The virtual birthing unit project/First hour after birth

''This lesson should take approximately 60 minutes and is appropriate for senior midwifery students, as well as anyone interested in childbirth. With a partner you will work your way through a scenario that focuses on the care of a woman and her baby in the first hour after the baby is born. This scenario is designed to support you to think about midwifery assessment and actions, decision-making and sharing information when you are working with women and newborn babies.''

Resources

 * Computer and Internet with access to Second Life
 * Basic ability to use Second Life and access the virtual birth unit http://slurl.com/secondlife/Kowhai/82/213/35/
 * Resource Pack that can be found in the meeting room on the second floor of the birth unit. -need to check that!!!
 * Midwife's self-assessment form and clinical notes, and script for woman.
 * Extra resources to support this scenario either as links or printed handouts:
 * New Zealand College of Midwives. 2008. Midwives handbook for practice. New Zealand College of Midwives: Christchurch


 * New Zealand College of Midwives. (No date). Providing feedback about your midwife. Retrieved 15 July, 2009, from: http://www.midwife.org.nz/index.cfm/1,136,html


 * Pairman, S., Pincombe, J., Thorogood, C., & Tracy, S. (2006). Midwifery. Preparation for practice. Sydney: Elsevier.


 * Soni BL. Effect of partogram use on outcomes for women in spontaneous labour at term: RHL commentary (last revised: 1 June 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.


 * Rory Windrim, P. Gareth Seaward, Ellen Hodnett, Hani Akoury, John Kingdom, Mary Ellen Salenieks, Shafagh Fallah, Greg Ryan. A Randomized Controlled Trial of a Bedside Partogram in the Active Management of Primiparous Labour. J Obstet Gynaecol Can 2007;29(1):27–34.

Clinical notes for midwife
Date xx/xx/xx Time 15 hours ago Phone call. Lisa Smith rang the birth unit with history of contracting 1: 10 mins, lasting 30 secs. Had been contracting 1:15 previously. G1 P0. Term plus 2 days. In good health. Urine normal but has had slight diarrhea for 24 hours. Also feeling slightly nauseated all day. Slight finger oedema. No headaches or visual disturbances. Intact membranes. No vaginal bleeding but small amount of mucasy 'show'. Good fetal movements.

Advised to stay at home and await events. Try to get as much rest as possible; relax in warm shower/bath. Continue to eat and drink normally. To ring again if contractions become more painful and/or frequent; membranes rupture and/or fluid is any colour other than clear; have vaginal bleeding; or have any concerns about baby's movements. AN Other Midwife

Date xx/xx/xx Time 9 hours ago Lisa Smith admitted to birth unit. In good health. Normal pregnancy. Slightly elevated blood pressure at the end of pregnacy but settled. No headaches or visual disturbances. Passing urine normally. No show. Good fetal movements. Contracting every five minutes, lasting 20-30 seconds, in-coordinate, mild on palpation.

T. 36.4 degrees C P.78/min  R. 16/min BP 120/70  Urine - Protein nil, Glucose nil, Ketones  nil, Blood  nil.

Abdominal palpation: fundus =dates, longitudinal lie, cephalic presentation, back on the left, posterior, head at brim, 3/5th palpable. Fetal heart 135, no deceleration heard during contraction.

VE to assess progress: Cervix posterior, partially effaced, soft, thick, poorly applied, 2 cm dilated. Head presents, 2cm above ischial spines, position not defined. No caput, moulding or cord felt. Membranes intact. Fetal heart 145, no deceleration heard during contraction.

Impression: Labour is progressing normally and both Lisa and baby are well. Plan: To await events. Advised Lisa to rest as much as possible and also moblise when she feels like it. Showed her around the birthing unit and invited her to help herself to food and drink. AN Other Midwife

Date: xx/xx/xx Time: 6 hours ago Lisa is starting to get uncomfortable. She is contracting 1:3 minutes, lasting 30-40 seconds, moderate to palpate.

T. 36.6 degrees C P.82/min  R. 18/min BP 115/75  Urine - Protein nil, Glucose nil, Ketones  +, Blood  trace.

Abdominal palpation: fundus =dates, longitudinal lie, cephalic presentation, back on the left, lateral, head engaged, 2/5th palpable. Fetal heart 145, no decelerations heard during contractions.

VE to assess progress: Cervix slightly posterior, effaced, soft, thinning, loosely applied, 5 cm dilated. Vertex presents, 1cm above ischial spines, left occipito transverse, flexed. No caput, moulding or cord felt. Membranes intact. Mucasy, blood stained show. Fetal heart 140, no decelerations heard during contractions.

Impression: Lisa is in established labour and coping very well at this stage. Plan: to continue ongoing monitoring and support Lisa to keep mobile, have a warm shower or get in to the birthing pool.

AN Other Midwife

Date: xx/xx/xx Time: 1 hour ago Lisa is having very strong contractions every two minutes, lasting 60-90 seconds, which she is finding very painful. Lisa's membranes have ruptured and she is draining a moderate amount of slightly blood-stained liquor. She is also starting to feel an urge to push at the height of the contractions. Lisa is coping reasonably well with the contractions and enjoying the relief of warm water in the birthing pool.

T. 36.9 degrees C P.84/min  R. 16/min BP 120/80 T. Urine - Protein nil, Glucose nil, Ketones  +, Blood  trace.

Abdominal palpation: fundus =dates, longitudinal lie, cephalic presentation, back on the left, anterior, head engaged, 1/5th palpable. Fetal heart 150, no decelerations heard during contractions.

VE to assess progress: Cervix central, effaced, soft, thin, well applied, fully dilated. Vetex presents, 1cm below ischial spines, direct occipito anterior, flexed. Small amount of caput, slight moulding. No cord felt. Moderate amount of clear liquor draining. Small amount of mucasy bloody show. Fetal heart 135, no decelerations heard during contractions.

Impression: Lisa's cervix is now fully dilated and she is approaching second stage of labour. Plan: To await events and continue to support Lisa by encouraging her to keep mobile, use water for pain relief and start to push as and when her body dictates. To continue monitoring progress and health of baby by listening to baby's heart every five minutes and watching the colour of draining liquor. AN Other Midwife

Date: xx/xx/xx Time: 5 minutes ago

Lisa pushed spontaneously for 40 minutes, made great progress and birthed a beautiful baby.

Baby well: apgar score 9/1 10/10. Baby dried and put to breast for skin-to-skin contact.

Blood loss was 300mls. AN Other Midwife

Midwife's self-assessment form
Use this /self-assessment form/ to assess your performance, reflect on what you did well and what you can improve in the future.

Script for mother
Here is the information about the last few hours for you to pass onto the midwife, along with your background story as and when it is appropriate or relevant. Feel free to add lib a little but please keep everything ‘normal’.

The idea of this scenario is for the midwife to support you as you bond with your new baby and birth your placenta and membranes. The midwife should assess your condition, advise you about how to birth your placenta and support you. Wait until the midwife asks you questions – don’t give out all the information at once. Feel free to ask questions which you think will help to test the midwife's knowledge of normal childbirth.


 * Contractions
 * You have had a tiring but normal labour and birthed your baby without any problems. You are very tired, and a little sad that your husband cannot be with you but you will ring him as soon as possible to tell him the news.


 * Birthing the placenta
 * You feel another big contraction and then birth the placenta. You feel a big sense of relief after the placenta is born. You feel a great sense of achievement because you haven't used any drugs at any stage of your labour.


 * Stitches
 * You may need stitches. You have a sore bottom and ask for pain killers. You are apprehensive about the need to be stitched but understand the need for it (if you do in fact need stitches).


 * Breastfeeding


 * You are very keen to breastfeed but have little understanding of how it works other than what you have read in pregnancy books.


 * Choices
 * You get to choose the name for the baby! :)

Also check your birth plan which is in the antenatal notes in the Resource Pack for the decisions you have made about your labour.

Here are some questions you may wish to ask.
 * What happens if I lose a lot of blood?
 * What do I have to do to birth the placenta?
 * Will it hurt when I deliver the placenta?
 * What happens to the placenta?
 * Do I need to have an injection for the placenta?
 * What do you think I should do about vitamin K for the baby?
 * How do I get the baby on my boob to feed?
 * How long do I need to feed the baby for?
 * How will I know the baby has had enough to eat?
 * Do I have to have stitches?
 * What happens when I have stitches?
 * When can I have sex again?
 * Should I get a rubber ring to sit on?
 * What can I have for my sore bottom?

Learning objectives

 * Demonstrate an understanding of the role of the midwife in the normal childbirth process.
 * Demonstrate effective evidence based, midwifery practice guided by a sound knowledge base.
 * Demonstrate an understanding of significance of concepts of accountability, responsibility and independent practice as they relate to midwifery practice in New Zealand.

Instructions for Scenario Three - Birth of the baby
1. Read the 'Introduction for students' which will give you a general background to the virtual birthing unit project. Set up your Second Life account and create your avatar. If you are using a personal computer, download Second Life. 2. Read the orientation package which will introduce you to Second Life and the skills you will need in this scenario.

3. Make your way with your partner to the back room of the birth unit, on the second floor.

4. Open the Resource Box - here are the instructions on how to open the Resource Box.

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8. The scenario ends when the woman is happy she has all the information she needs and has had all her questions answered and the midwife is satisfied with her assessment of the situation and the plan of action that she has developed.

9. Once the scenario ends, the woman will pass her feedback form to the midwife. The midwife will also carry out a self-assessment for her personal learning.

10. The midwife will complete her documentation on a notecard and post it into the filing cabinet in the midwives' office. The documentation will be automatically sent to a midwifery lecturer (in real life) who will give you feedback on how effectively you have documented your assessment and actions. The midwife will also be able to send her documentation to the woman. The student playing the woman will also be able to give feedback about the documentation. 11. Feel free to ad lib and role play as much or as long as you like but please remember that the scenario is programed to be a 'normal' labour and birth. For example, if you decide you would like to practice how to deal with an obstetric emergency, you will be unable to do so because the scenario has not been set up to present that eventuality.

12. This scenario involves role play so do not be shy; let your imagination run so that you and your partner gain maximum learning benefit from this simulation. At the same time, have fun. If you make a mistake or miss an action or assessment, you can start all over again and keep practicing until you are happy with your performance.