Midwives magazine: December 2009/January 2010
By Amanda Hutcherson, midwife practitioner in The Birth Unit at the Hospital of St John and St Elizabeth, with the support of Annette Weavers, Cathy Rowan and Thames Valley University.
Introduction
Since the publication of the
Winterton report (House of Commons Health Committee, 1992) and Changing childbirth (Department of Health (DH), 1993) the British government has advocated greater choice of maternity care for women and their babies (Tew,1998; DH, 2004; 2007a; 2007b), and the examination of the newborn baby, traditionally undertaken between six and 72 hours of life by a paediatric senior house officer (SHO) has been closely linked with this plan (Court, 1995; Michaelides,1996). The provision of training for midwives in performing this early screening examination (Michaelides,1996; 1997; Lomax, 2005) has offered improved continuity of care and increased satisfaction for women and families (Bloomfield et al, 2003a; 2003b).
The NMC,
through Midwives rules and standards (NMC, 2004), makes it clear that, except in an emergency, a midwife must be trained in the provision of any care or treatment that he or she gives to mothers and babies; ensuring that the needs of the woman and her baby are the primary focus of practice and, where deviation from the norm is detected, calling a qualified health professional with the necessary skills to assist (NMC, 2004). The RCM believes that it is entirely appropriate for midwives to gain competence in new skills, in accordance with NMC (2004) requirements to enable them to offer women a wider range of choices during maternity care (RCM, 2007). These statements provide the basis for professional development in midwifery, which includes the examination of the newborn course, now increasingly available through UK universities.
A programme of continuing professional development (CPD) supported by the health sciences department of a London university has prepared me to examine potentially healthy babies with a view to detecting abnormalities, particularly those of the eye, heart and hips, which might otherwise be overlooked and where early intervention can improve outcome (Johnston, 1999; Lomax and Evans, 2005). During this training period, my increasing ability has been welcomed by paediatricians of all grades. Some authorities highlight the fact that paediatric SHOs receive little training in this speciality (Bloomfield et al, 2003b), while others mention that being qualified doctors, who have already acquired the skills of performing a detailed physical examination gives them an advantage (Sherliker,1997). Experienced midwives have confidence in the handling and observation of neonates and for me this resulted in the development of a mutually supportive basis for shared knowledge and skills. Issues that have arisen on my journey from novice to competent practitioner (Benner,1984) in the examination of the newborn have been mainly those of auscultation of the neonatal heart and the pressures of service provision.
The practical component of the preparation of midwives course required ten initial examinations of newborn babies to be supervised by a paediatric registrar. This was followed by 27 self-assessed procedures, with a final three summative examinations assessed by a consultant paediatrician. Having completed the prescribed supervised neonatal checks and obtained agreement from the paediatric team around the issues of competence, autonomy and accountability related to taking responsibility for this screening examination, I was ready to begin the self-assessed phase of my training. Within the next few days, I was asked to perform newborn checks for two babies who had been born in a standalone birth centre. The birth centre midwives were under pressure from maternity management to expedite the postnatal discharge process, this being one of several, not inconsiderable, benefits of a midwife’s ability to perform the examination of the newborn check (Lomax and Evans, 2005).
Having reviewed the pregnancy and birth records in order to be aware of any medical or obstetric history or birth complications that might affect the baby (Baston and Durwood, 2001), I introduced myself to the baby’s parents, explained my position in relation to examination of the newborn and obtained consent to perform the procedure. I then began the screening check. The examination for this first baby was straightforward, the mother had no concerns and I found no abnormalities. However the second baby, although alert, active and feeding well, had a blue tinge to the lower area of his face and a small white spot on the tip of his penis. My first impression of the discolouration was that it was caused by facial congestion following birth (Johnson et al, 2003), or circumoral cyanosis, a bluish discoloration around the mouth which is associated with suckling and should resolve following the feeding episode (Hartley, 2002). At 2.7kg, this baby was not large, his birth had been uncomplicated, the midwife attendants at the birth had not documented a nuchal cord (Jefford et al, 2009) or any cause for concern and the mother felt that the birth had been straightforward. He was sleeping in his cot and had not been feeding recently. At this point I developed an acute awareness of the difference between the rudimentary midwives’ examination of the newborn after birth (Cameron et al,1992) and the responsibility of the screening test that I was about to carry out. This was a very different position from that of a midwife who discharges a baby that has been examined by a paediatrician or will shortly be examined by a GP. It was now my responsibility to detect deviation from the normal and refer as appropriate, to ensure that the baby obtained correct and timely intervention (Michaelides, 1998; Baston and Durwood, 2001). It was imperative that I took into account the implications of cyanosis and treated or excluded them before concluding that this baby was healthy and fit for discharge. The issues to be considered when neonatal cyanosis is present are:
Infection
This was of particular concern as a pustular lesion had been noted. The baby’s vital signs were within normal range, he was not cold or over-heated and his behaviour was normal. Michaelides (2004) reiterates the importance of thermoregulation in the neonate and its close relationship to health status. There were no facilities for oxygen saturation measurement in this low-risk birth unit. The mother was well, had not experienced abnormality in her routine observations during pregnancy and labour and had no history of beta haemolytic streptococcus, a common cause of neonatal infection (RCOG, 2003; Woods, 2005; NICE, 2007). The baby was keen to attach to the breast and there were apparent signs of normal bowel and bladder function with meconium in the nappy and a parental report of urine being passed. Palpation of the abdomen demonstrated nothing abnormal, a distended abdomen, or enlarged liver, spleen or kidneys would be cause for concern, either related to infection or to abnormality of these organs (Baston and Durwood, 2001). Displaced or enlarged liver or spleen could also be an indicator of cardiac anomaly (Macdonald, 2008).
Cardiac function
I had not noted any maternal or family history of illness or abnormality and there were no documented antenatal concerns. The Down’s syndrome screening risk was low (National Screening Committee, 2008) and the 20-week scan for anomaly had detected nothing abnormal. However, Wong et al (2003) found that approximately 40% of cardiac defects were detected in antenatal ultrasound scans, so this would not rule out a problem. Intermittent auscultation of the fetal heart in labour had been normal throughout. Embryological formation of the cardiac system is a complicated process that begins during the third week post-conception with the formation and fusion of two mesodermal tubes, which already possess myocardial cells (Davies and Richards, 2008). A series of valves in the fetal circulation enable blood detoxified and oxygenated in the maternal system to largely bypass the fetal liver and lungs. At birth, adaptation to extra-uterine life is dependent on the closure of the foramen ovale, preventing blood flow from the right to left side of the heart, and the ductus ateriosis enabling deoxygenated blood to travel to the neonatal lungs for oxygenation. Cessation of blood flow in the umbilical cord and initiation of respiration also a play major role. A circulation poorly perfused with oxygen enriched blood due to malfunction or abnormality of the cardiovascular or respiratory systems may be a cause of cyanosis (Baston and Durwood, 2001; Hartley, 2002). Failure of either of the aforementioned ducts to close or abnormality of the structure of the heart would result in audible or palpable murmurs, clicks, heaves or thrills (Hartley, 2002; Horrox, 2002; Macdonald, 2008). With the baby quiet and relaxed, I auscultated the four chest areas of the heart (Hartley, 2002; Baston and Durwood, 2001), which had been demonstrated to me during my ten supervised examinations. At this point in my learning, I had not closely examined the theory of cardiovascular examination and I had heard only one heart murmur, I could not hear any abnormal heart sounds in this baby and the breath sounds appeared to be normal. Hartley (2002) notes that these techniques require practice. Palpation of the femoral pulses did not demonstrate any irregularity. The rest of the body was pink, warm and well perfused.
Respiratory function
As with the cardiovascular system, poorly developed or malformed lungs may cause difficulties with respiration and thereby poor oxygen perfusion (Johnson et al, 2003). Respiratory infection is rare, but may be acquired in utero, or during the passage through the birth canal, and should be considered (Faix, 2006). Cyanosis may also be caused by a respiratory obstruction such as choanal atresia (Baston and Durwood, 2001).
Genitalia
Apart from a small pustule on the tip of the penis, the male genitalia appeared to be normal (Baston and Durwood 2001; Johnson et al, 2003; Macdonald, 2008).
Recognising that these problems were outside the scope of my skills at this point and in line with the
Midwives rules and standards (NMC, 2004), I discussed the issues with the parents in the sensitive manner necessary at this time of heightened anxiety, when fears of abnormality may well be paramount (Raphael-Leff, 1991; Bainbridge, 2009), documented my findings carefully in the maternity records (NMC, 2005) and referred this baby to a paediatric registrar. He was happy to accept my referral, found nothing abnormal and discharged the baby to the community. Michaelides (1997) establishes the importance of inter-professional teamwork in the examination of the newborn, noting that the process should be seen as part of holistic care rather than a one-off examination.
It must be considered that the overriding advantage of midwives performing the examination of the newborn check is that of continuity of care, of being able to provide complete care for the mother and baby unit. This avoids a situation where the midwife provides total care throughout the antenatal period and the birth, only to await the input of a medical practitioner to pronounce the baby healthy or refer for further advice (Michaelides,1998). There is a danger that strategic thinking may view this extension of the midwives’ role as one of increasing throughput of the maternity service by reducing bottlenecks on the postnatal and delivery wards (Lomax and Evans, 2005). The parents of this baby had stated that they were not ready to go home, they were young and were tired following the birth. They needed breastfeeding support as, although the baby was willing to feed, the mother was struggling to accept that the few drops of colostrum she could see would be sufficient to fulfil his nutritional needs (UNICEF, 2009). The satisfactory completion of the newborn screening check meant that she would be put under pressure to vacate the bed. Health promotion, including promotion of breastfeeding is an important part of the midwife’s role (Crafter, 1997; Ackerman, 2004; Piper, 2005), the opportunity afforded by the midwifery examination of the newborn should be seized and used to full advantage. Here is a chance to discuss the parents’ concerns on an individual basis and to remind them of health benefits such as baby safety, smoking cessation, vaccinations and general health checks. If this promotion of a healthy baby and family extends to recommending a one-night stay in the hospital or birth unit, then the examining midwife should not hesitate to do so. Bernstein et al (2007) suggest that postpartum discharge of mothers and infants, who are not medically or psychologically ready may put the family at risk, however, Baston and Durwood (2001) remind us that it is important to avoid stereotypes and to recognise that youth in the parents may not equate to lack of baby care and childrearing experience.
Conclusion
Midwives are in a pivotal position to perform the examination of the newborn check and by doing so increase their job satisfaction (Kirkham et al, 2000; Kirkham, 2004) along with satisfaction of care for women and their families (Lumsden, 2005). Following a retrospective study of 482 babies, Williamson et al (2005) felt reassured that midwives were clinically effective in this role. It is, however, critical that they have the time to encompass the examination into a holistic framework of care (Michaelides, 1998; Lumsden, 2005; Davies and Richards, 2008) and are not seen as a method of speeding up a conveyor belt of maternity service.
Michaelides (1997) makes the point that consideration should be given to including an examination of the newborn module in the student midwifery programme, thereby adding a further dimension to the role of a midwife and firmly cementing integrated and equal care of both mother and baby in midwifery practice. Is it important for midwives to have the confidence that comes with practice experience before embarking on this extended role? Or would this knowledge; possessed by all midwives and viewed as an intrinsic component of midwifery, aid its dissemination into a continuous midwifery care process, reducing the situation where newly-learnt skills are lost through lack of use (Steele, 2007)?
My own professional development has been rapid and exhilarating. After many years of practice, I have found the addition of this role to my already quite considerable skill base, to be both surprising in the extent of extra knowledge gained and a major enhancement of job satisfaction. The examination of the newborn course has provided me with effective and stimulating preparation for the use of a valuable screening tool, while equipping me with a platform from which my skills and confidence will continue to grow. I am certain that, at times, I will be asked to conduct a series of newborn examinations in order to facilitate the postnatal discharge process, and I accept that for many women this is what is required (Lomax and Evans, 2005). However I intend to remain vigilant to their needs and to balance these with service requirements in today’s climate of choice for mothers and babies.
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