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Okay, good evening everyone and welcome to the second webinar in our neonatal themed week here at Minor Bleep. Um It's my pleasure to be joined by Dr Phoebe Johnston, who is an S H O that has worked on a neonatal intensive care unit um and is here this evening to teach us all about the NYPD. So over to you, Doctor Johnston. Um Thank you James and welcome everyone joining today. Um As James said, my name is Phoebe. I'm an S H O um living in Manchester and working in East Lancashire. Um And I have to talk to you today about the night P or the neonatal exam happens in the 1st 72 hours. So today is gonna be a bit of a like Jack of all trades covering what the NYPD is. Um having a bit of a chat about um why and when it happens and then we're going to run through um the NIPT examination and questions. Um What some of the results may mean if you find any abnormalities and what are the next steps after you've completed the night going forward? So, the knife is a National Lies program. Um So it happens all up all over the country and it's involves an examination of all neonate within the 1st 72 hours of life. Um There are some exceptions to this when they're babies, particularly preterm or if they're unwell and admitted to NICU. But generally, the aim is to have this happen with to all babies within the 1st 72 hours. And the aim of it is to effectively detect any Children who are born with congenital abnormalities in four main areas. Um And these areas are the eyes, uh the hips, the heart and the test is in male babies. Um And effectively, it's just to try and reduce morbidity and mortality long term by doing this screening to everyone following the first night that that happens within 72 hours, there is a repeat examination that happens by the G P within the first 6 to 8 weeks and this is effectively like a second safety net to ensure that nothing is missed and that as babies develop and things become more apparent, they are picked up in primary care. So, um before you go into the Nike examination, it's really important, first of all, um to make sure that you've had a chat with mom and dad, um that you've had a look through uh mum's notes. Um and these are the notes from the antenatal from prior to that if they're mom's got any long term health conditions, if there's been anything that's been picked up on arch sound antenatal e in any of the scans. And if mom's had any particular screening, um and then it's really important to go through some questions with mom and dad. Um And these are to pick up risk factors prior to going into the examination. So the, the main um an important screen questions involve asking if there's any risk factors for baby having D D H or developmental dysplasia of the hip. So this involves whether baby was breech at any stage of the pregnancy. Um If the baby was a twin, if the other twin was breech at any point, um if there's any first degree relatives with D D H. So these are either um mom's parents or dad's parents. Um And if you have any risk factors there, regardless of your examination findings, it's important to book an ultrasound of the hips for the baby and this occurs at six weeks. Um And this is just to make sure that any babies who have these risk factors are safety netted, um examined, even if you can't find anything abnormal when you examine them. It's also important to ask screening questions about whether there's any family history of any congenital i conditions or eye conditions in the bath. Um Any congenital heart issues or any issues with the kidneys. And these are just the screening questions that you ask mom and dad before proceeding into the examination. Um Now going forward uh it's really important that when you're examining baby, obviously, you are somewhere that you can keep baby warm because you're going to be making sure that you see every aspect you want to completely undress the baby, you want to have a look at all of the skin. Um And so the best plan is to be either as a he's an incubator or resuscitate air so that you have warmth there. Also, you can explain to mom and dad what you're about to do, make sure that they're in the room in case the baby gets agitated and there's some parts of the examination that's really helpful, having an extra pair of hands there, especially if the baby is a little bit agitated at any point. So as with all um examinations of a patient, the most important thing to do at the beginning is just to have a, a step back and have a look at the the baby in general. So just having a look for babies, skin tone, having a look for um the pallor of the baby. Like if there's some pallor, you could, it could indicate that there's poor profusion. It could indicate that there's been uh like a hemorrhage as well. Um intestinal hemorrhage or um some kind of big bruising event after bath. Um You want to have a look to see if there's any evidence that baby's jaundice. So have a look at the sclera, have a look at the skin tone. Um, and there's gonna be another presentation this week all about neonatal jaundice. But does anyone who's watching have any idea what the risk of a baby with jaundice doesn't get treated what the jaundice can develop into. Um, just pop it in the, in the chat if anyone's got any idea. Well, it's a, as I said, it will, we'll go into a bit deeper in the presentation, which I think is tomorrow. Ah, there we go. Yeah, connect us. Brilliant. That is correct. And this is, um, effectively something that we're really worried about and we really want to avoid happening and can cause long term brain damage for babies. But as I said, we'll go into that a bit deeper later on in the week. Um, you also, then we'll just have a look at babies' tone, um, how they're lying in the bed. If, when you've been observing baby with mum, there's been any, any head lag. This is something that you want to keep an eye on because babies who are hypotonic will have difficulty feeding and could be a sign of something like an underlying sepsis or an underlying metabolic or neurological condition. Next, we move on to, um, having a look at baby's head. So you want to have a look at the pad look to make sure it's got a strange side or a strange shape. Um, so microcephaly is a small head. Um, so that's when the baby's head is abnormally small compared to what it should be. And macrocephaly is when babies has a bit larger, macrocephaly can be a sign of hydra crap Elice. So when there's a, like the ventricles in the brain are filled with too much fluid can also be a sign that there's genetic abnormalities. And you want to correlate the size of the baby's head with the size of babies body. Um A K is it symmetrical, is the head small and the body small or is it asymmetrical? Um when the head is particularly smaller and the bodies are normal size and this would warrant further investigation. You wanna have a look at the shape of the head um and have a feel for the baby sutures and for the fontanels, which are the parts whether um the plates of baby's skull having quite fused and you've got these soft patches, one at the front of baby's head and one at the back and you can have a feel at these fontanels. Um If they give you a quite a good sign of babies hydration status in a baby who's quite dehydrated, you can note that the fontanels are really quite sunken. Um Whereas in a baby who has raised entertaining pressure, um you might see that the fontanels quite bulging, you also want to make sure that you can feel the sutures because there's some conditions such a something called cranial synthesis where the sutures of the plates are fused too early and these confused in different places. And this needs onward referral as it would need surgical intervention. Um In order to allow babies to brain, to grow and the to be space for that, you also want to keep an eye out for any birth injuries that can happen to the skull. Um And there's, as you can see in the, the little diagram I've got here, there's a couple of different ones. Cap, it's a condom, which is a really common one and it's just a few subcutaneous collection. And the thing to note about the capital condom is it crosses the future line. So it's because it's just subcutaneous, it can like spread across the whole head. And these are other said really common. Um often following a one to use delivery or Kiwi delivery. Um and they tend to settle by themselves. A Catholic catholic hematoma is um a similarly a hematoma, but this one does not cross the suture lines. Um And this one is something to be aware of because in babies with big cattle hemotomas, it can lead to onward jaundiced is effectively just a big hematoma. A bruise that breaks down and then can lead to like after hemoglobin gets broken down, can lead to um joined us again. And then the one which is quite rabbit is something to be aware of is a subgaleal hemorrhage. And this is something that I've never seen that um is really uncommon. Um which is um uh hemorrhage between the scalp and the periosteum. So the bone and it's rare but it is quite life threatening. So, if ever you suspect it, the thing to do is just to get a senior review there next, we moved down and have a look at baby's face. So you want to make a mark of any birthmarks, any bruises, any lacerations, such as a lacerations from four steps. Often you find that in a baby that's had a forceps delivery, they have a distinct line or out like a sometimes even a little cut from where the four steps were when um, they were pulled out the womb and really important to make a note of all of this because especially when the baby goes home and they get home, visited by the midwife. If you've not specifically noted that there was a bruise on the left cheek or that there was a small operation or that you noted a bath mark. The midwife might go home and be concerned and reported as a safeguarding issue thinking that it could be a nonaccidental injury to the baby. Um So yeah, I said really important to make a note of that. And in the, these are in these three pictures that you can see from left to right are just an evidence of different types of birth marks that you might pick up on the left is a something called a salmon patch. Um, the middle one is a port wine stain and the right is a hemangioma and they're all reasonably common. And something just again to make note of you also want to keep an eye, um have a look at the face just again, a brief examination. Um note if there's, you know, any dysmorphic features, so low set is um like our my eyes. Um and anything that you would consider to be suggestive dance surgeon, it and the level that you will be doing, then I ps anything that you have any concern about the thing to do is just to get a C in your review. Um And it's better to be safe than sorry. Um The is as well. Have a look at the ears, have to check to see that they've got all the cartilage that you would expect. Um Sometimes you can note little ear tags um and or accessory oracles. Um And again, to something just let your senior have a note of and they can be referred onwards to, to E N T M plastics as appropriate. Next. Um It's really important to have an examination of the mouth and the palate, both the heart and the soft palate. And when you're examining um the mouth and the palate, it's really important not only to look right to the back baby's mouth, but you also have a feel because often you can't see everything. So you want to run your finger along the top of baby's mouth, have a feel for any cleft. Um And it's really important to pick these up, especially because they can have an impact on baby's feeding and baby's latching. Um So these are things that we refer and we try and get sorted urgently and actually the um that's something that you want to reassure mom and make sure that you're keeping an eye on. You also want to have a look to the back of the mouth. Um have a look at the uvula check to see if there's um you can get things where you have something called a bifid uvula, which is where the uvula looks like a little upside down heart. Um and just keep an eye on that. And you also want to check whilst your hair uh bit two babies, primitive reflexes. So one of these is the gag reflex and you've got to explain to the parents before you do this that you're gonna make the baby guard. Um And you just with a tongue depressor, just push likely to the back of baby's mouth and they won't like it, but it's something to make sure that they have. And also just as you're feeling along the top of baby's mouth, just allow them to have a suck of your finger because it's quite a good identification of how babies will latch and whether they'll feed well, if they have a good suck reflex and have a strong suck on your finger again, if you note that, um, like a baby's reflexes week or that they don't seem to be rooting and latching for your finger. Um, it's an idea to take a step back because sometimes these really non specific findings can be a sign of an infection and a baby. And again, there's a presentation later on in the week that's going into neonatal sepsis and some of the signs to look out for, but just be aware of it because a drowsy baby who's struggling to suck or who's not really rooting around. Um It's something just to keep an eye out of and they may actually have an underlying um sepsis. So next, we moved down um to have a look at babies' upper lips and you want to check when you're doing these examinations, it's really important to check the symmetry. So you want to make sure that the kind of tone and the muscle mass is symmetrical, you won't have a look for any extra digits, um a little extra nubbin or a finger. Uh This is something that I've come across and they look kind of cute at the time, but also really important to pick up and to reassure parents because a mom and a dad having a baby with six fingers on one hand, that's the kind of thing that's going to really make them anxious, they're really concerned about onward referrals about trying to get it chopped off and sometimes it's not something that gets sorted until uh the chart is three or four years old. Sometimes it's something that gets sorted much earlier and polydactyly or having an extra digit on the hand can range from something just being a little skin nubbin or can involve a whole structure of normal tissues, including bones, muscles, blood vessels and nerves. And in that kind of case, it would definitely need an onward referral to plastics because it's more than just you chop it off and you find there. So you probably need to get some imaging of the hand, have a look to see whether there's any neuro vascularity to the extra digit. Um and go from there. You also want to have a look at babies' hat and especially if you, you're concerned that you think that baby's just more fake. It'll have a look for the palmer crease. Does anyone know? Um in what condition you might have only one palmer crease as opposed to the to palmer creases that we or generally have? Yeah, brilliant. There you go dancing gym. Um So a single palmer crease is another thing that you would want to make a note of and going forward can be a sign of this trisomy. Now, next, we moved down. Once you've done the upper limbs, we move on to the thorax and the abdomen and I'm not gonna go too deeply into um a full examination of the chest and the abdomen. Again, it's something that is going to get covered a bit better in the such this power point. But you want to have a look at baby, you want to see what the work of breathing is. Um Have a look to see if babies got any intercourse of recessions. If they're working hard, if they're noisy breathing, you want to have a look to see when they're breathing. Does it look symmetrical? Um What's the respiratory rate? Does anyone know what the normal respiratory rate in, in a baby in the knee in a is this is a bit of a tough question but a clue is it's it's definitely a lot more than we look in an adult. Um over over triple quadruple what we expect in an adult. Um Yeah, brilliant. Um It's between 30 and 60 about is what you look for. You want to have a listen to the heart as well. Um Have a listen for the heart rate. Babies tend to have units tend to have a heart rate of about 100 to 100 and 60 BPM. Um and have a listen for any mama's if you do hear any mama. Um it's really important that again, you got to see in your review. Often systolic mama's in the 1st 48 hours are not abnormal and we just keep an eye on things, listen repeatedly over a couple of days to see what goes on. But if you have any concerns like baby's color or anything. It's not what you would expect that they're a bit SIA nose, then it's definitely something that you would need further investigation of. But effectively at your level, if you hear anything that you're concerned about that doesn't sound just like a normal love dub heart sound. Get a senior review of that. You also just want to have a little feel of babies tummy. Is it soft is extended? Um Can you feel any organomegaly, like particularly, can you feel the speed spleen particularly or the liver? Um, just have a lesson for, for bowel sounds as well. So next, and this is a really important one. Um, and something that I really struggled with the first few nights that I did, even though you think it's going to be something that's really, really quite easy. It's just to have a feel for the femoral pulses and a baby. And um, it's really important because, and you will i when you're having examining an adult, we have lots of pulse points that you can feel the radio pulse break your pulse. But in babies, they're pretty unreliable and often you can't feel them that. So you want to have a feel for both femoral pulses on either side. And it's important to be really patient here. Sometimes you press a bit harder and then you can't feel them because you're almost including the vessels. But you want to feel lightly and both in the creases of both legs, be patient and have a feel and you really need to be able to feel the pulse on both sides. And if you can't, and if you've listened for about three minutes or not, listen, felt for three or so minutes and you haven't been able to find anything. Um, then really important to, again, just get a senior to come and have a feel. Sometimes it's one of those things that you're trying too hard and then you get yourself worked happen, you can't find it. And I've had that a million times. Um, but this is something that in a sign when you have weak or absent femoral pulses, it could be a sign of um, some kind of cardiac congenital, cardiac abnormality. Um And so it's important to correlate it with the baby's oxygen saturations with the baby's color. Um And again, it might mean that the baby needs some further investigations, whether that's with an echo or something else moving down is then we move on to having a look at the genitalia. And obviously, this would be different for males and females. And as I said, the beginning of presentation, one of the reasons that we screen and then I P is um, to check that in men that you've got both testes and they are descended. Um So in men or boys, baby, baby boys, um, you want to have a look to see where the urethral meatus is. You want to have a look to see if there's any hypospadias, Expedia's whether um the urethral meatus is um not at the tip of the penis, but um somewhere along the length of it, you want to have a feel for both testes and again, something, make sure you explain to mom and dad what it is that you're doing and at the time that you're doing it. Um and I have a feeling sometimes the test, you can be quite retractor where they pull themselves back in. Um, so it can be a bit difficult again to try and work out whether you can feel the testes. But, um, again, be patient, sometimes you have to, um, examine one at a time and uh unilateral undescended testicle can be reasonably common and it's something that you flag up and you will need to follow up later, a later date. But if you can find neither testicle, if you have bilateral on center test is that is something that definitely needs to be investigated and could be a sign of a metabolic condition. Um Similarly, when you're examining the female genitalia, you want to have a look, um, check that the labor, aren't you check that you don't have any clitoromegaly, um, the clitoris is normal size. Um And again, if you have any concerns or any abnormal, any, there's any abnormalities that, um, again, it might be a sign of a metabolic issue next. Um And this is something that was really hammered into me. Um, and my time in the NICU is to check the anus. And it's something that actually in thinking that I was working in a baby had been sent home and it had been thought that that anus had been identified, but actually it had just been official to, um, and turned out that baby had, um, an imperforate anus and that it's, um, colon wasn't completely developed and it was very much another ever event. So you want to have a look. Um Sometimes it's easier if you roll baby onto their front, making sure that they're comfortable in the head to the side, have a look, have a look to make sure there's a sphincter around the anus um and make sure there's, it's a normal position that it's not too close to the genitalia which far away, but there's no other fischelis that you can see and it's really important that all babies past meconium um within the 1st 24 hours. And that's kind of the first, the very um dark green tea black like kind of poo that babies pass. Um And that shows you that the digestive truck seems to be all working um abnormal and I am biological development can result in what I was talking about earlier, which is an imperforate anus and this is when the anal canal can be missing. Um what's closed off such as you can see in the diagram there. Um and it can be associated with lots of other abnormalities as part of a syndrome or it can be isolated. So, if you have any concerns at all, it's something to flag up and it's very, very important that you make sure that you have seen the anus next. Um we move on to the hips and as we were talking about earlier with the screening. So even if you have spoke, gone through the screening questions, and you've noted that there's this baby has risk factors for developmental dysplasia of the hip. You want to make sure that you do this test to. And so there's two tests, one is called the Barlow's test, um which you'll do two all babies. And this is, as you can see in the diagram, it checks for posterior dislocation of the hip. So you stand at the end of the couch with the, the baby on its back. So you're effectively at the the bottom and you stand with holding the knees, you flex the baby's hip and you hold the knees so that your um first finger and second finger on the lateral edge of babies thigh, running down to the greater trochanter. Your thumb is on the medial part of babies thigh bilaterally and you push down and then push out and apply a little bit of pressure. And before you do this, you explain to mom and dad what you're doing, you're testing to see if the hips dislocate and you're feeling for a pop. Um And this will be the sign that the hip is dislocate, able. And I've personally never actually had a baby. He's been positive for borrows test. Um I've had babies that I've found that their hips are a bit cliquey, but I've been reassured by multiple consultants that having clicky hips, I'm feeling this pop are very different. And once you felt it, you will know it. If you think you have felt this pop, then you move on to Auto Lanny's and this is a test to check that the hip has actually dislocated posteriorly. And so you abduct the legs and you feel a clunk, which would be the hips moving back into place. So you only do water Lanny's if you have a positive bar list test effectively. Um And if you have, you note that you have this, it's an instant referral. Um And uh I know in my hospital that there was a separate referral pathway for babies with positive follows. And also honest as compared to those who have just screened and found that they're, they're positive. Um like risk factor wise, you then roll baby onto their front and you want to have a look all the way down babies back. As I said, it's really important in the NYPD that you have a look at every aspect of the baby. You do not want to be missing anything. You do not want to have not seen a part of the skin where there's a bruise or there's a uh lesion or nearby and you're looking at the baby's back for any signs of any scoliosis. Um, any, this diagram at the top, you can see the hair tuft and sacred pit. And then on the far right, that is what you would see in a full blown, um, spina bifida, which you would be unlikely to see on the night because it's probably even picked up Aunt in Italy, but just be aware that you can see neural tube defects that present as sacred pits or hair tuft in the baby's back. Um So anything that you think is a bit abnormal, if you notice a little patch of hair, you notice a lump or a bump or any opening in the lower part of babies back again, just get your reg or your consultant to have a look over it. Another thing that is really important and this is, it's more common in um Asian babies, babies with that dark skin is to have a look for a Mongolian blue spot, um or slate gray nieve. I, and this looks like a big bruise at the base of baby's coccyx. Um And as I was talking about earlier that it's really important to make a note of these, it can really look like a bruise. And if you send home a baby and you've not noted that they have this Mongolian blue spot and then the midwife goes and does a baby check the, a couple of days after the baby's feet sent home and sees it. They're going to think that this is, um, some kind of non accidental injury and they are going to raise it as a safeguarding event. So really, really important to not cause the stress to mom or dad and to make sure that babies are safe is make sure you note this and these tend to just disappear by themselves over time. Um Sometimes they can be quite extensive, quite large, sometimes they can be smaller and quite dark but just keep an eye out for it. Now, what I like to say is the red reflex further end of the examination because it can be something that you need mom or dad to come and give you a hand with because babies, they love to open their eyes and have a look around when you don't want them to. And then as soon as you want to go and have a look in their eyes, they screw them shut. So you want mom or dad to stay at the head and a baby and hold the head still. And you're gonna explain that you need to have a look at each of babies guys and you're gonna have a look with your fund Descovy up. Um So you make sure that you've got the light of the fun scope on and you want to be having a look in the people's in both sides of the people's and making sure that you can see the red reflex. Um And the red reflex is something that we all have. It's similar to when you take a picture with the flash on a camera flash and everyone has red eyes, it looks a bit scary. Um But an absent reflex is something that needs an urgent onward referral. Um So it can be a sign of a congenital cataract, which is the most commonly picked up thing that we see um in neonate. Um It could be a sign of a retinal detachment or vitreous hemorrhage and in less so, in um neonate the sensor as old, but in a slightly older child or baby, it could be a sign of a retinoblastoma. So this is something that you really, really do need to have a look in and make sure that both sides you can see that you have that reflex present. Again. Something that I like to say for for the end of my examination is check the baby's saturations. And this where you get these special little um saturation monitors for babies that you wrap around the wrist and the leg and you want to check the pred octel and postdoctoral saturations. Um And what I mean by the duct that I'm talking about is the doctors arteriosclerosis that is open um whilst baby is in the womb and it tends to close within the 1st 48 hours. And it's a little communication between the aorta and the pulmonary artery. As you can see in my little diagram here. And um what it allows is the mixing of oxygenated and on oxygenated blood in um whilst babies in the womb was, they're connected to center and getting their blood supply that way, but it tends to close in healthy babies within the 1st 48 hours. So you find that when you're talking about a pre ductal saturation, this is coming from the, the first vessels that leave the aorta. So it will be relevant to the right arm. So you check the right arm oxygen saturations and then you check the postdoctoral saturations and this can be left arm or either leg. Um And you want to make sure you check both of these and both of these should be above 95% option saturations. And you want to make sure there's less than a three per cent discrepancy. And the reason that we're so concerned about checking the pre and post doctor saturations in a baby is because um abnormalities in this and a big discrepancy or you're struggling to find it or the they're below 95% could be a sign again of the congenital heart defect. And so it's something you want to correlate again with the femoral pulses. Yeah, exactly. That's what you're looking for. That's so transposition of the great arteries is exactly the reason why Um we do pre imposed doctor saturations. And again, it's really rare to um to find this discrepancy in to pick up TJ, especially in a baby who's not been diagnosed aunt in Italy. But it's the thing that you're, you want to make sure that you don't miss. Um So yeah, and then finally the move on to just the last bit to tie up the whole examination and this, these are just the primitive reflex we spoke about earlier about the the sucking reflex and the routing reflex, which I find is quite useful to um to check in the at the beginning or just seen that the question, can it be common for fast nine P to have different production and postdoc till auction? Um So you find that you might have a discrepancy of one or 2%. Um But generally you do not want to have a discrepancy of more than that, as I said, anything more than 3% even within the 1st 48 hours. Um Is something that you want to flag up and be investigated. Generally, you find that the pre doctor saturations are slightly more so like they can be up to 9900% and often post doctors are 98 99% but they shouldn't be more of a difference than that. Um So even though the doctor is still open, you want to just make sure that you're not missing that. Um But yeah, back to the reflexes, you want to check um, the palm, a graph. So this is when, um, you pop your fingers in both the baby's hands and they should be able to grab on bilaterally, um, to your hands. Um And you also want to check the moral reflex and this is something that again, you really want to make sure that you've explained to mom and dad what you're about to do because it can look like you are about to drop their baby. But you make sure you have one hand behind babies back and you have one hand supporting baby's head and then you effectively do uh controlled sudden movement where you effectively release baby's head and drop baby down very quickly. And what baby tends to do is spring out both of their arms and move their head. And it's a sign that it's called the startle reflex. You're basically trying to start a baby and I should bring out there hands and it should be when you're looking at it, you want them to filling out their hands, both sides equally. You want to make sure there's no way symmetry there because again, if there is any symmetrical abnormalities, there could be a sign that maybe there was a birth injury, maybe there's um being a break your plexus injury like baby was born, there was any risk of shoulder dystocia. You want to make sure that there's no hypotonia there. And again, in, in babies who they don't have this reflex or they're a bit sluggish in the reflex. It might be a sign that the babies have are on. Well, maybe they're septic, maybe they're a bit drive because they're jaundice. So, um it's something that you'd want to have a look up with the rest of your findings. So, so after you have finished the Nike, you want to explain any abnormal results, you found two patient parents and you wanna explain to them if you have found anything that you're concerned about or that you want to see in your, you make sure that you say to parents, you're like, I thank you for letting me do this. I have noted that I wasn't able to fully get the red reflex of both eyes. Um just to make sure that I'm not missing anything, I'm going to get one of my seniors to come and have a look over if that's okay. Mom and dad are generally obviously really amenable to that. I'm just trying to be reassuring where you can and if you, the baby has passed with flying colors, then you can explain to them that um it was just a screening examination that never say to them, oh your baby's perfect or there's nothing wrong because it's just a screening but just say that um you didn't find any abnormal during the night p um But there will be a subsequent examination that happens about 6 to 8 weeks um in by their GP or within their like primary care. Um and then going forward from that, they will be then like checked up further or followed up with any um, scans or anything. Like as I said, like if you have noticed that they've got any risk factors for developing dysplasia for him, you might then explain that they have an arch sound about 6 to 8 weeks. Just have a look to see if there's any risk of the baby having dislocate able hips. And there are my references and yeah, thank you very much everyone for having listened to me. Does anyone have any questions or anything that I can help with at all? Well, thank you very much. I'll just give everyone a couple of minutes if they do want to ask any questions. Uh although that was a very comprehensive run through of the NYPD exam, uh by the end of your placement, were you able to do that from memory or did they have kind of a nice. So the first couple of times that I did the did it, I was, it was really difficult to remember everything because it obviously there's a lot to go through. But by the end, you're, you get into such a routine and it's why I've gone through quite system systematically here, kind of top to toe and then around to the back, you actually do find that you're, you run for it really easily really quickly. Um, it makes a lot of sense and also once you're, you note that the big things that you don't want to miss it becomes quite natural. Um, I'm not 100% sure about the 6 to 89. You have just seen Carers question. I've never had to perform one of those myself because they happened in primary care James. I'm not sure whether you're able to give more information on that, whether it's the same as the uh it takes a little while since I've done one. Um But I do think it covers most of the same areas. Um I think it might just be slightly more brief but perhaps just check um kind of what they're doing in your local area. Yeah. Um And with regards to a cardiology referral. So um it's done really not something that more personally. I found that it was never something that I had to do as the S H O. If ever I was concerned about a baby's saturations or about a baby's femorals. I'd get my restaurant coming a review and then following that, what would tend to happen is we'd make sure that you've got the baby on some cardiac monitoring, you'd get an echocardiogram of the baby. And then if there were any abnormalities there found or if Antenatal e there been any concerns about any cardiac issues, then it would be a case of a, probably a register to read or consultant consultant discussion, um, with, uh, cardiology center or, um, uh, was like an all the cardiology referral. Um, it's not something that I ever did myself. It was something that I always escalated that there were concerns and then the investigations happened following further investigations that were done within the NICU UNIT itself. Um, and tone wise. Um, it's something that is quite subjective to you. What I tended to do is it would be something that you observe the baby with their mom. You observe to have a lip. See is the baby um able to hold itself, is it moving its arms and legs like the same both sides? Often when you're checking the palmer, palmer grasp reflex, you can allow the baby to hold on your hand. Have a fear of both arms, check the muscle bulk, both sides. You'd want to check to see um if there's any headlines. So you do this by when you pick up the baby by the baby's torso, is the baby able like how long does it take for the baby to um pull the head up alongside the body? And obviously, um there will be a little bit of a head like an all babies, but you, you don't want to expect the baby's head to be lolling back completely. But the most important thing is just to make sure that whatever you're seeing that you're checking it symmetrically that so it's not just one sided, especially with the arms. I mentioned the break your plexus injuries that can happen, um, in like a shoulder dystocia birth or like a traumatic birth. And that's, you'd find that one arm is significantly, has, um, alter tone or reduced tone, um, compared to the other. And so it's just, it's just case of, as you examine more babies, you get used to it. Uh, anything else? Okay. I think that might be it for questions. But thank you very much for the presentation but also the really helpful answers and explanations there. I've just popped into the chat, a link to the feedback form. Um Please do take a few minutes just to give us some feedback. Um As I always say, we do read these and we do look at how we can improve things. Um but also all of our speakers, you know, giving up quite a bit of their time, not only to put on the presentation, but also to write it. Um So it's really useful for them to have some feedback to let, let them know kind of what was useful for yourself. But also if there are any areas that they can work on for their teaching, um Only other thing I wanted to say before we head off um is that we do have two more webinars this week, both at the same time. Um If you found this event through the Facebook Group, um links to registration are there in the event description Okay. Any other questions before we go? Okay. Well, thank you very much and enjoy your evening, everyone. Brilliant. Thank you very much.