Charles Darwin University Clinical Practice Record · 2016 Midwifery Clinical Practice Portfolio...
Transcript of 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
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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
Student Name: _________________________ Date: _____________
Competency Indicator
Achieved
Yes No N/A
4.3 Organises workload, equipment and collects records
1.2 2.1
Provides assistance and interpreter as required
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:
Satisfactory Unsatisfactory
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: _____________
Competency Indicator
Achieved
Yes No N/A
4.3 Has prepared equipment
1.2 2.2 4.1 5.1 Adheres to infection control measures and standard precautions
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:
Satisfactory Unsatisfactory
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
Student Name: _________________________ Date: _____________
Competency Indicator
Achieved
Yes No N/A
4.3 Organises workload, equipment and collects records
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
1.2 2.2 4.1 5.1 Adheres to infection control measures and standard precautions
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:
Satisfactory Unsatisfactory
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: _____________
Competency Indicator
Achieved
Y N N/A
4.3 Organises workload, equipment and collects records
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
Student Name: _________________________ Date: _____________
Competency Indicator
Achieved
Yes No N/A
4.3 Organises workload, equipment and relevant records
1.2 2.1
Provides assistance and interpreter as required
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 Addresses woman appropriately and seeks consent
3.1 3.3 4.1 10.1 Gives clear and relevant explanation
1.2 2.2 4.1 5.1 Adheres to infection control measures and standard precautions
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:
Satisfactory Unsatisfactory
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.
Student Name: _________________________ Date: _____________
Competency Indicator
Achieved
Yes No N/A
4.3 Organises workload and any equipment
1.2 2.1
Provides assistance and interpreter as required
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 Addresses woman appropriately and seeks consent
3.1 3.3 4.1 10.1 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 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
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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:
Satisfactory Unsatisfactory
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: __________ __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Student comments: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Assessor name & Designation: Assessor signature: ___________________________________________ Date: ___________________________________________ Student signature:
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4.8 Management of midwifery emergencies
4.8.1 Shoulder dystocia (simulation)* OSCA in CTB (MID303) Student Name: _________________________ Date: _____________
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 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: __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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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4.8.2 Vaginal breech birth (simulation)* OSCA in CTB (MID303) Student Name: _________________________ Date: _____________
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
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: __________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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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4.8.3 Management of Primary Postpartum haemorrhage (simulation and assume uterine atony) * OSCA in CTB. (MID303)
Student Name: _________________________ Date: _____________
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: __________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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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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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
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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
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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
Shape of Uterus: Scars/other features:
Fundal height: Lie:
Presentation: Position:
Engagement/Attitude: Fetal Heart Rate/Method:
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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
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
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
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
Shape of Uterus: Scars/other features:
Fundal height: Lie:
Presentation: Position:
Engagement/Attitude: Fetal Heart Rate/Method:
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5.3 Electronic Fetal Monitoring
Electronic fetal monitoring Date: 11/9/15
Supervisor : Name (print) designation & signature
B. Smith (RNRM)BSmith
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
Supervisor : Name (print) designation & signature
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:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
Electronic fetal monitoring Date:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
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Electronic fetal monitoring Date:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
Electronic fetal monitoring Date:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
Electronic fetal monitoring Date:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
Electronic fetal monitoring Date:
Supervisor : Name (print) designation & signature
Indication:
Uterine Activity: Baseline Rate:
Variability: Accelerations:
Decelerations: Type of Decelerations:
Overall status: Action:
Significance of findings:
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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
B. Smith (RNRM)BSmith
1/2/16
Dilation Effacement Consistency Application Membranes Station Caput /Moulding Supervisor : Name (print) designation & signature/ date
Dilation Effacement Consistency Application Membranes Station Caput /Moulding Supervisor : Name (print) designation & signature/ date
Dilation Effacement Consistency Application Membranes Station Caput /Moulding Supervisor : Name (print) designation & signature/ date
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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
Supervisor : Name (print) designation & signature
K.Curtin (RM)KCurtin
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
Immediate assessment of baby by(student/other):
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
Supervisor : Name (print) designation & signature
L.Vincent(RM)LVincent
Primary
Assist
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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
Immediate assessment of baby by(student/other):
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
Supervisor : Name (print) designation & signature
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:
Interventions and/or
Complications:
Third stage management
Method:
Oxytocic:
Placenta Membranes:
Blood Loss:
Perineum Role of student: (circle) Primary Assistant Observe
Immediate assessment of baby by(student/other):
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:
Time of onset:____ Length: 1 stage____ 2 stage____ 3 stage____ Total:
Type of Birth:
Interventions and/or
Complications:
Third stage management
Method:
Oxytocic:
Placenta Membranes:
Blood Loss:
Perineum Role of student: (circle) Primary Assistant Observe
Immediate assessment of baby by(student/other):
Apgar Score:
/1 /5
Resuscitation:
Fourth stage
Skin to Skin:
First breastfeed:
Sex Weight
Supervisor : Name (print) designation & signature
Assist
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DATE:
Birth Register No.
Age
G/P
Gest
Labour onset:
Time of onset:____ Length: 1 stage____ 2 stage____ 3 stage____ Total:
Type of Birth:
Interventions and/or
Complications:
Third stage management
Method:
Oxytocic:
Placenta Membranes:
Blood Loss:
Perineum Role of student: (circle) Primary Assistant Observe
Immediate assessment of baby by(student/other):
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:
Time of onset:____ Length: 1 stage____ 2 stage____ 3 stage____ Total:
Type of Birth:
Interventions and/or
Complications:
Third stage management
Method:
Oxytocic:
Placenta Membranes:
Blood Loss:
Perineum Role of student: (circle) Primary Assistant Observe
Immediate assessment of baby by(student/other):
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:
Time of onset:____ Length: 1 stage____ 2 stage____ 3 stage____ Total:
Type of Birth:
Interventions and/or
Complications:
Third stage management
Method:
Oxytocic:
Placenta Membranes:
Blood Loss:
Perineum Role of student: (circle) Primary Assistant Observe
Immediate assessment of baby by(student/other):
Apgar Score:
/1 /5
Resuscitation:
Fourth stage
Skin to Skin:
First breastfeed:
Sex Weight
Supervisor: Name (print) designation & signature
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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
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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
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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
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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
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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:
B. Smith (RNRM)BSmith
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:
K.Curtin (RM)KCurtin
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:
B. Smith (RNRM)BSmith
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:
_____________________________________
______________________________
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:
_____________________________________
______________________________
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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:
_____________________________________
______________________________
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:
_____________________________________
______________________________
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:
_____________________________________
______________________________
ADMINISTER EPIDURAL DRUGS 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:
_____________________________________
______________________________
2016 Midwifery Clinical Practice Portfolio Section 1 (Reviewed November 2015)
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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
Physical examination of the newborn
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
Physical examination of the newborn
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:
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Physical examination of the newborn
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:
Physical examination of the newborn
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:
Physical examination of the newborn
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:
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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
Supervisor Name/Designation & signature:
_______________________________ _______________________________ Date:
Type of episiotomy: Indication: Infiltration with LA: Episiotomy on simulator? Yes No
Supervisor Name/Designation & signature:
_______________________________ _______________________________ 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:
K.Curtin (RM)KCurtin
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: _____________________________________
______________________________
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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
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Circle
mode of birth
Day
General health
Emotions
Breasts & Nipples
Fundus &
Rectus abdominus
PVloss Perineum
Or Wound
Legs Elimination Baby Education
Medications
Supervisor Name (print) designation & signature
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
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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
K.Curtin (RM) KCurtin
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)
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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
K.Curtin (RM) KCurtin
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:
General Health: Date:
Age Group:
General Health: Date:
Age Group:
General Health: Date:
Age Group:
General Health:
Date:
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5.13 Speculum Examinations
Date G.P.
Gestation Indication for speculum examination/pathology
Assisted (A) or Performed (P)
Supervisor Name (print) designation & signature
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
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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
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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