NIPE 1 Flashcards
what are the first steps of NIPE?
Identify significant factors
what are the significant factors such should be identified in the first steps of NIPE?
- Any personal or family history which may be significant
- Any pregnancy information which may be significant
- Any significant risk factors from antenatal, intrapartum, postnatal
periods - If mum has any concerns with baby
- What feeding method and if baby has been feeding well
If baby has passed urine or bowel motions
what should be noted from the family history when performing a NIPE?
- Cardiac
- Hip problems
- Congenital cataracts
- Renal conditions
- Haemoglobinopathies (blood disorders)
- Cleft lip and/or palate
- Hearing problems
what should be noted about the mothers health during a NIPE?
- Endocrine (diabetes, hypo/hyperthyroidism)
- Cardiac
- Hypertension
- Haematological (anaemia, DIC (abnormal blood clotting), Sickle Cell, Thalassemia)
- Mental health
- Connective tissue disorders
- Medications ( prescribed medication e.g. labetalol - baby requires blood sugars) which then requires to check is blood sugars have been stable, if observations are stable and if baby has been feeding well.
- Social circumstances - substance misuse, child protection concerns)
- Smoking
- Infection
what should be noted about mothers pregnancy when performing a NIPE?
- Past obstetric history and children’s health
- Relate antenatal history to stage or fetal development and predict outcome in baby
- Results of antenatal screening (e.g. syndrome screening)
Gestational accuracy
what should be noted about the mothers obstetric history when performing a NIPE?
- Reduced fetal movements - tells us there might have been a lack of oxygen that’s why it was reduced
- Abruption
- Fetal distress
- PROM
- Meconium stained liquor - baby may be grunting, breathing recessions, nasal flaring, which could be due to meconium aspiration and there can be an infection developing.
- Maternal opiates - analgesia in labour and impact on neonatal sedation
- Neonatal resuscitation
what additional sources of fetal compromise should be noted when performing a NIPE?
- Smoking
- Alcohol
- Drugs - prescribed medication - recreational drug misuse
Infection - such as sepsis, GBS, PROM
what is the risks of smoking in pregnancy?
- Carbon monoxide reduces oxygen carrying capacity of mother and fetus
- Low birthweight (fetal hypoxia)
- Increased risk of glue ear - where the empty middle part of the ear canal fills up with fluid. This can cause temporary hearing loss.
- Increased risk of asthma
- Increased risk of orofacial cleft
Increased risk of NEC - Necrotizing enterocolitis (NEC) is the death of tissue in the intestine. It occurs most often in premature or sick babies
what is FAS?
FAS - Fetal Alcohol Syndrome
- Variable fetal effects depending on quantities of alcohol. - Microcephaly - small head - Small eyes - Hearing disorders - Large eyes - Shallow philtrum - Intrauterine growth restriction - Thin upper lip - Congenital abnormalities - cleft lip, palpate, heart defects
what congenital infections should be noted when performing a NIPE?
- Group b Streptococcus
- Cytomegalovirus (CMV)
- Rubella
- Toxoplasmosis
- Varicella Zoster (chicken pox)
- Listeria - food positioning
- Hepatitis B, C
- HIV
Herpes - genital warts
what information around the mode of birth should be noted when performing a NIPE?
- Posture and compression effects
- Birth injuries
- Effect of hypoxia
- Effects of maternal medication
what does the history review of a NIPE involve?
Be prepared
Understand the history of the pregnancy, birth, adaptation to birth and family history - review maternity notes
Appreciate and understand the pregnancy and birth journey
how do you display sensitive communication when performing a NIPE?
Demonstrate - respectful, sensitive, communication with clear and understandable explanations towards NIPE.
Ask - of any concerns and listen to parental concerns
Seek and obtain - verbal consent for screening from parents, which should be documented in notes.
Every - woman will be going through a different journey - don’t assume
Choose - words carefully, be aware of non-verbal cues such as body language and eye contact.
Compassion - and non-judgemental approach makes a different. Non-verbal cues are extremely important.
how does the interdisplinary team work in relation to NIPE?
- NIPE trained midwife
- ANNP - Advance neonatal Practioners - any concerns refer to ANNP
- Neonatal team - liaise very close with ANNP
Specialist team for referral - if concern is redeem as significant it is then referred to specialist team
how do you feedback a negative NIPE result?
- parents should be informed of the results in a clear and understandable manner.
- parents should be informed that the NIPE will be undertaken in the primary care setting at 6-8 weeks as some conditions can develop later.
how do you feedback a positive NIPE result?
- the parent should be informed of the result and any referral process that may be required, including expected appointment timescales.
- if baby is in a treatment pathway for one of the screening elements. inform the parents the NIPE 6-8 weeks will still be required to be completed for the remaining screening elements.
How do you record keep NIPE?
- Verbal consent from parents should be documented
- Record screening result
- Record referrals following screen positive result
- Each health board could record different on badger and have differing referral procedures
Have awareness of local arrangements to ensure all babies with screen positive results are referred and seen in line with national standards.
What is the purpose of the NIPE?
One of the main reasons for conducting the routine examination of the newborn is to screen for health problems and this may result in a referral
- Full systematic check of the newborn to screen for potential abnormalities. - Offered to parents and completed within 6-72 hours after birth - Similar to examination of the baby at birth but includes additional screening elements: Hips, Heart, Eyes, Genatalia, Palate, Pulses RECOGNISE AND REFER
what are the standards of the NIPE examination?
- Determines the relationship between antenatal (before birth) and intrapartum (occurring during labour and delivery) events that may impact on the newborn’s health status, and subsequent events that may impact on the 6- to 8-week infant
- Ensures that the environment is conducive to effective and safe examination
- Facilitates effective informed decision-making
- Utilises a holistic, systematic approach, to comprehensively examine the neonate/infant effectively and sensitively
- Records and communicates findings to parents and relevant professionals
- Maintains and further develops professional competence in examination of the newborn/6to 8-week infant
what should the examiner bare in mind in relation to labour and birth?
- Was the pregnancy prolonged?
- Was the labour induced or accelerated and, if so, why?
- How long were the fetal membranes ruptured prior to birth?
- Were there any anomalies of the fetal heart rate during labour?
- Was the liquor meconium stained?
- What were the methods of pain relief used during the labour and birth?
- What was the presenting part of the fetus during labour?
- What was the mode of birth?
- Did the baby require any resuscitation at birth?
Were any injuries or abnormalities noted at the birth?
what are the limitations to nipe?
- Only a snapshot in time
- Things change!
Repeated by the GP at 6-8 weeks.
- Things change!
what is the structure to the NIPE examination?
- Preparation
- Observation and Discussion
- Examination
- Explanation
- Documentation
what does the preparation to the NIPE involve?
- Review family, maternal and full perinatal history in notes.
- Gather and check equipment (ophthalmoscope, pen torch, tongue depressor, tape, stethoscope, pulse oximetry, thermometer.)
- Introduce yourself to parents, name and role. Offer congratulations.
- Briefly explain the procedure including limitations.
- Confirm with mum any significant history or clarify anything identified from notes.
- Confirm baby name and date of birth
- Seek and gain consent to complete NIPE
what is the equipment required for NIPE?
ophthalmoscope, pen torch, tongue depressor, tape, stethoscope, pulse oximetry, thermometer
what does the observation and discussion involve in NIPE?
- Ascertain any carers anxieties and observe interaction with the baby
- Observe baby’s general condition while settled and undisturbed: colour, breathing, behaviour, activity, tone and cry
- Confirm urine and stool output (if it is 6 hours in and no meconium this is okay)
- Establish feeding method and any concerns
- Perform hand hygiene and don PPE if appropriate
what is the stool output expected and colour?
1- 2 day - 1 meconium
6 hours - 0-1 meconium
3-4 2 and changing to greenish/yellow
what is the urine output expected?
1 day 1-2 wet
3-4 day 2-4 heavier
what does it mean by baby’s colour?
should be pink in colour
check for cynosis, jaundice, any marks etc
what does it mean by check baby’s breathing?
check there is no recession - chest sinks in
check that theres not extra effort breathing
what does it mean by checking babys behaviour?
baby alert, sleeping etc
what does it mean by checking babys tone?
baby should not feel floppy when held
what does it mean by checking babys activity?
ss
what does it mean by checking baby’s cry?
does the cry sound normal, not high pitched etc
what do you asses wen you are checking the skin?
Colour - no jaundice etc.
integrity - no cuts, breakages etc
birthmarks - blue spot etc
trauma - birth trauma e.g. forceps
what is the skins role?
Important role in temperature regulation, barrier to infection, balances electrolytes and stores fat.
what is the advice of using products on baby’s skin?
- Baby products along with exposure to urine or faeces could disrupt this protective barrier ‘Parents should be advised that cleansing agents should not be added to a baby’s bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild non-perfumed soap.’ (NICE, 2015)
baby skin is really healthy and new things like vernix can be rubbed in and moisturiser. baby’s tend to not need any moisturiser.
Baby’s all of ethnicities should have what colour of mucus membranes?
Baby’s all of ethnicities should have pink mucus membranes
why should vernix be left to be absorbed?
Vernix caseosa should be left to absorb as an antibacterial and antifungal skin barrier.
what else should you view/ look out for when assessing the skin?
- View oral mucus membranes, gums and tongue, especially when a baby has a darker skin tone.
Lanugo – downy hair present is much more present in premature babies, however term babies also have variable amount of lanugo.
what skin findings should you note?
- Port wine stains
- Mongolian blue spot
- Cradle cap
- Desquamation
- Erythema toxicum
- Milia
- Acne
- Naevus simplex (“stork bite”)
- Moles
what is this a picture of?
Cyanosis is the blue discolouration of the skin and mucous membranes caused by deoxygenated haemoglobin.
what is the difference between central and peripheral cyanosis?
Central Cyanosis - this condition produces a bluish discolouration, specially noticed on the mucous membranes of the lips, tongue, fingers and toes. Peripheral Cyanosis - this condition affects the fingers, toes and skin surrounding the lips, is not noticed around mucous membranes.
what is peripheral cyanosis associated with?
In neonates peripheral cyanosis is common in the first 24 hours of life and is not considered pathological if the baby is generally well.
what is central cyanosis associated with?
Central cyanosis is associated with pathology and can indicate respiratory, cardiovascular or haematological abnormalities. Therefore, it is essential that midwives are able to detect signs of cyanosis in neonates.
what should the examination of the skin also involve?
It should always involve examination of the lips and mucous membrane in the mouth and tongue because these are areas where there is thin epidermis and a good blood supply in all skin colours and therefore sites that are reliable indicators of central cyanosis.
what is this?
Erythema Toxicum Neonatorum (commonly called Newborn Rash) can look alarming but it is an insignificant, transient rash present in approximately half of babies in the first few weeks of life
what is this?
Neonatal pustular melanosis resolves spontaneously but similarly it can be very concerning for parents, particularly as the small pustules develop and then turn into flat, brown lesions
what is dermal melanocytiosis?
we strongly recommend using the correct name: dermal melanocytosis or simply blue spot. Inability to accurately recognise blue spot has led to this being confused with bruising.
They are always non-tender with no associated swelling or redness. Bruises may be tender with associated inflammation. They can be blue/grey but they are less uniform in colour and the colour also changes as the bruise ages; sometimes purple and yellow tones can be seen.
what is jaundice?
Jaundice is the yellow colouration of skin and sclera caused by raised bilirubin
jaundice in the first 24 hour is always pathological
physiological jaundice that spontaneously resolves without treatment. Less commonly, jaundice is pathological and can be life-threatening. require referral is an important part of neonatal care
A full visual assessment should be made in good light and particular attention should be paid to inspecting the whites of the eyes (sclera), gums, palms of the hands and small areas of skin temporarily ‘blanched’ by light digital pressure.
is this normal?
piterkea - infection
is this normal?
mottling not normal
is this normal?
no
what is this?
stork bites - normal
what is this?
strawberry mark normal
what does the head and face examination involve?
head and scalp
eyes
nose
mouth
ears
neck and clavicles
what things should you be looking our for when examining the head?
shape, size, sutures, head circumference (32cm-36cm), fontanelles (should not be raised - bleeding trauma, or sunken - dehydration), injury (birth injury - FSE Marker make sure they aren’t infected), caput - can press down on it, crosses suture lines. Cephalhematoma - hard feeling, does not cross suture lines, worry about jaundice, can get worse, refer to paeds.
what things should you be looking our for when examining the eyes?
Eyes - shape, symmetry, position, spacing/folds discharge, sclera and red reflexes. epicanthic folds can indicate Down’s, purulent discharge could indicate infection, fissures, keyhole - if part of the pupils leak into eyes - concerning. Using the ophthalmoscope away from eye then look at eye away from eye then look at eye. White red reflexes may be sign of cataracts.
what things should you be looking our for when examining the nose?
patency (size of the nostrils), philtrum - having a shallow philtrum may be sign of syndromes.
what things should you be looking our for when examining the mouth?
visualising and digital inspection of the hard and soft palate to uvula, tongue and gums, presence of suck reflex, jaw
what things should you be looking our for when examining the ears?
size, shape, position, level, abnormalities, hearing test
what are you checking for when palpating the vault of the skull?
Palpating the vault of the skull to check the degree of moulding by the amount of overriding bones at the sutures and fontanelles. The shape of a baby’s head as a result of moulding gives an indication of the presentation in utero. Parents can be reassured that moulding usually resolves within a few days.
what is caput?
oedematous swelling, caput may be noted over the presenting part as a result of pressure of the cervical os and disappears within 24hrs.
- Soft tissue oedema with poorly defined outline - Present at birth, does not increase in size - Swelling crosses suture lines - Disappears within hours to several days
what is this?
caput
why must the neck be examination in relation to the head?
- The neck must be examined to exclude presence of swellings and that rotation and flexion of head are possible.
during NIPE what should you measure?
- Head circumference of the occipitofrontal diameter should be 32-36cm for a term baby
what is important about the fontanelles?
- The anterior fontanelle remains present and palpable for up to 18 months, while the posterior fontanelle should be closed by 6 weeks following birth
- Examination of the fontanelles should be when the baby is at rest and should neither be raised or sunken.
rasied - trauma
sunken - dehydration
what is this?
cephalohematoma
where are the frontal bones?
where are the parietal bones?
where is the occipital bone?
where s the metopic suture?
where is coronal suture?
what is the sagittal suture?
what is the lamboid suture?
where is the anterior and posterior fontanelle?
where the palpebral fissure length?
where is the inner canthal distance?
where is the epicanthic fold?
which one of the is normal and which one is abnormal?
