Royal Society of Medicine Forum: Assessment of the newborn: whose job –midwife or neonatologist?

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 23rd February 2006. The meeting was chaired by Maggie Redshaw, social scientist, National Perinatal Epidemiology Unit, Oxford.

The report will be published in the Midwives Journal of the Royal College of Midwives, and appears here with their permission and our thanks.

Who should be responsible for the routine examination of the newborn?
Cathy Rogers (CR), consultant midwife, Barnet and Chase Farm NHS Trust, and senior lecturer, University of Hertfordshire

The routine examination of the newborn is an integral part of child health surveillance and has normally been performed by the paediatric senior house officer (SHO). It has three main aims, screening, health education, and parental reassurance (Hall & Elliman 2003).

Changes in the organization of maternity care, the reduction in junior doctors' hours, and government proposals for better utilization of the skills and expertise of all healthcare professionals has resulted in midwives and others developing their practice to include the routine examination of the newborn.

The objective of our study was to compare the relative cost effectiveness of midwives and paediatric SHOs performing the newborn examination. The study included a prospective randomized controlled trial (RCT) with mother and baby dyads randomized to examination by a midwife or SHO. In addition video assessment was undertaken of a sample of midwives and SHOs conducting the examinations, which were rated by independent experts. In-depth interviews were undertaken with a sample of mothers, midwives and doctors to evaluate their opinions on the examination and who should be responsible for it. In order to determine current practice and opinion a national survey was performed as well as interviews with representatives of professional bodies. The main outcome measurements were maternal satisfaction assessed shortly after the examination and at 3 months, appropriate referral rates, the quality of the examination as assessed by video, and the opinions of all key stakeholders. The study was undertaken in a district general hospital in south-east England over one year, recruiting 826 babies in the postnatal wards.

Overall maternal satisfaction with the newborn examination was high, with 81% (547/674) of mothers reporting that they were satisfied or very satisfied with the examination. Nevertheless mothers were more satisfied when a midwife rather than a SHO examined their babies. Discussion on healthcare issues and continuity of care were significantly related to higher satisfaction, and midwives were significantly more likely to discuss healthcare issues. (61% versus 33%).

We found no significant difference in referral rates by midwives or SHOs. Neither was there any significant difference in problems in the baby in the first year of life, whether identified or not identified at 24 hours.

In the video assessment, where significant quality differences in items were identified, the item was rated as carried out more appropriately by midwives or by SHOs. The overall quality of the hip examination by both professional groups was generally rated poorly, highlighting the need for more focused training.

The key findings of the interviews were that the examination was viewed as a useful screening tool, that either appropriately trained SHOs or midwives could perform the examination, but that the SHOs do not receive any formal training for it. The perceived benefits of midwives examining the baby were greater continuity and improved quality of care. Midwives generally felt that this examination fitted well with the core values of normal midwifery. These findings concurred with the opinions expressed by the representatives of the professional bodies and user groups.

Our national survey revealed that 44% of maternity units had midwives who were qualified to perform the neonatal examination. Of these units 51% reported that all and 18% that some of these midwives actually performed the examination. We estimated that overall in 2001 only 2% of babies were examined by midwives, and that many midwives who were qualified to do the examination did not do it.

The overall conclusions from this study were that the quality of the examinations by midwives was at least as good and in many aspects better than that of SHOs, and that midwifery practice should be developed to include the examination of the newborn. To achieve this we recommended that the core competencies to perform this examination should be included in the pre-registration midwifery training curriculum, and that post-registration courses be accessible to midwives already qualified. We also recommended improved training for junior doctors. Full details of this study are available on the Health Technology Assessment website.

References.

David M.B. Hall and David Elliman (Eds.) Health for all children. Fourth Edition 2003. Oxford University Press.

Townsend J, Wolke D, Hayes J, Dave S, Rogers C, Bloomfield L, Quist-Therson E, Tomlin M and Messer D (2004) Routine examination of the newborn: the EMREN study. This link to the Health Technology Assessment (HTA) Monograph Series appears here with thanks.

Evaluation of an extension of the midwife role including a randomized controlled trial of appropriately trained midwives and paediatric senior house officers. Health Technology Assessment NHS R&D HTA Programme.

Combining different assessment methods for a holistic approach to high risk infants.
Betty Hutchon, Head Occupational Therapist (Paediatrics), Royal Free Hospital, and Honorary Lecturer, University College London and Royal Free Hospital Medical School

In the group of children which we identify as being at high risk, those of very low birth weight (VLBW), up to 40% have been shown to have significant neurodevelopmental disability at school age. This may be the cause of difficulties with attention and behaviour, perception, co-ordination, speech and language and other specific learning and emotional problems (Hall A. et al). Follow up of these children is of course intended to identify such problems and enable early intervention, but must also include healthcare and developmental information relevant to each child, so enhancing the family's care giving skills, and it is this, and reassurance, which parents most appreciate. Where necessary we link families to community based services and provide specialised management for complex medical conditions.

Known now as anticipatory guidance, this approach is expected to cause a change in the attitude, knowledge or behaviour of parents (Telzrow 1978), helping them to understand better the challenges to a child's development; it is a mechanism for strengthening a child's developmental potential (Brazelton 1975), and is itself a tool for building relationships. Importantly assessment should have treatment utility, focusing on behaviour, neurological issues, and development. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) can prevent some problems in preterm infants; behavioural assessment observes whether a baby is irritable or calm, how he responds to stimulation - is he well regulated?

The Brazelton Neonatal Behavioural Assessment Scale was designed for newborns of gestational age 37 to 48 weeks (T. Berry Brazelton 1973). It has the advantage for parents that it focuses on a baby's achievements as well as on any problems, and leads naturally to educational discussion around his competence and complexity, emphasising the contribution he makes to the relationship with his parents, and helping them to read behavioural cues as meaningful communication.

A video record of the baby is made for the Prechtl Assessment of General Movements. This provides neurological and behavioural information from preterm age up to five months, though I employ it at term age and crucially at three months. It has been shown to have very high sensitivity and specificity for the diagnosis of cerebral palsy. [At this point the speaker showed videos demonstrating the the fidgety movements of a normal baby aged three months - circular movements of the wrists, ankles and hips, but in subtle ways affecting the whole body, confidently confirming the baby's normality. By contrast his damaged twin showed "absent fidgety" movement, a relative stillness never seen in healthy babies, and a definite sign of cerebral palsy. Another baby, four weeks preterm, showed the normal complex and variable movements of all the body parts; his abnormal sister showed poor repertoire movements, repeated again and again. At 3 weeks post-term age her movement pattern had deteriorated to "cramped-synchronised", an obvious stiffness.] Here were opportunities to demonstrate the abnormality to the parents, and to reassure them that much could and would be done for their baby.

Used in the early intervention setting, Brazelton's Neonatal Behavioural Assessment Scale and Prechtl's Qualitative Assessment of Spontaneous Movements complement one another very well; one helps us to understand the baby's behaviour and to pass that information on to the parents to help them in care-giving, and the other is a reliable indicator of the baby's neurological status, allowing us to target intervention if needed from a very early age.

References.

Hall A. et al. School attainment, cognitive ability and motor function in a Scottish VLBW population at 8 years – a controlled study. Dev Med Child Neurol. 1995; 37:1037-1050

Telzrow RW. Anticipatory guidance in pediatric practice. J Contin Educ Pediatr. 1978; 20:14 –27

Brazelton TB, Symposium on behavioral pediatrics. Anticipatory guidance. Pediatr Clin North Am. 1975 Aug; 22(3):533-44

Brazelton, T. B. (1973). Neonatal Behavioral Assessment Scale. Clinics in Developmental Medicine, No 50. London: Spastics International Medical Publications.

Prechtl HF. General movement assessment as a method of developmental neurology: new paradigms and their consequences. The 1999 Ronnie MacKeith Lecture. Dev Med Child Neurol 2001; 43:836-42.

Midwives' experiences of examination of the newborn.
Hilary Lumsden (HL), Senior Lecturer in Midwifery, School of Health, University of Wolverhampton (Co-author)

Newborn babies have traditionally been examined twice in the neonatal period, once by the midwife soon after birth, and again prior to discharge home by a junior doctor. The reduction of junior doctors' hours (NHS Executive, 1991) has resulted in fewer available doctors to perform this crucial aspect of newborn screening. The inception of the Scope of Professional Practice (UKCC, 1992) has enabled nurses and midwives to undertake some of the work which previously fell to the Senior House Officer (SHO). The University of Wolverhampton delivers a validated course, giving nurses and midwives the relevant knowledge and skills to take on this additional role. The service provided by the midwives in this study aims to provide seamless care to the mothers and babies within the Trust.

This presentation is based on a small study of the views of ten midwives on their undertaking full clinical examination of the newborn as part of their role for at least six months, and working in one Trust only. I got Local Research Ethics Committee (LREC) and university approval for the course, and the written consent of the midwives to the audio recording of our interviews. The examination involves, in addition to the usual check over to reassure parents of the normality of their baby, auscultation of the heart, examination of the hip joints, and detection of the retinal red reflex. The first course of training for this was that of Stephanie Michealides at Middlesex University (1995); there are now about 30 courses throughout the UK.

I opened my interviews with the following Grand Tour Question: "Can you describe to me your experiences of examination of the newborn as an aspect of your midwifery practice?" My taped interviews, all conducted in the clinical area for the convenience of the midwives, lasted 30 to 45 minutes, and the tapes were laboriously transcribed verbatim; data were collected over a six week period. Using Giorgi's (1985) procedural steps 14 categories emerged, and these were reduced to five themes.

Theme 1 concerned the interests of the mother and baby. The neonatal examination was seen to belong in a holistic view of care and continuity. Fears that the mothers would have preferred a doctor to examine their babies proved groundless: "They've always trusted us to examine their babies because they know us" and "Doctors don't see the full picture". One midwife suggested that she was aware of a lack of skill in the junior doctors, who were only too happy to hand over the task of examination.

The second theme was midwifery-led care. The comments reflected an improvement in knowledge, skills and attitudes: "Once I'd heard a heart murmur it was like opening the floodgates". There was a marked gain in professional and personal satisfaction - the neonatal examination completed for them the care they were giving mothers.

Theme 3 reflected the move from uncertainty to confidence and competence. These midwives' autonomy now includes the newborn: "You have to make a decision there and then". The fear of litigation following missed diagnoses diminished during the course of training, but midwives still feel less well supported than doctors in such situations; accordingly they ensure full documentation of their findings, and are careful not to leave parents believing that observations made at a later time would be unchanged. There are times when the gratitude of parents validates the midwife's experience when an appropriate referral has been made for abnormality, as when hydrocephalus was detected in a baby's home at 10 days. Consulting and being consulted was the fourth theme: "Our nurse practitioner is there if we need her"; "It feels strange when a doctor asks me what I think about a baby"; "We have an Advanced Neonatal Nurse Practitioner (ANNP) and she is very supportive".

The fifth theme reflected the feeling that the role of the midwife in neonatal examination was uncertain. She may find herself being asked to do the paediatrician a favour, and may experience the difficulty of having to make a choice. Other midwives may put her under the pressure of having to discharge a baby: "I always say no unless the baby is at 6 hours". Or the frustration and delay of getting the baby seen by a doctor may be irksome.

All the midwives interviewed express enjoyment in and an enthusiasm for their new role. "It's like running a whole parentcraft session with a mother". Their belief that they were providing a high quality service to families, and that mothers were satisfied with a midwife examining their babies confirmed other reports (Rogers et al. 2003; Wolke et al. 2002). They considered themselves competent at detecting abnormalities, and there was much evidence to support that; they felt that their positions as autonomous practitioners were strengthened. The ANNP was given much credit for the success of the scheme.

I believe that the accounts given by the midwives and the results of their work validate this small trial, and confirm the importance of continuing with the training. The EMREN study (2004) of routine examination of the newborn by midwives points the way to the future; national guidelines and competencies are expected. I am much encouraged by the attendance at the current training course of seven health visitors, who are keen to undertake examinations of babies aged two months; these will of course involve aspects of development.

References.

NHS Management Executive. Hours of work of doctors in training: guidance from the medical Royal Colleges and their faculties in the UK. Leeds: NHSME, 1991.

United Kingdom Central Council For Nursing, Midwifery And Health Visiting (1992) The Scope of Professional Practice. London: UKCC.

Michaelides S (1995) A Deeper Knowledge. Nursing Times. 91(33):59-61

Giorgi A (1985) Phenomenology and psychological research. Pittsburgh. Duquesne University Press.

Townsend D, Wolke D, Hayes J, Dave S, Rogers C, Bloomfield L (2004) Routine Examination of the newborn: . Evaluation of an extension of the midwife role including a randomised controlled trial of appropriately trained midwives and paediatric senior house officers. Health Technol Assess. 8(14):53-59

Rogers C, Bloomfield L, Townsend J (2003) A qualitative study exploring midwives' perceptions and views of extending their role to examination of the newborn - the EMREN study. Midwifery. 19: 55-62.

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 Diseases in Childhood. Fetal and Neonatal Edition. 86: F155-F160.

Discussion.

Beverley Beech of AIMS: Does this new role for midwives threaten the training of junior paediatricians? CR: Overall I feel that paediatricians recognise the wealth of experience which midwives bring to the examination, and that they would not feel threatened by midwives doing this. BH: Time has to be given to educating the professionals about the advantages of the change. Rona McCandlish, Chair of the NICE postnatal care guideline group asked delegates to contact NICE and make the guidelines better.

HL: At Wolverhampton we're not incorporating this training in the pre-registration midwifery course, believing that students already have enough on their plate. CR believes that space could and should be made in the midwifery curriculum to include competencies in the neonatal examination, given the advantages to women and the fact that it allows midwives to provide holistic care to the mother and baby. A consultant midwife pointed out that the curriculum is under examination at present, so that an opportunity for this change exists; a student midwife said that this would be a welcome part of the basic training.

A neonatal nurse practitioner asked whether there is audit of examination of the newborns by midwives, enabling them to learn the outcome of their referrals and to learn from any missed diagnoses. HL said that the great number of examinations, most of them of normal babies, precludes the such an audit.

A midwife and health visitor made a plea for new guidelines for examination of the newborn to apply equally to midwives and SHOs. A member of the UK National Screening Committee told us that they are working on competencies for all the relevant professional groups including GPs, all of whom should have the experience to maintain their competency; in addition, regarding quality assurance they are looking at the standards, parent information, timing, onward referral, where and what information needs to be recorded, the appropriate information technology, and the necessary training resources.

A community midwife from Basildon, where home births are encouraged, reported that until three of the community team had taken the training course in neonatal examination mothers often had to take their babies to the hospital to be examined; this never happens now. The course has been a great benefit for these families, and must increase the popularity of home birth.

Dr. Jeremy Bradbrook of the Association of Community Based Maternity Care reported that in the Chippenham area 1500 babies had been examined by midwives (in whose training he had shared) since the year 2000. Palpation of the abdomen is the only part of the examination which the midwives have found to be difficult, and referral to the paediatricians has been straightforward. Particularly in peripheral units the question "Is this baby ill - suffering from sepsis?" has to be answered urgently. He deplored the occasional practice of some GPs who asked mothers to bring their newborn babies to the surgery for examination.

BH described some of her experiences with NBAS, which combines the neonatal examination with the Brazelton scale, using as an example a baby's crying during the examination. We show parents how we stand back and watch the baby for a while, hoping to teach them to understand why she cries - does she want to be left alone to go to sleep, or to be picked up and played with, or to be fed? The known and trusted midwife is in a prime position to deliver this knowledge, rather than leaving parents to discover it by trial and error. The Brazelton highlights behavioural issues as a physical examination alone cannot; this is particularly useful for the mothers of babies withdrawing from their own drug abuse. They feel guilty, and anxious to do all they can to help in their babies' recovery. Irritability and self regulation are prominent issues here, and the Brazelton scale addresses them very usefully. Let NBAS be the next stage in training.

BH gave an example of the sort of caregiving tips which can be provided during a newborn examination. She was able to show the mother who was in despair over her baby's crying that it was simply caused by the baby trying to soothe himself by putting his fist in his mouth (something his mother had seen him do at a 34-week ultrasound scan). Now every time he did this he found a cotton mitt in his mouth, was frustrated and cried. Removing the mitts solved the problem; this baby would not be labelled, as he would have been, as the one who sleeps and cries and can't be played with.

Stephanie Michaelides of Middlesex University recalled setting up the first training course in 1992, when it was already entitled the neurobehavioural examination. She agreed with those who were of the mind that it does not matter who examines the baby as long as they are well trained, and do it in a holistic way. The full value of the examination can only be realised when behaviour is observed and understood. "I teach Brazelton every day to pre-registration students and others. The baby's behaviour is a vital part of examination of the newborn, and we need to be sure that the mother understands it too - we see the baby briefly, but she is the full-time carer. But to examine the baby comprehensively at one hour is not enough; the training must include continual assessment up to six weeks. Only in this way will mother and midwife identify problems earlier.

Dr. Luke Zander, retired GP obstetrician and teacher, and founder of the Forum: Subsequent to the Winterton and Cumberlege reports midwives have become the main providers of maternity care, and this is to be welcomed. It does matter who examines the baby - it's going to be the midwife, who has a holistic approach, and who represents primary care, where the task belongs. The exclusion of neonatal examination from the pre-registration course is much to be regretted, and I hope that steps will be taken for it to be included there.

The only neonatologist present pressed for the first examination to be carried out at two or three days, probably by a midwife in the family home. There must be a process whereby the omission of this is notified, as in the case of the Guthrie test, and by means of audit there should be feedback so that practitioners are made aware of their errors.

A representative of the Royal College of Midwives lent her support to the inclusion of neonatal examination in the pre-registration training course. She also encouraged submission to the relevant consultation on the website of the Nursing and Midwifery Council, but the author could not locate this.