Charles Darwin University Clinical Practice Record · 2016 Midwifery Clinical Practice Portfolio...

School of Health / Faculty of Engineering, Health, Science and the Environment

Bachelor of Midwifery

2016

Charles Darwin University

Clinical Practice Record Section 1

Record of Clinical Experience

2016 Midwifery Clinical Practice Portfolio Section 1 (Reviewed November 2015)

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Personal Details

Name: ________________________________________________ Student Number: __________________________________________________ Contact Details:

__________________________________________________ ___________________________________________________

This midwifery practice portfolio is the personal item of the person listed above. If found, could it please be returned to the contact address above or to: School of Health Charles Darwin University Casuarina NT 0909


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Declaration

I hereby certify that this Midwifery Practice Portfolio is my own work, based on my own assessments of women that I have cared for and signed by the Registered Midwife or equivalent* who checked my assessment. I also certify that I have not copied in part, or in whole, the work of another person in completing these assessments. *GP Obs/Obs/Registered Nurse Signed: ___________________________________________________ Date: ___________________________________________________


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TABLE OF CONTENTS

Charles Darwin University ........................................................................... 1 Clinical Practice Record ............................................................................. 1 Section 1 ................................................................................................ 1 Record of Clinical Experience ...................................................................... 1 School of Health / Faculty of Engineering, Health, Science and the Environment ....... 1 1. MANDATORY CLINICAL REQUIREMENTS ................................................... 5 2. INTRODUCTION TO THE CLINICAL RECORD. .............................................. 6 3. MIDWIFERY PRACTICE ASSESSMENTS SUMMARY ......................................... 7 4. MIDWIFERY PRACTICE COMPETENCY ASSESSMENTS: .................................... 8

4.1Assessment and care for a woman in her antenatal period ........................................ 8 4.2 Midwifery care for a woman experiencing a normal labour and birth ................... 11 4.3 Resuscitation of the newborn baby *OSCA in CTB (MID303) ............................. 15 4.4 Examination of the newborn baby .......................................................................... 17

4.5 Collection of blood for a newborn screening test. .................................................. 20 4.6 Postnatal care and assessment of the woman .......................................................... 22

4.7 Breastfeeding support and education. ..................................................................... 24 4.8 Management of midwifery emergencies ................................................................. 27 4.8.1 Shoulder dystocia (simulation)* OSCA in CTB (MID303) ................................ 27

4.8.2 Vaginal breech birth (simulation)* OSCA in CTB (MID303) ....................... 29 4.8.3 Management of Primary Postpartum haemorrhage (simulation and assume

uterine atony) * OSCA in CTB. (MID303) .................................................................. 31 5. RECORDS OF CARE .......................................................................... 33

5.1. Antenatal ASSESSMENT of a woman (Minimum of 100 in total including those

recorded in Clinical Record 2 - CoC record) ............................................................... 34 5.2 Abdominal Examination ......................................................................................... 36

5.3 Electronic Fetal Monitoring .................................................................................... 38 5.4 Vaginal Examination .............................................................................................. 40 5.5 Intrapartum Care Record ......................................................................................... 41

5.6 Complex care episodes (minimum 40) ................................................................... 44 5.7 Care of an epidural in labour .................................................................................. 48

5.8 Examination of the Newborn .................................................................................. 50

5.9 Episiotomy and Perineal Repair.............................................................................. 52

5.10 Postnatal Care Record ........................................................................................... 53 5.11 Perinatal Mental Health Referrals ......................................................................... 55 5.12 Women’s Health and Sexual Health ..................................................................... 56 5.13 Speculum Examinations........................................................................................ 57

6. Abbreviations: ............................................................................... 58 7. FLOWCHART FOR CLINICAL PLACEMENT UNITS........................................ 59


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1. MANDATORY CLINICAL REQUIREMENTS 1) Twenty (20) continuity of care experiences. Specific requirements of these experiences include: a) enabling students to experience continuity with individual women through pregnancy, labour and birth and the postnatal period, irrespective of the availability of midwifery continuity of care models; b) participation in continuity of care models involving contact with women that commences in early pregnancy and continues up to four to six weeks after birth; c) supervision by a midwife (or in particular circumstances a medical practitioner qualified in obstetrics); d) consistent, regular and ongoing evaluation of each student’s continuity of care experiences; e) a minimum of eight (8) continuity of care experiences towards the end of the course and with the student fully involved in providing midwifery care with appropriate supervision; f) engagement with women during pregnancy and at antenatal visits, labour and birth as well as postnatal visits according to individual circumstances. Overall, it is recommended that students spend an average of 20 hours with each woman across her maternity care episode; g) provision by the student of evidence of their engagement with each woman. 2) Attendance at 100 antenatal visits with women, which may include women being followed as part of continuity of care experiences. 3) Attendance at 100 postnatal visits with women and their healthy newborn babies, which may include women being followed as part of continuity of care experiences. 4) ‘Being with’ 40 women** giving birth, this may include women being followed as part of continuity of care experiences or 30 Spontaneous** and assist with 20 others 5) Experience of caring for 40 women with complex needs across pregnancy, labour and birth, and the postnatal period, which may include women the student is following through as part of their continuity of care experiences. 6) Experience in the care of babies with special needs.

7) Experience in women’s health and sexual health.

8) Experience in medical and surgical care for women and babies.

9) Experience in:

a) antenatal screening investigations and associated counselling; b) referring, requesting and interpreting results of relevant laboratory tests; c) administering and/or prescribing medicines for midwifery practice*; d) actual or simulated midwifery emergencies, including maternal and neonatal resuscitation; e) actual or simulated vaginal breech births; f) actual or simulated episiotomy and perineal suturing; g) examination of the newborn baby; h) provision of care in the postnatal period up to four to six weeks following birth, including breastfeeding support; i) perinatal mental health issues including recognition, response and referral. * understanding that midwives cannot prescribe in all jurisdictions

** Being with = ‘being with’ a woman refers to a woman-centred approach where the midwifery student is directly and actively involved with the

woman as she spontaneously gives birth to her baby vaginally and inclusive of the student attending to third stage and facilitating initial mother and baby interaction. ANMAC, 2009.Standards and Criteria for the Accreditation of Nursing and Midwifery Courses Leading to Registration, Enrolment, Endorsement and Authorisation in Australia – with Evidence Guide.


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2. INTRODUCTION TO THE CLINICAL RECORD. Welcome to midwifery at Charles Darwin University. It is a requirement of the Nursing and Midwifery Board of Australia (NMBA) that you achieve certain clinical requirements in order to register as a midwife. There are 2 sections to the clinical record: Section 1: Clinical Practice Record Section 2: Continuity of Care Experiences Record Section 1 (this document) is for you to record the mandatory requirements listed on page 5, from point 2 to point 9, inclusive. There is a separate record for your Continuity of Care journeys. This record contains a limited number of pages for recording your clinical requirements as you achieve these and you can download and print off further pages as required. Copies of the relevant pages will be available as pdf files on your units Learnline site. All your clinical achievements must be verified by a Registered Midwife, Obstetrician or General Practitioner Obstetrician. Your clinical records cannot be signed off by any other health care professional, except in the case of MID301 Women’s Health and MID307 Specialist Neonatal Care, a RN or GP may verify your record. You will note that with some requirements you have a specified number to achieve, e.g.100 antenatal visits, whilst others are not so, e.g. vaginal examination. Where there is a number specified this is the minimum you must achieve for registration with NMBA. With the other areas you should aim to gain as much experience as you are able to and record all of it. With items such as abdominal examination it is assumed you will perform an abdominal examination as part of most antenatal assessments/visits and there is space provided for you to record 20 abdominal examinations, you may record more if you wish. Items such as Perinatal Mental Health Referrals will not occur as often and it important to record all experiences. The NMBA require you to have exposure in this area and to be aware of referral pathways so the more you can record will provide the evidence to support this. The midwifery course co-ordinator does not need to see the original clinical record practice 1 until the end of the course. However, it is expected that you will document a progressive total of mandatory clinical skills in each of your clinical assessment portfolios on page 5. It is also recommended that you keep a certified copy of these clinical skills in case you are asked to provide this evidence for any prospective midwifery employer.

If you have any queries about the information in this record please contact: Midwifery Course Coordinator 08 8946 6596.


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3. MIDWIFERY PRACTICE ASSESSMENTS SUMMARY

SKILL DATE ASSESSOR PASS ANTENATAL

Provision of comprehensive antenatal care (MID202)

INTRAPARTUM

Provision of midwifery care with a woman experiencing a normal labour and birth. (MID204)

Management of midwifery emergencies/situations:

Shoulder Dystocia O (MID303)

Vaginal breech birth O (MID303)

Postpartum haemorrhage O (MID303)

NEWBORN

Resuscitation of the newborn baby O (MID303)

Examination of the newborn baby (MID202)

Collection of a NBST (MID202)

POSTNATAL

Postnatal Assessment (MID204)

Breastfeeding support and education (MID204)

O = Assessed in CTB by OSCA.


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4. MIDWIFERY PRACTICE COMPETENCY ASSESSMENTS:

4.1Assessment and care for a woman in her antenatal period

Student Name: _________________________ Date: _____________

Competency Indicator

Achieved

Yes No N/A

4.3 Organises workload to accommodate the assessment and collects records

1.2 2.2 4.1 5.1

Adheres to infection control measures and standard precautions

1.4 8.1 10.1

Provides assistance and interpreter as required

1.4 3.3 4.1 7.2 Maintains woman’s privacy and confidentiality

1.3 3.1 3.2 3.3 4.1 Frames questions to achieve optimum communication

1.3 3.1 3.3 4.1 Addresses woman appropriately and seeks consent

1.4 2.1 2.3 3.1 3.3 Listens to woman and responds appropriately

5.1 Calculates expected date of birth correctly (using Naegle’s rule)

5.1 5.2 Ensure accuracy of demographic details

3.1 5.2 5.3 7.1 9.1

Discusses woman’s health during her pregnancy

1.4 2.1 2.3 3.1 3.3 4.1 5.2 5.3 5.4

Identifies woman’s health history and discusses the significance of this if appropriate

1.4 2.1 2.3 3.1 3.3 4.1 5.2 5.3 5.4

Discusses woman’s state of health since last visit

5.2 5.3 5.5 6.1 7.1 7.2

Gives appropriate advice for the relief of minor disorders

4.1 5.2 8.2 9.1 9.2 10.1

Discusses/provides access to appropriate information/resources

1.4 2.1 3.1 3.3 5.2 5.3 Organises appropriate screening tests

1.4 2.1 3.3 5.3 7.1 7.2 Discusses screening tests


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2.1 2.3 3.1 7.2 7.1 8.1 9.1 9.2 10.1 12.1 12.2 14.2

Conducts screening programs according to hospital policy e.g. Domestic violence if appropriate

2.1 2.3 3.1 3.3 4.1 5.1 5.2 5.3 5.6 10.1 14.2

Conducts physical assessment as appropriate for woman’s gestation and needs, and according to hospital

clinical practice guidelines

3.1 3.3 4.1 7.1 7.2 Asks if woman has any further questions and responds appropriately

3.1 7.2 10.1 Advises woman of time and date of next appointment

1.1 1.2 1.3 1.4 Reports/documents all observations /findings and replaces record correctly

Discuss the significance of the following aspects of the antenatal history that you have collected, or that has been collected: Satisfactory Unsatisfactory

Demographic details

Obstetric history

Medical and surgical history

Family medical history

Social history

Discuss the rationale for, and the significance of, the following aspects of the antenatal assessment:

Satisfactory Unsatisfactory

Urinalysis

Blood pressure

Weight (if done)

Fundal height and palpation

Investigations/specimens

Effective communication

Abdominal examination

Discuss findings on abdominal examination that could indicate:

Satisfactory Unsatisfactory Oligo/polyhydramnios

Transverse lie

Breech presentation

Growth restriction

Posterior position


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Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


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4.2 Midwifery care for a woman experiencing a normal labour and birth



Achieved

Yes No N/A

4.3 Organises workload, equipment and collects records

1.2 2.1


8.1 10.1

Addresses woman appropriately and seeks consent

4.1 7.2 Maintains woman’s privacy and confidentiality

3.1 Listens to woman and responds appropriately

3.1 3.3 4.1 Gives clear and relevant explanation

1.2 2.2 4.1 5.1 Adheres to infection control measures and standard precautions

2.1 3.1 3.3 4.1 5.2

Palpates abdomen to determine fetal lie, presentation, position, attitude and level of

presenting part

2.1 3.1 3.3 4.1 5.2 5.3 Auscultates fetal heart rate per protocol

2.1 3.1 3.3 4.1 5.2 5.3 Measures maternal observations per protocol

2.1 3.1 3.3 4.1 5.2 5.3

Palpates uterine contractions to assess length, strength, and frequency

3.1 3.3 4.1 5.2 5.3 Observes vaginal loss

3.1 3.3 4.1 5.2 5.3

Ensures woman empties her bladder periodically

3.1 3.3 4.1 5.2 5.3 Performs urinalysis as per protocol

2.1 3.1 3.3 4.1 5.2 5.3 5.6

Performs other assessments as required and identifies significance of these findings

3.1 3.3 4.1 5.2 5.3 Advises women on mobility and positioning

2.1 3.1 3.3 4.1 5.2 5.3 5.5 6.2

Discusses pain management with woman as necessary


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3.1 7.2 10.1 Explains partner’s supportive role

2.1 3.1 3.3 4.1 5.2 5.3 5.5 6.2

Reports all observations/findings in terms of: progress of labour maternal condition

fetal condition

2.1 3.1 3.3 4.1 5.2 5.3 5.5 6.2 14.1

Assists woman to adopt appropriate and comfortable position at all times

1.2 2.2 Maintains a clean birth area

2.1 3.1 3.3 4.1 5.2 5.3 5.5 6.2 14.2

Assists woman with birth as per hospital protocol

Conducts third stage as per hospital protocol And respecting the wishes of the woman

Palpates height and consistency of fundus and observes lochia

Estimates blood loss

Examines perineum, vestibule and vagina for lacerations

1.1 1.2 1.3 1.4 2.1 3.1 3.3 4.1 5.2 5.3 5.5 6.2 7.1 7.2 8.1 8.2 10.1 11.1 12.1 14.2

Provides appropriate care to the newborn baby, woman and family as per hospital protocol, including

third stage management, immediate care of the newborn baby, initial neonatal assessment, initiation of breastfeeding and early care of the newborn baby

1.1 1.2 Reports/documents all findings and replaces record

Discusses the following aspects of management of the first stage of labour: Satisfactory Unsatisfactory

Assessment of progress

Nutrition and hydration

How can an occipito- posterior (OP) position be recognised in labour and what are the possible outcomes of labour?

How can pain in labour be managed?


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Discusses the significance of the following aspects of vaginal examination during labour:


What is the relevance of assessing the level of the presenting part?

What is the relevance of assessing the fetal position?

Discuss the advantages and disadvantages of artificially rupturing the membranes

Discusses the following aspects of conducting a normal birth:

Satisfactory Unsatisfactory What is the importance of frequently auscultating the fetal heart during second stage of labour?

What is your understanding of o crowning o restitution o internal/external rotation

What is the relevance of oxytocic administration?

How should the third stage of labour be managed in the absence of oxytocic administration?

Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


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4.3 Resuscitation of the newborn baby *OSCA in CTB (MID303) Student Name: _________________________ Date: _____________


Achieved

Yes No N/A

4.3 Has prepared equipment


1.2 1.4 2.1 2.3 3.1 6.2

Positions and handles baby appropriately and safely throughout

1.2 1.4 2.1 2.3 3.1 6.2

Demonstrates appropriate initial airway assessment and management

1.2 1.4 2.1 2.3 3.1 6.2

Demonstrates effective and correct use of ventilation equipment

1.2 1.4 2.1 2.3 3.1 6.2

Demonstrates appropriate initial cardiac assessment and management

1.2 1.4 2.1 2.3 3.1 6.2

Demonstrates correct external chest compression technique

1.2 1.4 2.1 2.3 3.1 6.2

Demonstrates correct ongoing assessment of baby during resuscitation

1.2 1.4 2.1 2.3 3.1 6.2

Evaluates effectiveness of interventions and modifies actions throughout

1.3 2.3 3.3 6.1 7.2 8.1 8.2

Reports/documents all observations /findings and replaces record correctly

Discuss the following aspects of resuscitation of the newborn baby:


What are the antepartum and intrapartum risk factors that may adversely affect the newborn baby?

What are the causes and physiology of neonatal asphyxia?

Explains the equipment that is required for neonatal resuscitation

What drugs are used in neonatal resuscitation?

What are the indications for endotracheal intubation and what equipment is required for this procedure?


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Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


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4.4 Examination of the newborn baby



Achieved

Yes No N/A


1.3 1.2 3.1 3.3 5.2 5.4

Gives clear and relevant explanation to the parent(s) and seeks consent

3.1 Listens to parent(s) and responds appropriately

3.1 4.1 Obtains details of labour, birth and subsequent care


1.1 1.2 1.4 Verifies baby’s identification

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Handles baby gently, appropriately and securely throughout

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Acts to maintain baby’s optimum temperature throughout

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Determines symmetry and general proportions of baby

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Observes posture and movements of baby unrestrained on flat surface

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Measures body weight, length and head circumference

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Examines mouth and tests integrity of soft and hard palate

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Examines sutures and fontanelles.

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Inspects ears and assesses level in relation to eyes

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Inspects eyes

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Inspects nose

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Palpates neck, shoulders and humerus

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Determines range of movement of head


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1.2 1.4 2.1 2.3 3.1 6.2 5.1

Assesses respiratory effort

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Auscultates heart

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Palpates breast tissue development

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Examines abdomen (shape, musculature, security of clamp etc)

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Extends arms to compare length

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Inspects hands

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Extends legs to compare length

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Determines range of movement in ankle and knee joints

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Inspects feet

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Tests integrity and range of movement of hip joints including Barlow and Ortolani maneuvers

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Palpates vertebral column for continuity

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Examines condition of skin (colour, texture, integrity, marks, trauma)

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Examines external genitalia and confirms gender

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Determines patency of anus

1.2 1.4 2.1 2.3 3.1 6.2 5.1

Dresses baby and positions safely

3.1 4.1 Listens to parent(s) and responds appropriately

3.1 8.1 Discusses findings with assessor and parent(s) as appropriate

1.3 2.3 3.3 6.1 7.2 8.1 8.2

Reports/documents all findings and replaces record


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Discuss the following aspects of examination of the newborn baby:


Why is Vitamin K recommended for newborn babies?

What is the importance of maintaining the temperature of the newborn baby and how is this best achieved?

What observations should be taken of the newborn baby within the first 4 hours following birth?

What is the significance of initiating breastfeeding, and when should this be done?

Assessor comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessor name & Designation: Date: ___________________________________________ Assessor signature: ___________________________________________ Student signature:


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4.5 Collection of blood for a newborn screening test. Student Name: _________________________ Date: _____________


Achieved

Y N N/A


1.3 1.2 3.1 3.3 5.2 5.4 Gives clear and relevant explanation to the parent(s) and seeks consent

1.1 1.2 1.4 4.1 4.3 5.15.2 5.3

Verifies neonates identity and age and notes > 48 hours since first milk feed

2.1 2.2 3.3 4.1 4.3 5.1 5.2 5.3 5.6

Ensures heel is warm

3.3 4.1 4.3 5.1 5.2 5.3 5.6

Selects correct puncture area

2.1 2.2 3.3 4.1 4.3 5.1 5.2 5.3 5.6

Uses appropriate lancet

3.3 4.1 4.3 5.1 5.2 5.3 5.6

Collects adequate amount of blood

3.3 4.1 4.3 5.1 5.2 5.3 5.6

Avoids skin contamination of the collection card

1.2 1.3 1.4 2.2 3.1 4.3 5.1 5.3

Stores/labels card appropriately

2.1 2.2 3.3 4.1 4.3 5.1 5.2 5.3 5.6

Comforts neonate

1.2 1.3 1.4 2.2 3.1 4.3 5.1 5.3

Completes appropriate documentation

Discuss the reasons for the newborn screening test.

Satisfactory □ Unsatisfactory □ Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature: ____________________________________________


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4.6 Postnatal care and assessment of the woman



Achieved

Yes No N/A

4.3 Organises workload, equipment and relevant records

1.2 2.1


7.2 8.1 10.1

Maintains woman’s privacy and confidentiality

3.1 4.1 7.2 10.1 Listens to woman and responds appropriately


3.1 3.3 4.1 10.1 Gives clear and relevant explanation


3.1 4.1 5.1 5.2 5.3 Establishes the woman has an empty bladder

3.1 4.1 5.1 5.2 5.3 Positions woman appropriately

3.1 4.1 5.1 5.2 5.3 Advises woman of possible discomfort

3.1 4.1 5.1 5.2 5.3 Asks woman about the condition of her nipples and breasts and examines if appropriate

3.1 4.1 5.1 5.2 5.3 Inspects abdominal wound if appropriate

3.1 4.1 5.1 5.2 5.3 Palpates uterine fundus

3.1 4.1 5.1 5.2 5.3 Assesses involution to satisfaction of assessor

3.1 4.1 5.1 5.2 5.3 Palpates abdominal rectus muscle

3.1 4.1 5.1 5.2 5.3 Examines legs

3.1 4.1 5.1 5.2 5.3 Observes lochia

3.1 4.1 5.1 5.2 5.3 Asks the woman about the condition of her perineal area and examines if appropriate

3.1 4.1 5.1 5.2 5.3 Asks woman about bladder and bowel function


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3.1 4.1 5.1 5.2 5.3 Asks woman about diet and fluid intake

3.1 4.1 5.1 5.2 5.3 Asks woman about rest, sleep, ambulation and feeling of well being

3.1 4.1 5.1 5.2 5.3 Takes maternal observations (as per protocol)

1.3 2.3 3.3 6.1 7.2 8.1 8.2 Reports/documents all observations, findings and replaces record correctly

Discuss the significance of the following aspects of postnatal assessment:


Involution/sub-involution

Care of the sutured perineum

Signs of postnatal depression

Educational issues for postnatal families

Assessor comments: __________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


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4.7 Breastfeeding support and education.



Achieved

Yes No N/A

4.3 Organises workload and any equipment

1.2 2.1


7.2 8.1 10.1

Maintains woman’s privacy and confidentiality

3.1 4.1 7.2 10.1 Listens to woman and responds appropriately


3.1 3.3 4.1 10.1 Gives clear and relevant explanation


2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Enquires as to woman’s experience with breastfeeding

Educates woman to recognize infants breastfeeding readiness cues

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Identifies any concerns that the woman expresses and prepares plan for assistance if required

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Provides education with hand expression and storage of breastmilk

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Observes woman prepare baby for breastfeeding

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Observes positioning of woman and baby and provides assistance if required

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Observes baby attachment and sucking and provides assistance if required

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Observes feed and provides assistance if required

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Observes detachment and provides assistance if required


25

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Discusses any further concerns with woman

2.1 3.1 3.3 4.1 4.2 5.1 5.2 5.3 5.4 5.6 7.2 8.1 8.2 9.2 10.1 11.1 12.1 14.1 14.2

Discusses breastfeeding strategies with woman and provides information about support services in the

community

1.3 2.3 3.3 6.1 7.2 8.1 8.2 Reports/documents all observations /findings

Discuss the significance of the following aspects of breastfeeding:


Timing of first feed

Attachment and sucking

Baby feeding and settling patterns

Positions to assist woman’s comfort

Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


26

Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


27

4.8 Management of midwifery emergencies

4.8.1 Shoulder dystocia (simulation)* OSCA in CTB (MID303) Student Name: _________________________ Date: _____________


Achieved

Y N N/A

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Recognises shoulder dystocia

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Calls for help

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Evaluates for episiotomy

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Performs McRoberts manoeuvre

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Applies suprapubic pressure (Rubin 1)

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Attempt to adduct the anterior shoulder (Rubin 2)

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Attempt Woods Screw

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Attempt reverse Woods Screw

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Deliver posterior arm

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Roll onto all fours

Discuss the potential complications of shoulder dystocia

Satisfactory □ Unsatisfactory □ Assessor comments: __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


28

Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


29

4.8.2 Vaginal breech birth (simulation)* OSCA in CTB (MID303) Student Name: _________________________ Date: _____________


Achieved

Y N N/A

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 9 10 11 14.1

Arranges for assistance

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 9 10 11 14.1

Allows birth to proceed spontaneously

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Appraises progress frequently

1.4 2.1 2.2 2.4 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Handles baby by hips only

1.4 2.1 2.2 2.3 2.4 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Ensures fetal back is anterior

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Demonstrates Lovsett manoeuvre

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Demonstrates Mauriceau-Smellie Veit manœuvre

Provide the rationale for allowing the breech presenting baby to birth spontaneously.

Satisfactory □ Unsatisfactory □ State the indications for handling/intervening during the birth.

Satisfactory □ Unsatisfactory □ Discuss the potential complications of vaginal breech birth.

Satisfactory □ Unsatisfactory □ Assessor comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


30

Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


31

4.8.3 Management of Primary Postpartum haemorrhage (simulation and assume uterine atony) * OSCA in CTB. (MID303)


Competency Indicator Achieved

Y N N/A

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 9 10 11 14.1

Calls for help/reassure woman

1.2 1.4 2.1 2.2 2.3 2.4 2.5 3.1 4.1 5.1 5.2 5.5 6.1 6.2 7.2 8.1 11 14.1

Massage fundus and assess blood loss

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Lay bed flat and apply facial oxygen

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Measure Vital signs

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 5.5 6.1 6.2 8.1 11 14.1

Establish administration of first line oxytocic/ administer second line oxytocic. States drug, dose & route

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Examine placenta and membranes for completeness

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Insert indwelling urinary catheter

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Look for obvious tears

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Continually assess blood loss

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Articulate the 4Ts

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Facilitate large bore IV access and arrange for fluid resuscitation

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Take blood for Group and XMatch FBE and coagulation studies

1.4 2.1 2.2 2.3 2.4 2.5 3.1 3.3 4.1 4.2 5.1 5.2 6.1 6.2 8.1 11 14.1

Arrange for IVI Hartmanns/Saline with 40 units Oxytocin to run over 4 hours or to policy.

What would lead you to suspect a woman is having a postpartum haemorrhage Satisfactory □ Unsatisfactory □ What are the key causes of primary postpartum haemorrhage? Satisfactory □ Unsatisfactory □ What is a common prostaglandin type drug used to treat PPH what are common side effects?

Satisfactory □ Unsatisfactory □ Assessor comments: __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


32

Remedial strategies (if necessary): Date for reassessment: __________ __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:


33

5. RECORDS OF CARE 5.1 Antenatal Assessment 5.2 Abdominal Examination 5.3 Electronic Fetal Monitoring 5.4 Vaginal Examination 5.5 Intrapartum Care 5.6 Complex Care 5.7 Care of an epidural in labour 5.8 Examination of the Newborn 5.9 Perineal Repair 5.10 Postnatal Care 5.11 Perinatal Mental Health Referrals 5.12 Women’s Health/Sexual Health 5.13 Speculum Examinations

5.1. Antenatal ASSESSMENT of a woman (Minimum of 100 in total including those recorded in Clinical Record 2 - CoC record)

No.

DATE

G.P. Gest

BP Fundal

Height

FM

FHR

U/A

(prn)

Abdominal Palpation

Screening &

Counseling

Pathology

Medications

Education Supervisor Name (print) designation & signature

1. G1 P0 14+2

105/60

N/A N/A SG 1.010 pH 6.0 NAD

Not done

DV screen EPDS- Anxiety Perinatal mental health referral

Hb 109 Iron tabs commenced

Healthy diet Nausea Care options

B. Smith (RNRM) BSmith

11/9/15

2. G3 P2 28+2

95/65

30cm FMF√ FHR 142 bpm

leuks ++

LOL Not engaged

Quit

GTT NAD Hb 120

BF education Healthy lifestyle

L. Vincent (RM) LVincent

14/9/15

3. G2 P1 37+2

125/70

36cm FMF√ FHR 148 bpm

Trace protein +

ROL 4/5↑

GBS +ve

FBE/ antibodies

VBAC When to present to hospital Self-care

S.Burn (RM) SBurn

21/1/16


35

No.

DATE

G.P. Gest

BP Fundal

Height

FM

FHR

U/A

(prn)

Abdominal Palpation

Screening &

Counseling

Pathology

Medications

Education Supervisor Name (print) designation & signature


36

5.2 Abdominal Examination

Abdominal Palpation Date:11/9/15 Supervisor : Name (print), designation & signature:

B. Smith (RNRM)BSmith

Shape of Uterus: Ovoid Scars/other features: Linea nigra

Fundal height: 38cm Lie: Longitudinal

Presentation: Cephalic Position: ROA

Engagement/Attitude: 3/5↑ brim Fetal Heart Rate/Method: 136bpm, auscultating with Doppler/Pinnards

Abdominal Palpation Date: 17/1/16 Supervisor : Name (print), designation & signature

J. Bloggs (RM)JBloggs Shape of Uterus: Round Scars/other features: Appendectomy scar

Fundal height: 24cm Lie: _

Presentation: _ Position: _

Engagement/Attitude: _ Fetal Heart Rate/Method: 156bpm, auscultating with Doppler/Pinnards

Abdominal Palpation Date: 21/2/16 Supervisor : Name (print), designation & signature

K.Curtin (RM)KCurtin

Shape of Uterus: Ovoid Scars/other features: Nil

Fundal height: 32cm Lie: Longitudinal

Presentation: Breech Position: LSA

Engagement/Attitude: Not engaged Fetal Heart Rate/Method: 140bpm via CTG

Abdominal Palpation Date: Supervisor : Name (print), designation & signature

Shape of Uterus: Scars/other features:

Fundal height: Lie:

Presentation: Position:

Engagement/Attitude: Fetal Heart Rate/Method:

Abdominal Palpation Date Supervisor : Name (print), designation & signature


Fundal height: Lie:




37



Fundal height: Lie:





Fundal height: Lie:





Fundal height: Lie:





Fundal height: Lie:





Fundal height: Lie:




38

5.3 Electronic Fetal Monitoring

Electronic fetal monitoring Date: 11/9/15

Supervisor : Name (print) designation & signature


Indication: Decreased fetal movements

Uterine Activity: Nil Baseline Rate: 135 bpm

Variability: 6-25 Accelerations: x2

Decelerations: Nil Type of Decelerations: _

Overall status: Normal

Action: O&G registrar review

Significance of findings: Normal CTG

Electronic fetal monitoring Date: 17/1/16


R. Rogers (RM)RRogers Indication: Meconium stained liquor (MSL)

Uterine Activity: 2:10 strong

Baseline Rate: 125 bpm

Variability: 3-5 reduced Accelerations: Absent

Decelerations: Present Type of Decelerations: late

Overall status: abnormal CTG

Action: Notified obstetrician

Significance of findings: Possible fetal compromise, prepare for caesarean

Electronic fetal monitoring Date:


Indication:

Uterine Activity: Baseline Rate:

Variability: Accelerations:

Decelerations: Type of Decelerations:

Overall status: Action:

Significance of findings:



Indication:







39



Indication:








Indication:








Indication:








Indication:







40

5.4 Vaginal Examination

Vaginal Examination

Dilation 5cm 8cm 2cm Effacement 0.5cm Fully 1cm Consistency soft soft soft Application good poor -- Membranes intact bulging # (ruptured) Station -1 0 -2 Caput/ Moulding +caput, nil moulding +caput, ++moulding Nil felt Supervisor : Name (print) designation & signature/ date

K.Curtin (RM)KCurtin 21/12/15

L.Vincent(RM)LVincent 9/1/16


1/2/16

Dilation Effacement Consistency Application Membranes Station Caput /Moulding Supervisor : Name (print) designation & signature/ date




41

5.5 Intrapartum Care Record

INTRAPARTUM CARE SPONTANEOUS (40 Spontaneous births as primary midwife* OR 30 Spontaneous* and assist with 20 others) *Being with = ‘being with’ a woman refers to a woman-centred approach where the midwifery student is

directly and actively involved with the woman as she spontaneously gives birth to her baby vaginally and inclusive of the student attending to third stage and facilitating initial mother and baby interaction.

DATE:

Age

29y

G/P

2:1

Gest 39+2

Labour onset:

Time of onset: 1500hrs Length: 1 stage 2:15 2 stage 10 3 stage 8 Total: 2:33

Type of Birth:(Spont etc)

NVB

Interventions and/or

Complications:

Nil

Third stage management

Method: Active

Oxytocic: 10iu oxytocin IMI

Placenta Complete Membranes: Ragged

Blood Loss: 250 mls

Perineum

intact

Role of student: (circle) Assistant Observe

28/8/15

Birth Register

No.

150

Immediate assessment of baby by(student/other):

vigorous and cying

Apgar Score:

9/1 9/5

Resuscitation:

Nil

Fourth stage

Skin to Skin duration: 2hrs

First breastfeed: within 20mins

Sex

F

Weight

3250g



DATE:

Age 18y G/P 1:0 Gest 40+6

Labour onset: Time of onset: 1125hrs Length: 1 stage 9:26 2 stage 1:42 3 stage 22 Total: 11:30

Type of Birth:(Spont etc) Ventouse Interventions and/or Complications: IOL preeclampsia Prolonged 2nd stage Ventouse for fetal compromise

Third stage management Method: Active Oxytocic: 5iu oxytocin IV Placenta Complete Membranes: Complete

Blood Loss: 450 mls

Perineum 20 Tear

Role of student: (circle) Primary Observe

30/8/15

Birth Register

No

168


poor respiratory effort

Apgar Score:

7/1 9/5

Resuscitation: Stimulation

Fourth stage

Skin to Skin duration: 2:45 First breastfeed: within 40mins, good feed

Sex

M

Weight

4250g


L.Vincent(RM)LVincent

Primary

Assist


42

DATE:

Age 36y G/P 2:1 Gest 39+2

Labour onset: Time of onset: -- Length: 1 stage -- 2 stage -- 3 stage -- Total: -- No labour

Type of Birth:(Spont etc) Elective caesarean Interventions and/or Complications: Previous caesarean

Third stage management Method: Manual as per theatre Oxytocic: Carbetocin 100mcg IV in theatre Placenta Complete Membranes: Complete

Blood Loss: 450 mls

Perineum intact

Role of student: (circle) Primary Observe

25/1/16

Birth Register

No.

120


Good condition

Apgar Score:

9/1 9/5

Resuscitation: Nil

Fourth stage

Skin to Skin duration: delay 10mins, then 1hr First breastfeed: within 40mins, good feed 10mins

Sex

M

Weight

3850g


R. Rogers (RM)RRogers

DATE:

Birth Register No.

Age

G/P

Gest

Labour onset:

Time of onset:____ Length: 1 stage____ 2 stage____ 3 stage____ Total:

Type of Birth:


Complications:


Method:

Oxytocic:

Placenta Membranes:

Blood Loss:

Perineum Role of student: (circle) Primary Assistant Observe


Apgar Score:

/1 /5

Resuscitation:

Fourth stage

Skin to Skin:

First breastfeed:

Sex Weight


DATE:

Birth Register No.

Age

G/P

Gest

Labour onset:


Type of Birth:


Complications:


Method:

Oxytocic:

Placenta Membranes:

Blood Loss:



Apgar Score:

/1 /5

Resuscitation:

Fourth stage

Skin to Skin:

First breastfeed:

Sex Weight


Assist


43

DATE:

Birth Register No.

Age

G/P

Gest

Labour onset:


Type of Birth:


Complications:


Method:

Oxytocic:

Placenta Membranes:

Blood Loss:



Apgar Score:

/1 /5

Resuscitation:

Fourth stage

Skin to Skin:

First breastfeed:

Sex Weight

Supervisor: Name (print) designation & signature

DATE:

Birth Register No.

Age

G/P

Gest

Labour onset:


Type of Birth:


Complications:


Method:

Oxytocic:

Placenta Membranes:

Blood Loss:



Apgar Score:

/1 /5

Resuscitation:

Fourth stage

Skin to Skin:

First breastfeed:

Sex Weight


DATE:

Birth Register No.

Age

G/P

Gest

Labour onset:


Type of Birth:


Complications:


Method:

Oxytocic:

Placenta Membranes:

Blood Loss:



Apgar Score:

/1 /5

Resuscitation:

Fourth stage

Skin to Skin:

First breastfeed:

Sex Weight



44

5.6 Complex care episodes (minimum 40)

No: Date:

Period (circle)

Description of issue

Care given Outcome Supervisor Name (print) designation & signature

1 Date:

1.1.16

IP PN

Gestational diabetes

BSLs pre and post meals Insulin Education and referral to Diabetes Nurse

BSLs within normal range Self-administered insulin with good technique

R. Rogers

(RM)RRogers

2 Date: 1.1.16

AN PN

Abnormal CTG trace

Continuous monitoring in labour Regular medical review Fetal scalp sampling

Ventouse birth due to fetal compromise

L.Vincent(RM)

LVincent

3 Date: 1.2.16

AN IP

Flat nipples and nipple trauma

Plan made with woman Express prior to attachment Assist attachment

Good attachment Woman developed good technique

K.Curtin

(RM)KCurtin

4 Date: 2.2.16

EPDS 23 Suicidal ideation

Reassurance Partner contacted Referral to mental health team, admitted

Mental health consultation: discharged on medication Caring for self and baby

B. Smith

(RNRM)BSmith

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

AN

IP

PN

AN IP PN


45

No: Date:

Period (circle)

Description of issue

Care given Outcome Supervisor Name (print) designation & signature

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN


46

No: Date:

Period (circle)

Description of issue Care given Outcome Supervisor Name (print) designation & signature

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN


47

No: Date:

Period (circle)

Description of issue Care given Outcome Supervisor Name (print) designation & signature

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN

No. Date:

AN IP PN


48

5.7 Care of an epidural in labour SET UP FOR EPIDURAL AND ASSIST ANAESTHETIST Parity: 2:0 Gestation: 39+5 Indication for epidural: OP position Involuntary pushing at 5cm dilated

Type of epidural: Continuous infusion

Risk factors: Essential hypertension, Hb 86, Platelets 78

Description: Group and hold obtained prior to insertion Woman assisted into sitting position for insertion, reassurance and instructions Sterile field maintained Polybag 0.125% bupivacaine and 2mcg/mL used

Achieved via simulation? Yes No X Supervisor Name/Designation & signature:


SET UP FOR EPIDURAL AND ASSIST ANAESTHETIST Parity: 5:2 Gestation: 40+6 Indication for epidural: Pain relief

Type of epidural: Patient controlled epidural anaesthesia (PCEA)

Risk factors: Nil Description: Group and hold obtained prior to insertion Assisted with insertion Instructed the woman on the use of the PCEA

Achieved via simulation? Yes No X

Supervisor Name/Designation & signature:


ADMINISTER EPIDURAL DRUGS Parity: 2:0 Gestation: 39+5 Indication for epidural: OP position Involuntary pushing at 5cm dilated

Type of epidural: Continuous infusion

Risk factors: Essential hypertension, Hb 86, Platelets 78 Description: Under direct supervision of

2 midwives: maintained sterile field Checked drugs with 2 x RMs, documented Epidural line primed with Polybag 0.125% bupivacaine and 2mcg/mL solution Line attached to epidural port 5ml bolus administered via epidural pump maintenance dose of 1ml/hr administered

Achieved via simulation? Yes No X Supervisor Name/Designation & signature:


SET UP FOR EPIDURAL AND ASSIST ANAESTHETIST Parity: Gestation: Indication for epidural: Type of epidural: Risk factors: Description: Achieved via simulation? Yes No Supervisor Name/Designation & signature:

_____________________________________

______________________________


_____________________________________

______________________________

ADMINISTER EPIDURAL DRUGS Parity: Gestation: Indication for epidural: Type of epidural: Risk factors: Description: Achieved via simulation? Yes No Supervisor Name/Designation & signature:

_____________________________________

______________________________


49


_____________________________________

______________________________


_____________________________________

______________________________


_____________________________________

______________________________


_____________________________________

______________________________


_____________________________________

______________________________


_____________________________________

______________________________


50

5.8 Examination of the Newborn

Physical examination of the newborn

Date: 21/1/16

Supervisor

Name/Designation & signature: B. Smith (RNRM)BSmith

Temperature: 36.7 Eyes: clear Chest: normal shape Toes: NAD Reflexes: Rooting present

Resps: 42 per min Nose: patent Abdomen: soft Genitalia: normal male Reflexes: Sucking present

Apex Beat: 148 Ears: normal Cord: C&D Spine: NAD Reflexes: Grasp present

Skin: erythema toxicum Mouth: normal Clamp: removed Anus: patent Reflexes: Stepping present

Skull: normal Palates: intact Arms: NAD, symmetrical Sacral area: NAD Feeding: BF, NAD

Fontanelles: normal Neck: normal Fingers: NAD Range of movement: NAD Bowels: HPM

Sutures: normal Head movement: NAD

Legs/feet:: NAD, symmetrical

Reflexes: Moro present Urine: HPU

Information to parents: common skin conditions explained, normal newborn behaviour


Date:

Supervisor

Name/Designation & signature: K.Curtin (RM)KCurtin

Temperature: 36.4 Eyes: conjunctival haemorrhage

Chest: barrel Toes: polydactyly Reflexes: Rooting present

Resps: 52 per min Nose: patent Abdomen: soft Genitalia: undescended testes

Reflexes: Sucking present

Apex Beat: 164 Ears: ?low set Cord: sticky Spine: NAD Reflexes: Grasp present

Skin: NNJ K2 Mouth: epsteins pearls

Clamp: removed Anus: patent Reflexes: Stepping present

Skull: cephalhaematoma Palates: cleft Arms: NAD, symmetrical Sacral area: dimple Feeding: poor BF feeding

Fontanelles: normal Neck: R) mass Fingers: syndactyly Range of movement: NAD Bowels: HPM

Sutures: saggital fused Head movement: NAD

Legs/feet: R) talipes Reflexes: Moro present Urine: HPU

Information to parents: Neonatologist/paediatric review, treatment of jaundice, treatment of talipes


Date:

Supervisor

Name/Designation & signature:

Temperature: Eyes Chest: Toes: Reflexes: Rooting

Resps: Nose: Abdomen: Genitalia: Reflexes: Sucking

Apex Beat: Ears: Cord: Spine: Reflexes: Grasp

Skin: Mouth: Clamp: Anus: Reflexes: Stepping

Skull: Palates: Arms: Sacral area: Feeding

Fontanelles: Neck: Fingers: Range of movement: Bowels:

Sutures: Head movement Legs/feet: Reflexes: Moro Urine:

Information to parents:


51


Date:

Supervisor











Date:

Supervisor











Date:

Supervisor











52

5.9 Episiotomy and Perineal Repair

Type of episiotomy: Right mediolateral Indication: Forceps birth Infiltration with LA: 10mls 1% lignocaine Episiotomy on simulator? Yes No X

Supervisor Name/Designation &

signature:

K.Curtin (RM)KCurtin Date:21/1/16

Type of episiotomy: Indication: Infiltration with LA: Episiotomy on simulator? Yes No


_______________________________ _______________________________ Date:

Type of episiotomy: Indication: Infiltration with LA: Episiotomy on simulator? Yes No


_______________________________ _______________________________ Date:

Type of trauma: 2nd degree tear Suture material: 2.0 vicyl Description of repair: Genital tract inspected and cleaned Sterile field maintained Infiltrated 10mls lignocaine 1% Repaired in layers, good hemostasis, subcutaneous sutures to skin, anatomical alignment achieved. PR check NAD PR analgesia given Swab and needle count attended Vaginal plug not used Repair on simulator? Yes No X Supervisor Name/Designation &

signature:


Date: 22/2/16

Type of trauma: Suture material: Description of repair:

Repair on simulator? Yes No Supervisor Name/Designation & signature:

Date: _____________________________________

______________________________

Type of trauma: Suture material: Description of repair:

Repair on simulator? Yes No Supervisor Name/Designation & signature: Date: _____________________________________

______________________________


53

5.10 Postnatal Care Record Postnatal assessment of a woman (minimum of 100 in total including those recorded in the CCJ log)

Circle

mode of birth

Day

General Health

Emotions

Breasts & Nipples

Fundus &

Rectus abdominus

PV loss Perineum

Or Wound

Legs Elimination Baby Education

Medications

Supervisor Name (print) designation & signature

No. 1 Date: 1/1/16

Day 2 PN well Happy

Breasts soft & filling Nipples tender

F&C4F↓@ Nil DRAM

sm rubra

20 tear, C&D nil swelling

NAD BNO Nil dysuria

Cord C&D Skin clear Eyes clear

Peri hygiene, Coloxyl with senna given

K.Curtin (RM) KCurtin

No. 2 Date 1/1/16

Day 3 PN well Happy

Breasts full Nipples R) grazed

F&C2F↓@ DRAM 5cm

sm rubra

Dressing intact, nil further ooze

odema

mid-calf

↓↓

BO HPU

Cord C&D Skin NNJ Eyes clear

Physio referral B0 SBR advice Endone/ Diclofenac

B. Smith (RNRM)

BSmith

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

NVB

CS


54

Circle

mode of birth

Day

General health

Emotions

Breasts & Nipples

Fundus &

Rectus abdominus

PVloss Perineum

Or Wound

Legs Elimination Baby Education

Medications


No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes

No. Date NVB CS F/V

Cord Skin Eyes


55

5.11 Perinatal Mental Health Referrals

Perinatal mental health referrals Supervisor

Name (print) designation &

signature Date:2/1/16 Parity:2:1 Antenatal: √ Postnatal: Weeks/Day: 14 EPDS Score: 22 Breastfeeding: Yes No Significant other: Partner FIFO worker Risk factors: Minimal social support Recently relocated Housing issues

Presentation/reason for contact Midwifery first/booking visit

Midwifery actions/referral Reassurance; pamphlet re: emotions in pregnancy and support services given; recruit to Group Pregnancy Care; referral to Perinatal Mental Health Service; referral to social worker

Ongoing management (if known) G.P. and counsellor for depression. On medication. Repeat EPDS next visit

Outcome (if known) Feeling more supported. Engaging with services

L.Vincent(RM)

LVincent

Date:2/1/16 Parity:3:1 Antenatal: Postnatal: √ Weeks/Day: Day 5 EPDS Score: 22 Breastfeeding: Yes No Significant other: Unstable relationship Risk factors: Hx depression No social support Financial difficulty Housing issues

Presentation/reason for contact Postnatal ward Issues with bonding

Midwifery actions/referral Reassurance; PND education; clearance for extended midwifery home visiting (3 weeks)

Ongoing management (if known) Nil current management plan

Outcome (if known) Discharged with G.P., Community Health Nurse and Social Worker follow-up. Ongoing Perinatal Mental Health consultation


Date: / / Parity: Antenatal: Postnatal: Weeks/Day: EPDS Score: Breastfeeding: Yes No Significant other: Risk factors:

Presentation/reason for contact

Midwifery actions/referral

Ongoing management (if known)

Outcome (if known)

Date: / / Parity: Antenatal: Postnatal: Weeks/Day: EPDS Score: Breastfeeding: Yes No Significant other: Risk factors:

Presentation/reason for contact

Midwifery actions/referral

Ongoing management (if known)

Outcome (if known)


56

5.12 Women’s Health and Sexual Health

Person details Purpose of visit/care

episode Care given Supervisor

Name (print) designation & signature

Age Group: 25yrs

General Health: Endometriosis Date: 2/1/16

Admitted for laparoscopy for abdominal pain

Reassurance Prepare for theatre Ensure consent Post-op care Administration of analgesia Follow-up appointments made


Age Group: 45yrs

General Health: Date:

Attended clinic for results of pap smear. Diagnosed CIN III

Reassurance Education re LLETZ procedure Consent gained Surgery scheduled

L.Vincent (RM)

LVincent

Age Group:


Age Group:


Age Group:


Age Group:

General Health:

Date:


57

5.13 Speculum Examinations

Date G.P.

Gestation Indication for speculum examination/pathology

Assisted (A) or Performed (P)


21/1/16

3:2 32/40 Threatened preterm labour

A S.Burn (RM)SBurn

11/2/16

1:0 38/40 ?PROM P K.Curtin (RM) KCurtin


58

6. Abbreviations:

# Ruptured +ve Positive ↓↓ decreasing 4/5↑ Four fifths above the pelvic brim 4F↓@ Four fingers below the umbilicus 9/1 & 9/5 Apgar score 9 at 1 minute and 9 at 5 minutes AN Antenatal B0 Baby BF Breastfeeding BNO Bowels not opened BP Blood pressure bpm beats per minutes BSL Blood sugar level C&D Clean and dry CDU Charles Darwin University CIN III Cervical intraepithelial neoplasia grade 3 CoC Continuity of Care CS Caesarean section CTB Clinical Teaching Block CTG Cardiotocograph DRAM Diastases of the rectus abdominus muscle DV Domestic violence EPDS Edinburgh Postnatal Depression Scale F Female F&C Firm and central F/V Forceps/Ventouse (Vacuum) FBE Full Blood Examination FHR Fetal heart rate FM Fetal movement FMF Fetal movement felt G.P. Obs General Practitioner/Obstetrician G.P. Gravida Parity GBS Group B Streptococcus Gest Gestation GTT Glucose tolerance test Hb Haemoglobin HNPU Has not passed urine HPM Has passed meconium HPU Has passed urine Hrs Hours Hx History ICM International Confederation of Midwives

IOL Induction of labour IP Intrapartum iu International Units IV Intravenous IVI Intravenous infusion leuks Leukocytes LLETZ Large Loop Excision of Transformation Zone LOL Left occipito lateral LSA Left sacro anterior M Male mcg Micrograms Mins Minutes mls Millilitres MSL Meconium stained liquor NAD Nil abnormalities detected NBST Newborn screening test NMBA Nursing and Midwifery Board of Australia NNJ Neonatal jaundice NVB Normal vertex birth, or normal vaginal birth O&G Obstetrics & Gynaecology Obs Obstetrician OP Occipito posterior OSCA Objective Structured Clinical Assessment PCEA Patient controlled epidural anaesthesia pH Measure of acidity PN Postnatal PND Postnatal depression PPH Postpartum haemorrhage PR Per rectum PRN As necessary PROM Prelabour (premature) rupture of membranes R) Right Resps Respirations RM Registered Midwife RN Registered Nurse ROL Right occipito anterior ROL Right occipito lateral SG Specific gravity sm Small tabs Tablets U/A Urine analysis (Urinalysis) VBAC Vaginal Birth After Caesarean

Midwifery Clinical Practice Portfolio Section 1 Bachelor of Midwifery

59

7. FLOWCHART FOR CLINICAL PLACEMENT UNITS

COMMENCE PLACEMENT

CLINICAL APPRAISAL

Progress determined as satisfactory by

Agency/Facility clinical supervisors,

educators, preceptors and Unit Coordinators

Progress determined as

unsatisfactory by Agency/Facility

clinical supervisors, educators,

preceptors and Unit Coordinators

i.e.

Not achieved year level

standard

Not achieving scope of practice

Not demonstrating professional

conduct

Feedback provided to student

Placement Finished

Clinical Portfolio completed and submitted to

appropriate CDU unit co-ordinator within two weeks of

completion of clinical placement

Assessment

elements graded

as unsatisfactory

All elements graded as satisfactory and a grade is

recorded

One Learning

Agreement

opportunity for the

remainder of

placement, or

additional

placement

arranged as per

Learning

Agreement

Learning

Agreement

achieved

Learning

Agreement NOT

achieved by set

date

Student to meet

with the BM

Program Manager/

Theme Leader to

discuss course

progression

Student proceeds to the next level of study or if

course complete grade transcript signed and

forwarded to Nursing & Midwifery Board of Australia.

FAIL recorded for

unit

UNSAFE

PRACTICE

reported – student

working outside

identified scope of

practice

Student removed

from clinical

placement

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