Documentation for student midwives: how to write up an abdominal palpation

I have just spent some time with midwifery students. One of the things I have found is a general lack of confidence with documentation. In all my years as a midwifery educator, this has probably been one of the most common themes, and continues to be an issue into practice as registered midwives. So here is the first of several posts that will talk about basic midwifery documentation.

Abdominal palpation
I write up an abdominal palpation in the way I actually carry it out. I start with the reason for carrying out abdominal palpation and briefly write about any particular information I gave mum and that she gave her consent.

• General observations about the mother's health eg has she been feeling any abdominal tightenings or pain?
• General observations about baby's health ie what has been the pattern of fetal movements?
  
• General observations about the abdomen eg are there any scars and what is the significance for pregnancy?
• Fundus - is it at the level you would expect for the baby's gestation? If not, by measuring the fundus (by inspection or using tape measure), what size do you think the uterus is?
• What is the lie? If there are more than one baby, this may be difficult so you need to document what you feel and your "impression" of what you felt, acknowledging if you're not sure.
  
• What is the presentation?
• Where is the baby's back?
• Some people actually document what position they think baby is lying in. I have to admit I do not. Whilst I might be pretty sure, I always wait until I have confirmed the position by vaginal examination, if I ever get to that stage.
• Engagement of the presenting part. So if I can feel 4/5th of the head above the brim, I document that - there is no need to write not engage because that is evident. However, if the head is sitting at 3/5th engaged, just at the brim, I confirm that it is not engaged.
• Whilst we know that listening to the fetal heart in pregnancy is of no use, I have to admit I still do it. I document the heart rate, as well as how I heard it ie with a pinard or doppler.

I complete my documentation with the information I share with the woman and any action plan I have developed with her.

Example of documentation
Visited Lisa at home for her 36 week ante natal check up. Lisa is in good health and happy with how everything is going. She is feeling Braxton Hicks contractions at times but no regular contractions. Baby has been moving a lot, especially first thing in the morning and late at night, at least 10 movements every 12 hours.

Carried out abdominal palpation to check growth of baby with Lisa's permission.
Abdomen - healthy with linea nigra
Fundus = dates (fundal height = 37 cm)
Singleton - Longitudinal lie
Cephalic presentation
Back on the left and anterior, ?LOA
Head not engaged - 3/5th palpable
Fetal heart heard with pinard - 140 beats per minute

Discussed findings with Lisa - baby is growing well and lying in a good position ready for when Lisa goes into labour in a few weeks' time.
Plan: for routine ante natal visit at home in 2 weeks on 9th August 10.00 hours. Lisa has been advised to contact me if she has any concerns about the baby's movements - if she feels less than usual or none at all.

What do you think of this example of documentation. Have I forgotten anything? How would you do it - is there anything you would write differently?


Image: '240 - Checking In'
http://www.flickr.com/photos/8566600@N07/2801690057

Is blogging going out of fashion?

Last week I was talking to a crowd of people about social media and told them that I wouldn't be without my blog because I thought my blog was essential as my home...my base...from where I went to places such as Twitter, Flickr and so on. But having sung the praises of blogging, I have been wondering if it is as relevant...popular....necessary...now we have Twitter and Facebook?

Do people subscribe to blogs anymore?
I have a number of people who follow or subscribe to my blog. I can check this out by using various analytic tools. What I have noticed is that the number of followers has stayed static for about a year. And yet the number of people who look at pages of my blog has increased. So clearly people are visiting my blog but not necessarily subscribing to it.

Where does Twitter sit in all this?
I only have to look at my own use of social media to get a sense of how people are behaving toward blogs. I don't subscribe to blogs any more either. I have a Google Reader account but very rarely use it to read blogs. What I do these days is read blog posts that people recommend on Twitter. This is a random approach to keeping up to date but I find works very well for my own particular learning needs.

Blogging is as relevant as it always has been
As I said last week, I don't think blogging will go out of fashion for the time being. I will continue to blog for my own learning and development needs, if nothing else. Here is where I process my thoughts and have deeper conversations with people than I can have on Twitter or Facebook.

But I do think that we need to pay less attention to the number of people who subscribe to our blogs and more to the number of pages accessed because that is a truer reflection of how 'popular' our blogs are.

What do you think? Do you read particular blogs regularly? Do you follow or subscribe to blogs? If you are a blogger, what have you noticed about your blog stats over the last six months to a year?

Top 10 places for student midwives to go to find evidence-based information for clinical practice

I was asked last week what websites I would recommend to student midwives, where they could find free access to evidence-based information to use in clinical practice and also to support their academic studies. So here are my top 10 suggestions, in no particular order.

1. National Institute for Health and Clinical Excellence: http://www.nice.org.uk
NICE is a collection of clinical guidelines, research reviews and recommendations for health care. The NICE guidelines for maternity care are often quoted and include recommendations about ante natal, intrapartum and post natal care, hypertension in pregnancy, electronic fetal monitoring, induction of labour and cesarean section.

2. Cochrane database: http://www.thecochranelibrary.com
The Cochrane database of research reviews is considered to be one of the top sources of research evidence. It contains 401 reviews of research pertaining to pregnancy and childbirth. Whilst many consider the Cochrane reviews as "gold standard", there have been critiques of the methodology that reviewers use. For example, there have been concerns that several of the breech reviews are carried out by one of the main authors of the Breech Term Trial which has been largely discredited.

3. Royal College of Midwives: http://www.rcm.org.uk
The RCM website has free access to up to date news and research in its monthly magazine and professional journal "Evidence Based Midwifery". It also links to the RCM Supporting normal birth website which has heaps of resources about normal birth including the Top 10 Tips to supporting normal birth.

4. New Zealand College of Midwives: http://www.midwife.org.nz
The section of the NZCOM website I would pay most attention to is the consensus statements. Covering topics from family violence to the third stage of labour, the consensus statements give a clear over view of the issue and evidence-based recommendations. Of course they have a New Zealand context, but none the less may be used by midwives in other countries. And if nothing else, they have useful references that may be followed up.

5. RANZCOG: http://ranzcog.edu.au
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists regularly release information leaflets and guidance statements about a large number of topics pertaining to childbirth. I have to admit that sometimes I do not see eye to eye with what they say for example, RANZCOG recommends active management of third stage of labour for all women whereas I believe there are times when it is appropriate for women to physiologically birth the placenta and membranes. Nevertheless, the RANZCOG website is a good source of information for midwives practicing in Australasia.

6. Pubmed: http://www.ncbi.nlm.nih.gov/pubmed
Pubmed is a huge database of medical journals and resources run by the U.S. National Library of Medicine. Whilst many of the journals will only give you access to abstracts, Pubmed does include journals that have free access to full articles.

7. Midwife Thinking: http://midwifethinking.com
Rachel Reed is a midwife, midwifery educator and PhD student. Rachel is building a lovely blog full of reasoned discussion and evidence-based information. What I love about the way Rachel writes is she puts things in a way that anyone can understand without being patronising. I especially have enjoyed her recent posts on induction of labour and VBAC.

8. Google Books: http://books.google.com
The problem with books is that the time they hit the book shelf they are often out of date, and by the time they become fully available in Google Books this is even more true. However, some maternity text books are seminal books that stand the test of time but are not necessarily easy to access or cheap to buy. Having said all this, I always think its good to check what you can find on Google books - whilst a book may not be fully available, it's surprising how much information you can find.

9. YouTube (http://www.youtube.com) and Slidehare (http://slideshare.net)
I know there is a lot of rubbish on YouTube and information that is either mis-information or does not suit one's own practice context. But more and more educators and practitioners are posting informative videos on YouTube which are very useful. The same applies to Slideshare, which is like YouTube for PowerPoint presentations.

10. Maternity Care Discussion Group email list: To subscribe, email mkd(at)cfpc.ca
This email list is moderated by Dr Michael Klein on behalf of the College of Family Physicians of Canada. I think this email list has been a bit of an open secret. It is aimed at GPs but midwives are flocking to it because of the resources that are shared and the quality of discussion around research into maternity care. Student midwives are not encouraged to interact on the list, but you are very welcome to join, lurk and learn.

What sources of information of resources would you recommend to student midwives? What have you found useful?

Image: 'Melissa and Cara at Ayla's birth'
http://www.flickr.com/photos/26667277@N00/311398745

What will be the effect in years to come on babies who have a digital identity before they are even born?

Over the last few days I have been doing some research for a talk I am giving student midwives about social media and the way it impacts on childbirth choices for women. What I have found has been very interesting but left me with more questions than answers.

Digital identity, pregnancy and babies
What I have found fascinating in my latest research is the statistics about how parents are using the Internet to share stories about birth, and broadcast videos and pictures about their pregnancy, birth and young children. And as far as I can tell, there has been little commentry about this and certainly no long term research looking at the effects on children as they grow up.

Ross Dawson reported in 2010 that:

• In Canada, 37% babies have a digital identity before they are born
• Australia/NZ 41% newborns are on the net
• USA 92% children have an online presence by the time they are 2 years old

The parents responsibility toward their child's digital identity
Susan Bainbridge wrote an insightful blog post about this issue last year: Protecting the digital identity of my unborn child. In it she said:

I jokingly said that we needed to be careful what we said and how we said it because we could upset a teenage Asher in the future.... Then it hit us - this is a big deal. We are responsible for our unborn son's digital identity, for now anyway.

and
His young life will be very public.And none of it will go anywhere. Once it's on the web, it's on the web forever. How will he feel about that one day? Where will the future of the web head and is it anywhere our son will even want to be? Are we ok to make that call on his behalf? Now? Before he's even born?

And it isn't just parents who talk about their babies. I was struck a few weeks ago about the very personal nature of the comments made by a grandmother on Facebook about her sick grandchild. I have no idea if she had her daughter's permission to talk about the baby but I did wonder how "appropriate" it was.

Future research
I suspect this is an issue that many parents haven't even thought about. We know that people do not think about their own digital identity and footprint so I imagine they think even less about the impact of digital identity on their unborn babies. I think this is an area that needs longitudinal research. And maybe educating parents about their use of the Internet and digital identity is something that midwives need to pay more attention to? What do you think?

Have you talked about your pregnancy, birth or baby online? Have you ever thought about what your baby would think in years to come? Have you considered how you manage your baby's online 'brand'? Does it matter?

Do you know of any research that has been carried out on this topic? I'd be really grateful for your thoughts and/or references.



Image: 'Free Child Buried in The Sand Creative+Commons'
http://www.flickr.com/photos/40645538@N00/185075930

Social media, childbirth and midwifery practice

I am giving a short talk to student midwives tomorrow about the effect of social media on childbirth choices and midwifery practice. I have put together a short slide show but to be honest, I am not sure I have really dealt to the questions because I don't think we know if and how social media impacts on childbirth. This is an area that needs a lot more research.

I do know that women look for information on the internet and I feel it is my responsibility to provide quality information about birth online that women can refer to. Social media gives me an opportunity to listen to what women say about birth and maybe align my practice more with what they are saying. I also think social media can bring midwives and women together giving us one voice which in itself gives us an ability to work together to achieve mutual aims. Whether this is impacting on the provision of maternity care, especially in a global way, remains to be seen.

I'd love to hear from anyone who is researching this area, or has ideas about the impact of social media on maternity care. If you are a parent, how much do you rely on social media for information and ability to communicate with other parents? If you are a midwife, how is social media impacting on your practice?

Social media, birth and midwives

View more presentations from Sarah Stewart

http://www.slideshare.net/sarahs/social-media-pregnancy

10 top tips for using social media for successful networking, connecting and learning

On Thursday I had the pleasure of talking to the Social Media Club Gold Coast about my experiences of social media, and how it has helped me connect, learn and hook into opportunities that otherwise would not come my way.

While I was reflecting on my presentation, I came up with my top 10 tips for using social media to connect with people and broaden your horizon.

1. Be prepared to give time to networking and don't expect things to happen over night
I have been privileged to have made wonderful friends, connect with learning opportunities and go places such as Pakistan, all as a result of my use of social media. But it does take time. So I see the time as a worth-while investment into my professional development and future career.

2. Be consistent about how you 'brand' yourself
I have made a strategic decision to brand myself 'Sarah Stewart'...professional person...midwife, researcher and educator. That is how I am found on Google. To do this I use 'Sarah Stewart' on all my social media accounts so that I have a greater chance of being found when people do a Google Search. Again, this takes time and careful thought. It also means I have to behave in a professional way so I do not compromise my branding.

3. Be open
I take a very open approach to my digital identity and social media presence but I recognize that would not be everyone's cup of tea. However, it has worked with me for various reasons. People realise that what they see is what they get. This has made it a lot easier to connect with people, especially when I go on to meet them face-to-face. I feel very human to them which facilitates our communication. I do not publish very personal details such as my bank account details but being open actually protects my identity. It is so easy to track who I am and what I do that it would be difficult for anyone to take my work and pass off for their own.

4. Focus on what you can give as opposed to what you can receive
If you start to use social media because you think you will immediately make money... gain customers...become famous...you're going to be bitterly disappointed. You will only reap what you sow. So you've got to spend time with people and spread the love. Once you do that, then you will start to benefit from your connections.

5. Focus on quality, not quantity
For the life of me, I cannot understand why people drive to get so many followers or friends on Facebook, Twitter and so on. The number of followers you have means nothing. You can bet your bottom dollar that at least half of them are marketers or spammers. Social networking is about conversation and interaction. It's much more effective and productive to have meaningful conversations with 100 followers than face total silence with 10,000 followers.

6. Be authentic
This relates back to my point about being open. If you pretend to be something that you are not on Twitter or Facebook, you will be caught out and you'll lose all your credibility. Have a look at this post I wrote to get a better sense of what I'm talking about: I am only human.

7. Practice what you preach
You've got to experience social media and social networking to know what it can do. It's no good just talking about it...you've got to do it.

8. Always respond to people when they contact you
I cannot bear it when I talk to people on Twitter and Facebook or leave comments on people's blogs and then they do not reply. It's like going up to someone in the street and talking to them and being completely ignored. If you do that, you will quickly find that people do not return to your site and then you lose opportunities for engagement. I have found it incredible what opportunities come out of the smallest (and what seems unlikely) conversations.


9. Have a blog and Twitter account
I know a lot of people think blogs have passed their use-by date, but I still consider my blog to be my digital 'home' where I have my most in-depth conversations, and where I do my most constructive thinking and processing. However, if you have a blog and use it in-frequently people will think you do not 'live' there anymore, and will not continue to 'visit' you. I see Twitter as a vital tool for synchronous connection, and again, advise that you post at least one comment a day so people see the person behind the account.


10. Use a license on your “stuff” so that people can share and re-use it
I use a Creative Commons license - usually By Attribution. I feel strongly if if I share my stuff via Facebook, Twitter, Flickr, Youtube and Slideshare, that I contribute to a global body of knowledge that people can make use of.

I have found the 'pay it forward' approach to social networking to be an extremely effective approach to connecting, networking and learning and highly recommend you try it out.

What are your tips for effective networking, connecting and learning using social media?


Image: 'Talking Girls-- Edit 2'
http://www.flickr.com/photos/28859335@N00/120018144

E-Learning in the 1930s

I found an absolute delight on YouTube yesterday.

There's been a huge emphasis over the last few years on using alternative media, embedding blogs, wiki, videos and audio recordings into our teaching, especially when we're teaching online, to meet different learning styles and engage students. A lot of us are struggling to keep with "modern" technology, and I have heard a number of complaints from teachers that it is not their role to be making videos etc.

So I was thrilled and somewhat humbled to find a video about the mechanism of labour made at the University of Bristol in 1934, and I am thinking if they could do it back in those days, then we have no excuse in 2011 not to be thinking more creatively.

What are the issues facing midwifery education today?

I have to write an essay for my EdD: A critical review of the major educational issues related to the participant’s own professional practice.

This essay is designed to start me thinking about what I am going to look at for my research thesis.

"This assignment is not about some general educational issues, but issues that are specifically related to your own work, your own practice. These issues should also be related (directly or indirectly) to your thesis research."

To be honest, I haven't clue what to do for my research. I am interested in so many things. Life is further complicated by the fact I wear two hats - one as midwifery lecturer and the other as educational facilitator/developer. So I don't feel I am any closer to having a topic decided on than I did six months ago when I started my EdD.

What I have noticed over the last few months is I am getting far more midwifery "gigs" than anything else - in the last couple of weeks I have been asked to help out with the designing of a midwifery program for Pakistan as well as develop a midwifery curriculum in Nepal. So I am thinking my research will be focused on midwifery education.

In terms of my own practice, one issue is the globalization of midwifery education. How do we maintain consistency and make sure we all teach from the same page? Do we need to? How can we support midwifery educators in resource-poor countires who are endeavoring to teach midwives to work in the most trying of circumstances. How can we share resources that can be contextulised freely?

The other big issue in my own practice is blended delivery of undergraduate midwifery education. How do I engage students with the online delivery of content that can be integrated into clinical practice? How do I support students who are very focused on content delivery to move to being life-long learners? How do we integrate clinical practice and academic learning into a portfolio environment which sets students up and ready to go once they are registered midwives and subject to professional and statutory regulations?

So this leads me to ask those of you who are midwives, students or anyone interested, what do you think are the issues that face midwifery education today...not just undergraduate, but ongoing education for midwives once they are registered?

Image. Birth: http://www.flickr.com/photos/bellymotherbaby/12647636/in/photostream

Free online course starts 18th July: Facilitation Online 2011

It's that time of year again when I have the great pleasure to facilitate the free online course Facilitation Online. This course looks at what online facilitation is in all contexts...education, business and non-profit. And it gives you practical experience of using online communication tools including social media to facilitate classes, meetings, collaborations, discussions, events and campaigns.

You can join in for free, or enroll as a facilitated or formal student if you want one-to-one personal support.

If you want more information, please feel free to get in touch.

Here's a fun quiz to do to check if you're ready for Facilitating Online 2011!

How to write a paper in six weeks: Week 5

1. Review the how/where/when you write - if you're not sure about this, go back to the discussion of Week 4.

• What did you notice?
• What are you going to incorporate into your writing practice and what are you going to exclude?

2. Review the instructions of the journal you are submitting to. Make sure you are clear about all the features of the article like font, size of font, reference style, tables and figures and structure. Review the language you are using to write the article - are you using the format and language that will appeal to the audience of this particular journal?

3. Write the abstract for your article. The abstract is the précis of the whole article rather than a summary of what you particularly want people to take away which goes into your conclusion.

4. By now you should have completed at least half of your article. By next week, have the whole article completed and ready to be to go. Give it to your critical friend for editing and feedback.


Image: 'Moleskine'
http://www.flickr.com/photos/39154012@N00/4072560067

How to write a paper in 6 weeks: Week 4

1. Writing habits
This week you are to think about your writing habits - focus on the good habits that work for you. Don't worry about what the theory says makes a good writer. If you write well standing on your head on top of your chimney, then continue to write that way. But if you know you do not write well with the television on, then turn it off or move to a room where there is no TV.

• Take notice of where, when and how you write best. What noise or activities do you like in the background. Do you write better with the radio on? Do you like to write in a study or own the sofa with all the kids about? Do you better early in the morning or later at night? Do you "dump" or do you wait for the muse to strike? Once you recognise a pattern, focus on doing what is "best practice" or most effective for you.

2. How good is your sentence structure and grammar?
Pay attention to how you construct your writing.

• Turn on the grammar checker when you are writing.
• Make a note of when you get a green wavy line which indicates you have a problem with your sentence structure or grammar.
• If you notice you have a particular problem, find out how to fix it eg have a look at one of the numerous grammar guides that you can find on the Internet such as The Guide to Grammar and Writing or the OIL Grammar and Style resource for students.

3. Editing
If you are a person who always goes over the word count, you need to think carefully about how you edit your work without losing the sense of what you are trying to say.

• Look for little words that can be made into one word.
• Pay attention to the format the journal uses to publish papers. If it uses two columns, or is an online journal, use short sentences which are easier for the reader to follow - helps the reader to keep her concentration.
• For more tips on how to edit your writing, have a look at: How to Edit or Proofread an Essay or Paper

If you are working through this writing challenge with more than one person, take a paragraph from your work (no more than 250 words) and swap it around with each other and edit it. Use track changes so you can all see how each other has done the editing. If you are working on your own, try to find a critical friend who will edit your paragraph. And to get practice with editing yourself find a piece of writing on the Internet, maybe a blog post, and edit it.

4. Keep working on the body of your paper
By now you should be half way through writing the body of your paper as outlined in Week 3. Don't forget to embed your references into your paper as you go along - this is a lot less time-consuming than hunting around for appropriate references after you have written your paper.


Image: 'Woody with the editing skillz'
http://www.flickr.com/photos/31929257@N00/2093589494

How do you know you are a good parent?

I am the mother of two children who are young adults. They have just both left home which leaves my husband and me starting our new life as Darby and Joan, and has caused me to stop and reflect over the last 23 years as a mother and parent.

I'd admit there have been quite a few times over the years when my husband and I have angsted over how good a job we've done as parents. Neither our kids have ended up in prison so I have always taken comfort in that. But there have been times when I have wondered if I could have done better and asked myself questions like: have I instilled the right morals in the kids?; have I modeled a good work ethic?; what could I have done to help the kids get better marks at school?; why aren't the kids making billions of dollars from their own Facebook company by now?; how can the kids be good global citizens when their bedrooms are like pig stys!!?? And so on...

Then it dawned on me the other day...

My husband and I have done a bloody good job as parents. How do I know?

My children have both left home and moved to new cities and country with little or no support from us...on their own volition...and just got on with things. They have both found jobs and somewhere to stay within a couple of weeks. Neither of them have got much money and certainly no support where they are now living. But they've got drive, motivation, confidence and insight to take a risk and go out and make things work for them.

I have been blessed with two wonderful children who are now making their way in the world. Yes, they're doing it on their own and I am extremely proud of them, but I am going to give my husband and me a little credit for giving them the skills to take this step into adult life. This is how I know I have been a good parent.

How have you measured your performance as a parent? What do you think makes a good parent? How do you get your kids to keep their bedroom tidy!!??

Writing about that namby pamby stuff

The paper I am planning for the How to Write a Paper in 6 weeks is about blogging and reflective practice. This paper will be based on my personal experiences as opposed to a research project, and is a paper I have been thinking about writing for some time. I made a start in the form of an essay for my EdD - now I have to get on and finish it off as a paper for publication.

Here is the mapping I have done which meets the requirements of Week 2 of my writing project.

Reflective practice

• what it is
• why it is important for practicing midwives different models and processes - confusing at the best of times
  
• journaling is consistently seen as a valuable tool for reflective practice
  
• clarify the difference between reflective practice & journaling – what are the other ways/tools for reflective practice

Journaling

• journaling and reflective practice
  
• what makes journaling so effective
• how you do it – model for reflection – levels of learning (Bronwyn's thesis)
  
• evidence of reflective journaling for midwives – why they have to do it
  
• problems with journaling – learning styles, level of learning – people do not engage with deeper learning
  
• one adaptation is the modern blog

Blogging

• what a blog is...is similar to journalling but it is a separate thing with its own pros & cons....open journalling
  
• how it can be used for reflective practice - how it differs from paper journaling evidence about its effectiveness – do people do deeper reflection in a blog?
  
• problems with blogging – confidentiality, online reputation, digital literacy, Internet access

My experience

• multi-media suits my different learning styles
  
• I write in an anonymous way that protects the events/people I am reflecting on, as well as myself
  
• open blogging allows me to engage with readers - community of learning
  
• challenged to take me reflection to a deeper level – does my experience tie in with what the literature says
  
• information shared, connections made, conversations all add to my learning – conversations go else where...can leap frog into FB, Twitter etc...or go from blog to blog...don;t know who is going to respond to that post...or what perspective is offered...any perspective will make you think
  
• different perspective, not just from colleagues – I hear from health consumers and people from all walks of life
  
• people support me when the going gets tough
  
• people see what I have learned and how I have responded to that learning – accountability to the people I care for & teach
  
• contribute to others' learning eg article about burn out
  
• challenging to people who are uncomfortable with reflective practice, especially in open environment
  
• views people have about admitting your mistakes in public, especially in obstetrics
  
• what I blog about – some examples, with the comments people leave (probably this in interwoven through my narrative)

Recommendations

• Give it a go
• Keep things simple – digital literacy education
  
• Think about your online profile – how you're going to present yourself
  
• Get a mentor – some great midwifery bloggers and other healthcare professionals about to model your practice on and to link in with
  
• Get your posts checked if you think you're likely to breach confidentiality
  
• Blog in general terms rather than specifics
  
• Be patient – takes time to build a community of learners