department of Health. (1999) Making a difference: strengthening the nursing, midwifery and health visiting contribution to health and health care. HMSO: London. Department of Health. (2000) NHS Plan: a plan for investment, a plan for reform. HMSO: London. European Parliament and Council. (2000) Directive 2000/34/EC. Official Journal of the European Community L195: 41-5. Holt K. (1974) Screening for disease in infancy and childhood. The Lancet November: 1057-61. House of Commons Health Committee. (2003) Provision of maternity services. Fourth report of session 2002 to 2003. HMSO: London. Lee T, Skelton R, Skene C. (2001) Routine neonatal examination: effectiveness of trainee paediatrician compared with advanced neonatal nurse practitioner. Archives of Disease in Childhood ± fetal and neonatal edition 85: 100-4. Lomax A. (2001) Expanding the midwife's role in examining the newborn. British Journal of Midwifery 9(2): 100-2. MacKeith N. (1995) Who should examine the `normal' neonate? Nursing Times 91: 34-5. Naidoo J,Wills J. (1996) Health promotion foundations for practice. Balliere Tindall: London. Rahi J, Dezateux C. (1999).National cross-sectional study of detection of congenital and infantile cataract in the UK: role of childhood screening and surveillance. British Medical Journal 3(18): 362-5. Robins J. (2001) Congenital cataract: the role of the neonatal nurse practitioner in screening and provision of psychological support. Journal of Neonatal Nursing 7(3): 91-4. Rogers C, Bloomfield L, Townsend J. (2003) A qualitative study exploring midwives' perceptions and views of extending their role to the examination of the newborn baby.Midwifery 19: 55-62. RCM. (2000) Vision 2000. RCM: London. Wolke D, Dave S, Hayes J, Townsend J, Tomlin M. (2002) Routine examination of the newborn and maternal satisfaction: a randomised controlled trial. Archives of Disease in Childhood ± fetal and neonatal edition 86: 155-60.