Postnatal checks: How to use phone consultations to reduce contact
Dr Shivani Patel and colleagues share their practice's approach
How to carry out six-eight week baby checks remotely
GP registrar Dr Shivani Patel and GPs Nazmul Akunjee and Muhammed Akunjee explain how the approach to baby checks has changed at West Green Surgery in north London.
Why a new approach is needed
Covid-19 has shaken the way primary care functions on a daily basis making what was previously the norm of 10-15 minute face-to-face appointments a rarity.
Despite this pandemic, NHS England provided guidance that six-eight week baby checks should continue. However they advised that the newborn and infant physical examination (NIPE) infant check can be delayed until eight weeks of age to coincide with the first primary childhood immunisations so they can be done in one visit.
With midwife and health visitor home visits being kept to an absolute minimum, and local weighing centers closed, it is important for the six-eight week baby check - even if delayed due to Covid-19 - to occur in order to help identify early warning signs such as decreasing baby weight, prolonged jaundice and parental feeding concerns and anxiety.
With most consultations now video or telephone, this poses the question as to how one conducts a thorough baby check whilst minimising the risks of Covid-19 for both the parent and child, as well as one’s own risk. Our practice has now restructured our baby clinics to a dual appointment approach using,telephone as well as face-to-face consultations.
How to reduce face-to-face contact when carrying out postnatal checks
Minimise visits to the practice
Where possible or practical the practice should consider realigning the baby check to run parallel to the nurse’s eight week immunisation clinic. If your practice has the capacity, consider having this as a joint clinic whereby the child is assessed first in the room by the doctor before the nurse attends completing the eight-week immunisations.
Use the largest room available in the practice, preferably the nurses / treatment room where the immunisations would likely to be stocked and available for use. This should help reduce unnecessary visits to the practice and thereby reducing risk of Covid-19.
Robust advance telephone consultations
An earlier telephone appointment gives an opportunity for the GP to ask Covid-19 related questions whilst also asking focused screening questions along with the parent’s ideas and concerns. Many of these can be addressed during the telephone call, however, any concerns that could not be addressed immediately can be reserved for the face to face consultation which the clinician books into themselves offering a specific time.
If the parent or child reports positively for Covid-19 related questions (i.e. cough, temperature in the household) then the telephone assessment should continue but the face-to-face appointment should be delayed by two weeks. If this is not possible, then the baby should be booked into an available hot hub site for review where the focused examination can be conducted safely with full PPE.
Example of a typical baby six-to-eight week clinic
Questions to consider asking the parent when taking a telephone history
- Does the baby have a new cough or temperature?
- Does anyone in the family have symptoms of a fever or a cough or is self isolating?
- Was the baby born through normal vaginal delivery or was it a C-section? Was it an assisted delivery (forceps)? How many weeks gestation at delivery?
- Any NICU or SCBU admissions?
- Any problems during the new-born physical examination (NIPE)?
- Any concerns about feeding or weight?
- Is the child being breast or bottlefed?
- Does the baby ever go blue?
- Do eyes look yellow?
- Do you think your baby can’t ever fully open both eyes?
- Do you think your baby doesn’t make good eye contact and hold his/her gaze at you?
- Do you think that your baby doesn’t follow your face if you move your head from side to side when standing near him/her (less than 1 metre)?
- Do you think that your baby’s eyes shake/flicker/wobble?
- Do you think there is something unusual about or in your child’s eyes, eg. cloudy pupil or the eyeball is an unusual shape or size?
- Does the baby smile after six weeks?
- Does the baby's head shape look ok? Was it distorted in delivery?
- Does the tip of the nose appear yellow?
- Does the baby startle to loud noises?
- Does the baby follow mum’s voice?
Hip (to exclude DDH)
- When you change your baby’s nappy, do you find that one leg cannot be moved out sideways as far as the other?
- Does one leg seem to be longer than the other?
- Do you have any concerns about your baby’s hips?
- Any close (first degree) family history of hip problems?
- Was baby born breech?
- Any Intrauterine problems (i.e. reduction in amniotic fluid)?
- Was it a multiple pregnancy?
- When you lift your baby are they floppy? Does the head lag behind as the infant is pulled from to sitting in an upright position?
- Is your baby moving all four limbs equally?
- Does your baby seem breathless or sweaty, at any time, especially when feeding?
- Do your baby’s lips go blue at any time?
- Any family history of heart problems?
- Does your baby have any birthmarks or remaining scars from delivery?
- Any birthmarks in the lower back or sacral dimples/ sinuses? (spina bifida)
- Any concerning rashes?
- Are you worried about your BCG scar, cradle cap or baby acne? (common parental anxieties)
- Does your baby open bowels every day? Is it regular? What colour are the stools?
- What colour is the urine?
- Any lumps or hernias ?
- Are the testes symmetrical, and felt on both sides?
- Does external genitalia look normal?
Minimal exposure during a face-to-face examination
When the child is invited back for a face-to-face examination, they are offered a fixed appointment time for which the examination can be conducted. Sufficient time should be permitted between face-to-face appointments to permit the clinician to change their PPE accordingly. Baby weighing scales and tape measures should be wiped down between examinations.
To minimise risk to other members of the family only one parent is invited with the baby for examining. The parent is encouraged to have the baby dressed in light clothing permitting rapid reclothing post examination.
As described earlier, the nurse immunisation clinic can be merged with the baby clinic such that after the child has had their six-eight week baby check they are offered their immunisations immediately afterwards by the nurse. This helps reduce unnecessary delay or exposure to the parent and child.
Performing a condensed face-to-face baby examination
- Inspect the baby as normal at first glance
- Check the skin for rashes and colour, tone when baby held my parent, hands and feet for digit appearance/ number, talipes (cyanosis or severe respiratory distress may be signs of congestive heart failure consider urgent admission)
- Inspect eyes, gaze and eye movements, does the light reflect symmetrically in each eye,inspect pupils. Elicit red reflex and inspect for congenital cataracts
- Palpate fontanelles, check head shape, parents may be increasingly anxious about cradle cap
- Check palate with your gloved finger, can also inspect for tongue tie if patients are worried or there is a feeding history
- Listen to heart sounds for murmurs and palpate femoral pulses
- Palpate abdomen looking for umbilical or inguinal hernias, check for organomegaly
- Palpate testes and inspect external genitalia
- Examine hips - examining thigh creases, leg position and length and perform Ortolani's and Barlow's tests.
- For the Barlow’s test, grasp the child’s thigh near the hip. Flex at 90 degrees and apply gentle pressure downwards. Listen for a clunk suggestive of a dislocatable hip.
- Next for the Ortalani’s test, abduct the hip and apply gentle pressure to relocate the hips back into the acetabulum. If the hip joint relocates then a ‘click’ or ‘clunk’ can be heard and felt.
- Check spine and anus - particularly for dimpling, sinuses or birth barks that may mask or indicate possible spina bifida
Weight and head circumference
- It may be easier to plot these directly into the EMIS system rather than the red book, as this can be time consuming and will lead to more exposure with the patient. If there has been any concerns it may be more appropriate to plot in the red book to be able to see trends. GP computer systems also permit the printing and emailing of growth charts and centiles should parents request this.
- It may also be more efficient to document the examination directly on to EMIS as most practices will have an electronic proforma making the check easier to document.
- Should abnormalities be found a further phone consult will be offered to discuss these in detail maintaining reduced exposure between clinician and parent.
Things to consider for maternal mental health and safeguarding
It is important to consider maternal mental health. This is an increasingly difficult time for all mothers, due to likely reduced social support due to shielding of older relatives / grandparents and the extended lockdown period.
This is particularly difficult for first time parents as it can isolate parents from close relatives and other parents who would have had the knowledge and experience to provide support and guidance. Therefore, during the check it is essential to ask about maternal mental health, even probe into issues such as domestic violence as appropriate to be able to intervene as early as possible.
It may be appropriate to ask how the new mother is coping. Useful questions such as
- Is this first baby?
- Was delivery traumatic?
- How has your mood been since delivery?
- Who else is at home?
- Is there a partner and if so are they supportive?
- How many other children are at home, particularly those under 5?
In cases where there are high risk safeguarding concerns or mental health concerns, open telephone or face-to-face reviews may be necessary, to allow mothers to disclose concerns in person and to make a full assessment.
During these difficult times, it is paramount to be more thorough and illicit possible children safeguarding concerns due to reduced face-to-face contact.
It is important to monitor child protection alerts and check if other children in the house have ever been under the child protection register. Are the parents known to services or have a criminal history, is there drug or alcohol misuse in the household, previous domestic violence.
Source: information provided by Dr Shivani Patel [supplied 1 May]