Assessment of the baby
Daily examination
Learning outcomes
Having read this chapter, the reader should be able to:
During the postnatal period the midwife will undertake an examination of the baby each day while the baby is in hospital and when visited at home to monitor early changes and ensure optimal progress is occurring. Whilst normality is identified, deviations from normal can also be recognized and appropriate action and referral instigated. NICE (2014) recommend the use of a postnatal care plan to guide individualized care for the mother and baby; this is updated each visit. Furthermore, parents should be given information and advice that will enable them to assess their baby’s general condition so they can recognize signs and symptoms of common health problems for babies and seek appropriate help (NICE 2014). Although it is referred to as a daily examination, it is not essential to see the baby every day during the postnatal period but according to clinical need. This chapter considers how the daily examination of a baby is undertaken and the role and responsibilities of the midwife in relation to this. This chapter should be read in conjunction with a number of other chapters which are referred to within the text.
Principles of the daily examination
Parental care
The facilitation of optimal infant health and development relies significantly on the skills, education and care given by the parents. This process begins during pregnancy with the midwife working with families in the beginnings of infant health and wellbeing and the development of the postnatal care plan. The midwife teaches by example (e.g. handwashing) as well as with verbal (wherever possible, evidence-based) suggestions. During the daily examination of the baby, the midwife relies on communication with the parents to appreciate the complete picture of how the baby is progressing. Equally, it is a time for guiding, educating and advising parents, as well as supporting and encouraging them in their new role.
Consent
The procedure should be discussed with the parents and informed consent gained, as the baby cannot give consent for the examination. There will be times when the parents may not give consent; for example, the baby is now asleep, having been awake all night. The midwife undertakes a risk assessment, based on detailed conversation, to appreciate whether a physical examination must be undertaken or whether it can be postponed until later. The examination should ideally be undertaken when one or both parents are present, as this provides a good opportunity for discussion as issues from the examination arise.
Reducing infection risks
The baby is considered a ‘compromised host’ at birth, at risk from infection that can affect morbidity and mortality. Standard precautions should be utilized (see Chapter 8) and it is important to avoid cross-infection from other sources; hand hygiene should be scrupulous (see Chapter 9). If contact with body fluids is anticipated, then personal protective equipment is used (e.g. gloves, apron).
Examination of the newborn
The daily examination is not a copy of the birth examination, but an assessment of progress thereafter. It therefore relies on the fact that all body systems have been screened and deviations from normal are known about, with progress assessed accordingly. It should be undertaken methodically, in a good light and a warm environment.
Initial observations
Observations on entering a woman’s personal environment (hospital or home) can give immediate indicators as to the situation and provide the midwife with prompts when giving care advice. The midwife should observe:
• how the parents are feeling by looking at them: peaceful, tired, tearful, happy, etc.
• whether the parents immediately begin to express problems or anxieties
• how the baby is positioned and dressed within the sleeping area
• how the parent(s) handle and react to their baby
The following observations are likely to lead into more detailed discussion and provide an opportunity for reassurance, education and support:
• Feeding patterns: is the baby waking for feeds and how often? What is the approximate feeding pattern? (This will vary according to feeding method.) If breastfeeding, is the mother happy that the baby latches correctly and is achieving an effective feed? (see Chapter 41) If formula feeding, are amounts taken appropriate for the age of the baby? Is the mother fully conversant with sterilizing and preparing feeds (see Chapters 43 and 44)? Is the baby settled after a feed? Is there any vomiting or posseting? In the event of vomiting green bile, or any projectile vomiting, a direct referral is made to a paediatrician.
• Do the parents have any other concerns or questions at this time?
General observation of the baby
Observing the baby before undressing it can reveal several potential problems:
• Respirations: the respiratory pattern is noted (often irregular in newborn babies, see Chapter 6), with a normal respiratory rate of 30–40 per minute expected when the baby is at rest with no signs of respiratory distress. The respiratory rate can increase to 60 per minute with crying. Chest movement should be symmetrical (this is often better assessed when the baby is undressed), nasal flaring should not be seen.
• Obvious signs of vomiting or posseting (see above).
• Skin colour: the baby should appear pink all over, reflecting good peripheral perfusion. With skin that is highly pigmented, signs of peripheral perfusion can be assessed by observing the mucous membranes, the palms, and the soles. Cyanosis with or without signs of respiratory distress should be reported to the paediatrician immediately. If the baby appears pale, this should be reported, as it could be indicative of underlying illness. Physiological jaundice, seen as a yellow discoloration of the skin (and sometimes the sclera and mucous membranes) is not unusual in babies. Physiological jaundice usually appears from the third day and may deepen over the next couple of days before beginning to subside by the seventh day. If the jaundice appears severe and widespread, particularly if the baby is very sleepy or not feeding, the serum bilirubin level should be estimated. Clinical estimation of the degree of jaundice can be inaccurate and is influenced by the type of lighting, the reflective ability of objects around the baby and the peripheral blood flow (Johnston et al 2003). Arkley (2007) advises that prolonged jaundice (lasting longer than the first 2 weeks) should be considered abnormal and a split bilirubin blood test undertaken. The majority of prolonged jaundice cases will be breast milk jaundice and the parents can be reassured. However, liver disease is sometimes the underlying cause.
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