All babies are offered a clinical examination within 72 hours of the birth, by a professional who has been trained to do so (Department of Health 2008). This person has traditionally been a paediatrician but increasingly midwives and neonatal nurses are undergoing additional programmes of education and supervised practice to enable them to fulfil this role (Mitchell 2003). For the purpose of this chapter, this professional will be referred to as the practitioner. It is important that all midwives understand what the clinical examination involves so that they can discuss it with parents, both before and after the event. This chapter outlines the content of the examination and describes some of the issues that can arise from it.

As well as being checked at every postnatal examination, the newborn baby is checked systematically twice within the first 72 hours of life. The first head-to-toe examination is carried out by the midwife before she leaves the woman after a home birth or before the mother and baby are transferred from the labour ward, if birth has taken place in hospital (see Chapter 3). The purpose of that examination is to rule out gross physical abnormality (National Screening Committee (NSC) 2008) but also provides an opportunity to reassure parents and promote health and wellbeing (Baston & Durward 2001). A subsequent examination is then performed, usually before the baby leaves hospital, ideally within 24 hours (Hall & Elliman 2006) but before the baby is 3 days old. This examination is sometimes referred to as the ‘neonatal examination’ (Hall 1999, Mitchell 2003), ‘examination of the newborn’ (Baston & Durward 2001, Townsend et al 2004), ‘physical assessment of the newborn’ (Lumsden 2002) or the ‘newborn physical examination’ (NSC 2008). Irrespective of the name given to the examination, its purpose is to detect less obvious conditions through a more detailed clinical assessment. The baby will be examined again at 6–8 weeks, as some physical conditions do not become evident until the baby is older.

There are now a range of professionals who are able to undertake the examination of the newborn – a role traditionally held by paediatricians (Lumsden 2002). Midwives and neonatal nurses must undertake further education and supervised clinical practice in order to perform this role. There are many education programmes available throughout the United Kingdom, each currently having a range of criteria for successful completion and competency to undertake the role. However, in order to standardize the content of the examination performed and the competency of the individuals who undertake the examinations, the National Screening Committee (NSC 2008) has launched Standards and Competencies against which future commissioning should be based (Davis & Elliman 2008). The NHS for Scotland has published a Best Practice Statement (NHS Quality Improvement Scotland 2008a) which also includes core competencies and an audit form to assess Compliance.

When practitioners other than paediatricians started to undertake the neonatal examination, there was considerable debate as to how effective they would be, how acceptable they would be to women and what the cost implications might be (Lomax 2001). In a qualitative study exploring midwives, GPs’, junior paediatricians’ (Senior House Officers (SHOs)) and mothers’ views (Bloomfield et al 2003), all groups felt that midwives and SHOs were appropriate professionals to carry out the examination. The majority felt that it was most appropriate for midwives to undertake the role as they had a better rapport with women and were not as rushed as SHOs. However, there was concern by some midwives about their capacity to take on additional roles within their current remit. There was little evidence of SHOs being trained for this specific examination.

In a prospective study comparing SHO referrals to specialist clinics with those from Advanced Neonatal Nurse Practitioners (ANNPs) (Lee et al 2001), it was concluded that ANNPs were more able at detecting hip and eye abnormalities. There was no difference between the professions at detecting cardiac anomalies.

In a randomized controlled trial of 826 mother and baby pairs (Wolke et al 2002), comparing paediatric SHO examination with midwife examiners, it was concluded that women were more satisfied if the examination was conducted by a midwife. This was because midwives were more likely to engage in discussion of healthcare issues. When continuity of carer and discussion of healthcare issues were taken into account, there were no differences between the groups. The study also highlighted that only 51% of newborns were eligible for examination by a midwife due to strict exclusion criteria and that midwives took about 5 more minutes than the SHO to examine the baby. In the quantitative aspect of the study (Townsend et al 2004) there were no significant differences between the doctors and midwives with regard to subsequent inpatient admissions, missing problems or referrals to consultants in the first year of the baby’s life. The study also concluded that if midwives were to undertake more of the examinations, there would be a considerable saving to the NHS but some increased costs would be incurred by midwifery departments.

It is not the remit of this chapter to prepare the reader to be able to undertake this detailed examination, but to highlight what the practitioner should include so that you can prepare the parents and understand what you observe. For a detailed explanation of the content of the examination see Baston & Durward (2001).

The neonatal examination comprises five phases (Table 4.1).