OSCE PN examination Flashcards
1.Explain how you would approach this episode of care (5)
Firstly, I’m going to introduce myself to Blessing. Hi Blessing, my name is Ayesha, and I am a student midwife. It’s nice to meet you and congratulations on the birth of your beautiful baby Aisha. I would like to check I have the right person in the right place at the right time so I will ask blessing to confirm her details for me and I will compare this with her case notes. I will also need her case notes.
I will then ask Blessing open ended questions about her health and wellbeing and allow her time to answer as this may be an emotional and vulnerable time for a new mother, and she may have some worries that she wants to ask about. I have often found that service users may have particular worries that would be addressed as part of the examination anyway, such as breastfeeding, but they feel are urgent to get off their chest upon meeting a midwife so it would be important to listen to Blessing before beginning the examination. I will also observe her verbal and non-verbal cues to ensure these match. I would also take a trauma informed approach as it is best to assume anyone has experienced trauma that can be triggered through midwifery care such as a postnatal examination.
I will then make sure there are no contraindications for performing this postnatal examination today for example if she was feeling unwell, I would want to focus on this and explore what the issue is.
With your informed consent and if now is an okay time for you, I will be performing a postnatal examination on you. I will explain the procedure to you so that you are aware of what you are consenting to. I will observe if Aisha looks settled so that I have an idea if this is a good time for Blessing as her baby being hungry/ needing a nappy change etc may distract her.
- What is the purpose of postnatal care? (5)
The purpose of postnatal care is in order to maintain and promote maternal health and wellbeing and to offer any support and information where required with breastfeeding, baby care etc. I would also want to give her education regarding her health, parenting, signs of infection etc, all to encourage her confidence as a new parent. This is also an important time to assess maternal and neonatal safety as gender-based violence rates can increase during and/or after childbirth. It is also an opportunity for detecting deviations from the norm and escalating these to the appropriate person. Maternal mental health can deteriorate fast after childbirth, so it is important to keep a close eye on this and provide input where required.
- How would you prepare the space for the postnatal examination? (2.5)
To prepare the room for the examination, I’m going to make sure the room is at a good and comfortable temperature. To maintain Blessing’s privacy and dignity I’m going to close the door, window, and curtains and if possible, use a do not disturb sign so that we won’t be disturbed. If there are visitors present in the room, blessing may want them to leave for the examination. I’ve found that in certain cultures, Blessing may want her partner to leave the room for privacy if personal topics such as her lochia or perineum are going to be discussed and examined.
- How would you prepare yourself and what equipment would you require? (7.5)
I’m also going to wash my hands to prevent cross infection as Blessing and her baby are particularly vulnerable at this time. I’m going to follow the WHO 5 moments of hand hygiene and the 7 steps of hand washing. If my hands were visibly clean i would use the alcohol gel. I’m going to use an apron and gloves and I’m going to make sure I have the equipment I need and that my equipment is clean and working. I’m going to need a watch to count Blessing’s pulse, a sphygmonometer, a stethoscope, thermometer and Blessing’s case notes.
5.Using the phantom demonstrate how you would perform this examination? (11.5)
Start with assessing Blessing’s health and well being
Start with assessing Blessing’s health and well being
Throughout the examination, I am going to be asking open ended questions. Before beginning the examination, I’m going to ask Blessing about how she’s feeling and how the past day or night has been for her. This will give me information on her health and also emotional health. As it is day 2, we know that for majority of women this is when they will feel the baby blues due to a drop in hormones. We would want to inform Blessing that this is normal and to keep an eye on this and if this doesn’t lift, give advice to Blessing on who to contact and how to get help.
I’m going to ask you about your sleeping pattern, and I’ll provide comfort, advice and reassurance depending on what she tells me. If Blessing is struggling to get enough sleep, which will be the case with most new mothers, I’d want to give her advice on making sure she is at least eating enough and relaxing when she can, through visualisation or asking her partner or family members for help with baby care if possible. I’d also want to have an idea of her home situation as many mothers can overwork themselves as they return to their family.
I would also want to discuss the safe use of any medicines she may be taking such as supplements and ensure that she has analgesia to take home as we know she has a second-degree tear. It would also be important to share with her worsening advice, such as signs of infection, persistent/severe headaches which could be a sign of pre-eclampsia or hypertension. I would also want to discuss a postural headache, and the difference between this and a normal headache is that it is much more painful when sitting upright and is improved by lying in a supine position. I will also discuss migraines and any other intercranial issues she may have.
6.a Observations in the postnatal period are important, demonstrate what observations you will take and explain why (6.5)
I will take postnatal observations in line with local guidance. Previously guidance lines were to take postnatal observations every day for the first 3 days. Postnatal observations include temperature, pulse, respiration and blood pressure.
I am going to take her blood pressure and compare this with Blessing’s previous blood pressures from the antenatal period and the reason for this is to look for any signs of pre-eclampsia. I am also going to take her temperature and the normal range of this would be between 36 and 38 degrees. The reason for this is to look for signs of infection.
I’m also going to do Blessing’s radial pulse for one full minute, checking for rate, rhythm, and regularity. The normal rate would be between 60 and 100 beats per minute. After this I would move on to her respiratory rate and whilst doing so I would want ot make sure there is no effort on inhalation or exhalation and that both her ribs are rising and falling equally. The normal rate of respirations would be between 12 and 18 resps per minute.
Once I have taken all of the observations I will record these in the MEWS chart, the maternity early warnings system and will report any deviations to the appropriate person.
6.b How would you assess oral intake? Why is this important? (3.5)
I would ask Blessing if she is managing to drink okay and how much she has drank today. I would then re encourage her to continue to have a good oral intake as this can avoid constipation and ensure she is hydrated, and also aids in healing and repair. I would encourage her to maintain a diet rich in fibre as to keep her digestive system working and in iron as her iron levels will have dipped during pregnancy and during labour through blood loss.
Blessing may not have a great appetite so we would recommend that she has smaller nutritious meals and snacks when she can.
6.c Provision of support with chosen method of feeding forms part of the postnatal examination. Demonstrate your approach to this element of care. (3)
As we know Blessing is breastfeeding, I would want to provide support with this and ask to observe a feed if Blessing is comfortable with this, to ensure a good positioning and attachment and provide any further tips. I would ask open ended questions about how she is managing to breastfeed and if she has managed to find a position which is most comfortable for her.
I would also provide advice on how to protect her posture and adapting a sustainable position.
I would want to take an assets-based approach, which means appreciating what blessing already knows and feels confident with and adding to this knowledge.
6.d Routine observations of breasts form part of the assessment, demonstrate how you will undertake this (8)
When observing Blessing’s breasts, it would be important to be aware of what ‘normal’ looks like on different skin tones, for example Blessing’s nipples may be a lot darker. It would also be more difficult to visibly see any inflammation so it would be helpful to ask blessing if her breasts feel hot to the touch. I would want to continue asking open ended questions about whether she has any discomfort or tenderness in her breasts, and if her nipples are misshapen at the end of a feed. I would want to give her advice on worsening symptoms such as a localised tenderness or pain and inflammation could lead to mastitis and if she had any symptoms, I would advise her to for example massage her breast from the outwards towards the nipple towards the nipple. I would encourage her to continue feeding so that Aisha can effectively drain the breasts to prevent any blockages and continuously stimulating milk production. If these self-help measures don’t improve blessing’s symptoms, then I would tell her the importance of reporting this to us so that we can provide her with the correct treatment.
6.e Routine fundal palpation is not always necessary; however, this is an essential skill for midwives. Please demonstrate how you would palpate Blessing’s fundus. (5)
As we are taking a systematic approach, we would move on to palpate Blessing’s fundus. Firstly, I would ask Blessing if it’s okay that I have a feel of her fundus and make sure she has emptied her bladder so that she is comfortable and that the palpation is correct. Whilst doing a fundal palpation I need to make sure to maintain Blessing’s dignity and privacy, meaning asking her to move the overs to a place where she is comfortable with an only exposing what is necessary. Starting at the umbilicus, I’m going to gently palpate with the side of my hand downwards until I feel a firm fundus. As blessing is on day 2 postnatally, we would expect to feel the fundus at about 2 finger spaces beneath the umbilicus. Her uterus should not be deviated to the left or right.
6.f How would you assess Blessing’s lochia? (17)
What advice should you give Blessing around prevention and monitoring for signs of infection
To assess Blessing’s lochia, I would ask her open-ended questions about the volume of lochia, the colour of her lochia. I would also provide her with worsening advice such as if her lochia had an offensive odour. I will tell her that she may notice a colour change, so in the beginning the colour will be red which we call rupra to a lighter and pinker colour and less heavy by the end of maybe 10 to 14 days. Sometimes this can take longer for some people, and this is called lochia alba and there is nothing to worry about if this is the case. I would also ask Blessing if it okay that I observe her pad, again ensuring to maintain her privacy and dignity. She may be okay with us observing the pad she has on or may want to take off the pad and show it instead. Im looking at this now and it looks absolutely normal, there is a normal volume of blood and there is no offensive smell.
So Blessing, im going to give you some information regarding prevention and monitoring for signs of infection. If your lochia did have an offensive smell or if you pass any clots that you are concerned about, it would be important to report this to us so that we can observe the clot if possible and provide further support or treatment if necessary. I would also advise her to avoid using tampons, so just using sanitary towels for the 6 weeks and this is because of the risk of infection. I would also encourage that you change your sanitary towel every time you go to the toilet and make sure to wash your hands before and after doing so. Again, this helps to prevent infection, particularly streptococcal e at this point. I would also encourage you not to use any scented products when you are taking care of your vulval hygiene, but make sure to wash yourself frequently in the shower or using a jug of water when sitting on the toilet. This is to keep your perineum as clean as possible and I would also advise that you keep it dry. If you have any abdominal, pelvic or perineal pain or are feeling shivery or feverish or have any vaginal discharge that have an offensive smell, we encourage you to report this to us as these are key signs of infection. If you were at home, you would phone maternity assessment.
6.g Demonstrate or discuss how you would inspect the perineum? (1.5)
Firstly, I would ask Blessing for her consent to inspect her perineum. We have made sure the room protects her privacy and dignity as the curtains are drawn and there is a do not disturb sign on the door or I have drawn the bed curtains. I would ask Blessing to either lie on her left hand side and lift her leg or she can lie on her back and lift her knees, whichever feels more comfortable for her. I am bringing back the covers as far back as needed, Blessing may want a towel to cover her legs as these will be exposed unnecessarily. I am visualising the suture line and looking for signs of healing or infection or any other concerns. I may need to use a hands on approach as to be able to visualise the stiches if they were more internal, and I would make sure to ask for Blessing’s consent before doing so. Everything looks fine here Blessing, I will advise you to keep taking your painkillers as required and to practice your hygiene as you are doing, well done.
6.h Demonstrate inspection of Blessings legs? (7)
Whilst the covers are up to inspect Blessing’s perineum, I will move on to inspecting her legs. If she had her legs covered whilst I was inspecting her perineum I would move this cover with her informed consent. I will move the covers down to cover her perineum again. I am looking for signs of oedema, problematic varicose veins or deep vein thrombosis. This may show as any swelling, areas of hot or red. I will also ask her if she has any pain or discomfort in her legs. They may be sore after birth; however, I am looking for any localised pain that may be red or hot to the touch. I’m also comparing her legs to each other to look for any swelling. A small amount of swelling postnatally would be normal as Blessing’s kidneys are returning to their non pregnant physiology and her circulation system is a bit slow. I would encourage Blessing to mobilise to encourage her circulation and when she is in bed try to put her legs up and mobilise her feet and toes.
6.i elimination (6)
I’m going to move on to ask Blessing about her bowels and her bladder. You should not have any leakage of urine, or any stress incontinence so leaking when you cough or sneeze. If you do notice anything like this, I would encourage you to report this to us. It would help your urinary function and bladder control to do your pelvic floor exercises, and someone will talk to you about how to do this and how frequently to do this. I would encourage you do your pelvic floor exercises for the rest of your life because it’s good for your pelvic floor.
I’m also going to ask you about your bowel movement. As you are only 2 days postnatal, it would be completely normal if you haven’t moved your bowels yet. I am going to give you some advice about supporting the suture line on your perineum as this can feel uncomfortable when moving your bowels and relaxing your pelvic floor. I’m also going to ask you if you’ve had any fecal fluids coming from your bowels or any incontinence associated with moving your bowels. This all seems normal today which is great.
- Overall approach to the care episode (4)
- Taken a systematic approach to the care episode. This helps me cover every factor and also helps Blessing feel more comfortable and less overwhelmed.
- Maintaining privacy and dignity throughout the examination
- Demonstrating compassion and empathy in this vulnerable time for Blessing and giving her the opportunity to ask me any questions or any concerns she has. I’ve made sure to be patient when listening to her and taken this postnatal care episode as an opportunity to provide her with knowledge and advice regarding her health.
