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Phase Two

This page showcases learning from the following classes I have completed in midwifery school:
All course descriptions are taken directly from the MCU Course Catalog.
Midwifery 2010: Prenatal Care One: Foundations of Prenatal Care
Clinic 2010 and 2020: Phase Two Practicum
Midwifery 2020: Prenatal Care Two: Prenatal Care for a Healthy Pregnancy
Clinic 2030: Phase Two Practicum
Midwifery 2030: Labor, Birth, and Immediate Postpartum
Midwifery 2040: Postpartum Care
Clinic 2040: Phase Two Practicum
Midwifery 2050: Pediatrics
Midwifery 2060: Clinical Testing in the Childbearing Year
Midwifery 2070: Obstetric Pharmacology
Midwifery 2080: Ante/Intrapartum FHR Surveillance
Midwifery 2090: Pelvic Health and Suturing
Midwifery 2100: Well Person Care
Clinic 2050: Phase Two Competencies
Prenatal Care One: Foundations of Prenatal Care
This course focuses on the basics of prenatal care: from establishing initial contact, taking a thorough client history, initiating ongoing prenatal care including both maternal and fetal evaluations, addressing common discomforts and physiological changes of pregnancy, and facilitating referral when indicated. With the Midwifery Model of Care and an individualized approach, students will make charts for routine prenatal care, client handouts, and the NARM Informed Consent document. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife. 
Client Handout Assignment:
Clinic 2010 and 2020: Phase Two Clinical Practicum
In this course, the student is in clinical placement with an approved preceptor. The student assists with appropriate prenatal, labor and birth, postpartum and newborn care duties with an approved preceptor and describes in writing or oral presentations one case from each area (prenatal, labor and birth, postpartum and newborn care), linking knowledge or skills acquired in assistant experiences with knowledge acquired in phase two of study, including current research in the field. Students evaluate learning gained from assistant clinical experiences. Students should plan to spend a minimum of 100 hours in clinical placement during the trimester (an average of about 7 hours/week). 
 
For the summer 2018 semester I was in 2 clinical classes so my requirement for hours and birth numbers were doubled. It was a lot of fun and I am glad I decided to double it!
Reflection Essay Assignment:

Reflection on Assistant Experiences

 

           The Summer 2018 semester was my first semester as a Phase 2 student midwife, acting as a midwife’s assistant. I have been looking forward to this stage since starting school in May of 2017. I enjoy learning and improving new skills and being more hands-on at appointments and births. I have spent the summer away from home in Northern Colorado assisting a midwife who has a home birth practice; it is a little “summer abroad”.

            As I am just starting to assist, I have experienced a lot of firsts. I have attended over 100 prenatal visits, 10 births and the newborn exams to match them, and more than 20 postpartum visits. I am comfortable with my new skills in obtaining maternal and newborn vitals, measuring fundal height, finding fetal heart tones, assessing fetal position, and engaging in discussions and answering questions during client visits. I feel at home in the prenatal and birth space with clients and my relationship with my preceptor. I have noticed a deepening trust of the birth process, which I didn’t think was possible. I feel more strongly now that birth works, and women are powerful. I am more confident when I assure a mama in the throws of labor that yes, she can do it, and that she is amazing. I have learned more about prenatal care, lab work, testing, and what is normal vs. abnormal. I am improving my skills of shared decision-making and informed choice. The skills I have gained come from my schoolwork: reading, assignments, handouts, and case studies. I have also gained knowledge from my preceptor. She has taught me what to listen for with the doppler to know if we are hearing through the fetal back vs. a cord or placenta, how to discuss diet and exercise, etc. Observing her interactions with clients has been helpful. I have also received feedback from clients about what helped them, and where they appreciated my input and encouragement, and that has helped me immensely.

            My current clinical learning strategy is to show up, dive in, and take on the situation at hand. I can no longer spend a lot of time preparing and planning everything ahead of time. Before this summer I was more of a planner and wanted to be prepared but I have realized that powerful lessons come regardless, and in spite, of preparation. My classwork and apprenticeship prepare me for what is expected of me, and the rest has flowed as I continue to interact with clients and their families.

            I have learned truths about myself in this role. I need more coffee and more sleep than I thought I did. I don’t sleep well at client’s homes during labors, and I also don’t get homework done there. I like to see mamas moving around in labor and it is common for me to suggest position changes. I don’t like to get behind in my work, and I want to get things right the first time. I tend to want to get all of my work done first and play/relax later, but that is not conducive to the life of a student midwife. In fact, I am learning that I must find a way to work and play or I will never have downtime to myself until school is over. I second-guess myself more than I should. Lastly, I always crave a big, juicy cheeseburger (gluten free bun please) after a birth – no matter the time of day.

            I am so thankful and feel incredibly blessed, to have this “summer abroad” experience. It is a gift to work with a midwife who values you and wants to see you succeed; that is not lost on me. The clients that I have had the pleasure of serving have been so sweet, caring, and interested in my studies and have even expressed well wishes and the desire to see me again. I am so grateful for the opportunities that I have been given, and plan to make use of them and continue on my path toward becoming a midwife of excellence.

Prenatal Care Two: Prenatal Care for a Healthy Pregnancy
This course focuses on various elements of promoting a healthy pregnancy and caring holistically for clients. Students will create client handouts and which address nutritional, physical, environmental, emotional, social and sexual needs, changes and risks during pregnancy. Students will develop practice guidelines for several common disorders, diseases, and infections during pregnancy as well as developing guidelines for addressing issues of substance abuse. With the Midwifery Model of Care and an individualized approach, students will also prepare NARM general midwifery practice guidelines for use in their practice. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife.
Client Handout Assignment:
Labor, Birth, and Immediate Postpartum
Physiology and management of first, second and third stages of Labor are taught in this class. Students also learn about the mechanism of Labor for occiput anterior, transverse, posterior, face, brow, military, and breech presentations. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife.
Client Handout Assignment:
Clinic 2030: Phase Two Clinical Practicum
In this course, the student is in clinical placement with an approved preceptor. The student assists with appropriate prenatal, labor and birth, postpartum and newborn care duties with an approved preceptor and describes in writing or oral presentations one case from each area (prenatal, labor and birth, postpartum and newborn care), linking knowledge or skills acquired in assistant experiences with knowledge acquired in phase two of study, including current research in the field. Students evaluate learning gained from assistant clinical experiences. Students should plan to spend a minimum of 100 hours in clinical placement during the trimester (an average of about 7 hours/week). 
Reflection Essay Assignment:

Reflection on Assistant Experiences

 

            ...I am really thankful for the preceptor that I have and her willingness to allow me to come to clinic days as it fits with my school schedule. This helps me to get assignments done, but I have noticed that my relationship with clients isn’t as strong as it could be. When I am in clinic I spend time charting in the electronic system and do some hands-on assessments of clients. I am feeling confident in my clinic charting abilities. This semester I performed a few initial physical exams for clients in my preceptor’s practice. I have done initial exams in the past, but every midwife does these differently, so this was a new and different experience. I am learning a lot about the options that midwives have in customizing their practice styles, and I am thankful for the opportunity to learn new skills.

            During births, I assist the midwife and primary student in setup and cleanup, which I am pretty familiar with by this time. I also do some charting and assessing of the client and baby. I am still learning the ins and outs of all that is required for charting and paperwork at the birth, but I learn something new at each one. Repetition really helps me to solidify knowledge, so between attending more births, and incorporating what I am learning in my classes, I feel like I am gaining knowledge as time goes on. 

            One thing that has really stuck in my mind this semester is that I have adequate tools in my hands, ears, and eyes. My preceptor has reminded me that while we have actual tools that we need to use to assess our clients, we can trust what we hear, see, and feel. We can ask our clients questions, we can listen to the sounds of a baby’s cry, we can assess color and muscle tone and gather information from that. I have learned some great things with my preceptor this semester: handling shoulder dystocia, waiting for placentas to come, assessing blood loss, and more...

Reflection on Assistant Experiences

 

            ...I am really thankful for the preceptor that I have and her willingness to allow me to come to clinic days as it fits with my school schedule. This helps me to get assignments done, but I have noticed that my relationship with clients isn’t as strong as it could be. When I am in clinic I spend time charting in the electronic system and do some hands-on assessments of clients. I am feeling confident in my clinic charting abilities. This semester I performed a few initial physical exams for clients in my preceptor’s practice. I have done initial exams in the past, but every midwife does these differently, so this was a new and different experience. I am learning a lot about the options that midwives have in customizing their practice styles, and I am thankful for the opportunity to learn new skills.

            During births, I assist the midwife and primary student in setup and cleanup, which I am pretty familiar with by this time. I also do some charting and assessing of the client and baby. I am still learning the ins and outs of all that is required for charting and paperwork at the birth, but I learn something new at each one. Repetition really helps me to solidify knowledge, so between attending more births, and incorporating what I am learning in my classes, I feel like I am gaining knowledge as time goes on. 

            One thing that has really stuck in my mind this semester is that I have adequate tools in my hands, ears, and eyes. My preceptor has reminded me that while we have actual tools that we need to use to assess our clients, we can trust what we hear, see, and feel. We can ask our clients questions, we can listen to the sounds of a baby’s cry, we can assess color and muscle tone and gather information from that. I have learned some great things with my preceptor this semester: handling shoulder dystocia, waiting for placentas to come, assessing blood loss, and more...

Postpartum Care:
This course provides instruction in understanding, preparing for and meeting the normal physiological and emotional changes that may occur postpartum period. It includes what to do in the first few hours after birth as well as providing excellent care and record keeping in the subsequent postpartum care visits. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife. 
Client Handout Assignment:
Pediatrics:
This course is specifically designed to explore the anatomy and physiology of the newborn from birth through eight weeks. Students will become understand normal and abnormal findings. Assessment, age-appropriate strategies, and cultural differences will be discussed. Current research will be reviewed by participants to enhance the midwife’s care of the neonate and case studies will be utilized. 
Essay Assignment:

Extra-Uterine Transitions in the Newborn

 

       The events and anatomical changes that take place at birth are intense for the fetus. The transition from complete dependence in utero to the complete independence of extra-uterine life takes place in a few major ways. The respiratory and circulatory systems change due to the change in environment, hormones, stimulus, and need of the newborn. Living outside of the uterus, without the support and protection afforded inside the mother’s body, creates a need for the newborn to regulate their blood sugar levels and body temperature in addition to learning how to breathe and adjusting to a new blood flow pattern. 

      The system of newborn oxygenation makes a dramatic change from fetal oxygenation. While in utero, the fetus achieved gas exchange (oxygen and CO2) through the umbilical cord and the lungs were not used in the process. After birth, newborn respiratory system changes dramatically and the lungs become the main site of gas exchange and the umbilical cord quickly goes from being a lifeline to no longer being essential for life. Three main things happen: fluid is cleared from the lungs, the lungs expand, and circulation changes considerably (King, Brucker, Osborne & Jevitt, 2019). The processes of the last days of pregnancy and vaginal birth clear some fluids from the respiratory system and, with the pressure and temperature changes of life outside the uterus, the newborn begins breathing, which fills the lungs with air and pushes fluids into the tissues. (Davidson, London & Ladewig, 2016) (King et al., 2019). Crying is an effective way for the newborn lungs to inflate fully and not collapse, however fluid may still be heard in the lungs during the immediate postpartum time as the extra-uterine transition continues (King et al., 2019). Breathing also causes a shift in blood vessel pressure and blood flow to the lungs (Davidson et al., 2016). When the blood flow through the umbilical cord is stopped, the ductus venosus collapses (due to lack of blood flow and pressure changes) and the liver is perfused with blood flow that is needed for extra-uterine function (Davidson et al., 2016). These circulation and pressure changes also cause the foramen ovale (flap between atria) in the heart to shut (within 1 to 2 hours after the birth) and change the way blood circulates through the heart (Davidson et al., 2016). Another change that takes place is the constriction of the ductus arteriosus (by about 18 hours postpartum), which connects the aorta to the pulmonary artery in utero (Davidson et al., 2016). This change happens because of the change in oxygenation and the lack of prostaglandins that were produced by the placenta during pregnancy, which kept the vessel open (Davidson et al., 2016)(King et al., 2019). The newborn circulation is now a closed system, and the support and regulation through the umbilical cord, including the umbilical arteries, is no longer needed. 

         Newborns are not good at regulating their body temperature like older children and adults because of normal differences in their body composition(Davidson et al., 2016). Things like: an increased body surface to weight ration, less subcutaneous fat, more heat being released from organs through the skin, thin skin, lack of shivering, and increased water content in the body make it difficult for the newborn to maintain appropriate body temperature as so much heat is being released (Davidson et al., 2016). The four main ways that newborns lose heat are convection – through air currents, radiation – through indirect contact with cooler surfaces, evaporation – through water vapor after birth or bathing, and conduction – through direct contact with cooler surfaces (Davidson et al., 2016). When the newborn experiences lower than optimal body temperature there are a few mechanisms that work to restore appropriate body temperature. When ambient temperature in the room is low, newborn oxygen use may increase by 50% and glucose consumption also increases (Davidson et al., 2016). Both of these adaptations are part of increased metabolism in response to the need for thermoregulation (Davidson et al., 2016). Healthy newborns also have stores of brown adipose tissue (brown fat) in the mid-trunk and shoulder areas that are metabolized to produce heat when the newborn is in a hypothermic state (Davidson et al., 2016). Through this process the blood is warmed as it circulates which warms the rest of the tissues and restores temperature balance (King et al., 2019). This brown fat is useful but is not repeatedly produced so cannot offer continual thermoregulation (Davidson et al., 2016). When the body temperature falls and the newborn system has to work harder, weight gain and growth may suffer (Davidson et al., 2016). The best way to support appropriate newborn body temperature is through skin-to-skin contact with their mother, which minimizes heat loss and can act as a heat source (King et al., 2019).

      While in utero, fetal blood glucose levels are affected by maternal blood glucose levels and usually sit around 60-80% of maternal blood glucose values (Davidson et al., 2016)(King et al., 2019). Glucose that is not being used is stored in multiple body systems (liver, heart, muscles) for later use when needed (Davidson et al., 2016). After birth the maternal system no longer regulates the newborn blood glucose so newborn system relies on stored glucose and breastmilk or formula for energy. In the first few hours postpartum newborn blood glucose levels reach an all-time low (King et al., 2019). Stored glucose is then released by the retaining body systems so that the body can metabolize it as needed for energy while breastfeeding is being established (Davidson et al., 2016). This release and use of glucose results in a rise and regulation of blood glucose levels 3-4 hours postpartum, however the stores can be quickly depleted so newborn feeding is important for blood glucose regulation (Davidson et al., 2016).

      It is truly amazing that the newborn body is able to handle these changes and needs. Even more impressive is the ability for each newborn to adapt to their individual birth experience and how the intensity, length, and circumstances of their labor and birth affect their transition and recovery time in the postpartum period. The clinical care provider can be assured that when these transitions don’t take place well the newborn will exhibit signs and symptoms of needing extra help.

 

Reference

Davidson, M., London, M., & Ladewig, P. (2016). Chapter 27: Physiologic responses of the newborn to birth. In Olds' maternal-newborn nursing &                  women's health across the lifespan, (10thed.) (pp. 651-659). Boston: Massachusetts: Pearson.

King, T. L., Brucker, M. C., Osborne, K., & Jevitt, C. M. (2019). Chapter 36: Anatomy and physiology of the newborn. In Varney's midwifery(6th ed.)                    (pp. 1271-1277). Burlington, MA: Jones & Bartlett Learning.

Ante/Intrapartum FHR Surveillance:
This course offers a thorough review of fetal heart surveillance procedures. It discusses the physiological basis and instrumentation of monitoring, baseline fetal heart rate and antepartum monitoring. The course teaches what AAT (Auscultated Acceleration Test) is and how we can use it prenatally and during labor. The second part of the class is about problems that can arise, like bradycardia, tachycardia, sinusoidal pattern and periodic and nonperiodic changes. The assignments include several case study evaluations. 
This course offers a thorough review of fetal heart surveillance procedures. It discusses the physiological basis and instrumentation of monitoring, baseline fetal heart rate and antepartum monitoring. The course teaches what AAT (Auscultated Acceleration Test) is and how we can use it prenatally and during labor. The second part of the class is about problems that can arise, like bradycardia, tachycardia, sinusoidal pattern and periodic and nonperiodic changes. The assignments include several case study evaluations. 
Comparative Chart Assignment:
Antenatal Testing:
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Clinic 2040: Phase Two Clinical Practicum
Students assist with appropriate prenatal, labor and birth, postpartum and newborn care duties with an approved preceptor and describe in writing or oral presentation one case from each area (prenatal, labor and birth, postpartum and newborn care), linking knowledge or skills acquired in assistant experiences with knowledge acquired in phase two of study, including current research in the field. Students evaluate learning gained from assistant clinical experiences. Students should plan to spend a minimum of 100 hours in clinical placement during the trimester (an average of about 7 hours/week), and since this practicum marks the end of Phase Two, all Phase Two required experiences should be completed by the end of the course. 
Reflection Essay Assignment:

Reflection on Assistant Experiences

          This semester I attended 5 births with my preceptor. I fulfilled my phase 2 assistant birth requirements, and I really do feel a difference from where I started the semester and where I stand now. I can’t believe I am at this point; it feels like it took forever to get here and at the same time that it happened in a flash. I think that the biggest benefit I receive from my preceptor and the primary student in the practice is clear communication, understanding, and working with people who are willing to teach along the way. 

         The main thing I notice now is that I feel ready to move forward. I feel ready to be pushed to my limit in the next phase, pushed to grow and expand my skills. I think this readiness comes in big part because of the patience, encouragement, and trust of my preceptor. She has created a safe learning environment and it makes a huge difference. I feel like I can step out and try new skills in a safe and supportive space. She recently encouraged me to think about what else can be done at births. She gave me positive feedback about my skills, and said that the last step before moving into the primary role is to think ahead for the midwife and prepare what is needed next. Not just what is next for my role as the assistant, but what is next for the midwife and how can I prepare what is needed so she doesn’t have to ask. I am looking forward to practicing those things during the next few births we have together. I really enjoy these conversations with my preceptor because they help me to solidify what I am doing well, get rid of what isn’t working, and add new things to my skills list. I am so appreciative to have a preceptor who truly wants me to succeed and is helping me grow to be a great midwife.

         ...I am feeling a lot more confident and ready to step into the next role as my knowledge and skills have increased. I feel the itch to break out of the assistant role and take on a heavier responsibility. I didn’t know what this would look or feel like when I started assisting last year. I couldn’t imagine myself wanting to be done with this role, but here I am and it just seems like it is time for me to graduate up to the next thing...

Pediatrics
This course is specifically designed to explore the anatomy and physiology of the newborn from birth through eight weeks. Students will understand normal and abnormal findings. Assessment, age appropriate strategies and cultural differences will be discussed. Current research will be reviewed by participants to enhance the midwife’s care of the neonate and case studies will be utilized. 
Newborn Gestational Age Assessment:
Clinical Testing in the Childbearing Year
This course includes the physiological changes of pregnancy, disease conditions relating to pregnancy and the reproductive organs, tests to detect physical conditions (both physiological and pathological), fetal diagnosis, maternal metabolic disorders and postpartum testing. Case studies will hone the understanding of screening and diagnostic tests and appropriate management plans for the scope of the Certified Professional Midwife. 
1st Trimester Genetic Screening Options:
Obstetrical Pharmacology
The purpose of this course is to teach students basic facts about the administration of drugs commonly used in the direct entry practice of midwifery. A midwife should be familiar with methods of research and client education regarding the safety of drugs in the childbearing years, and educate clients about benefits and risks. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife. 
Over The Counter Medications Reference Chart for Provider Use:
Ante/Intrapartum Fetal Heart Rate Surveillance
This course offers a thorough review of fetal heart surveillance procedures. It discusses the physiological basis and instrumentation of monitoring, baseline fetal heart rate and antepartum monitoring. The course teaches what AAT (Auscultated Acceleration Test) is and how we can use it prenatally and during labor. The second part of the class is about problems that can arise, like bradycardia, tachycardia, sinusoidal pattern and periodic and nonperiodic changes. The assignments include several case study evaluations. 
Oxygen Pathway Chart:
Pelvic Health and Suturing
At the completion of this course, the student will be able to demonstrate knowledge and skills in checking for and identifying first through fourth degree tears, and other types of pelvic damage. Students will learn the appropriate use and repair of episiotomies, forms and usage of anesthetic agents, how to tie off and postpartum repairs appropriate for the midwife in an out-of-hospital setting. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife. 
Post Repair Perineal Care:
Well Person Care
This course explores the basic health of women across the lifespan. Topics covered include: the normal reproductive cycle, dysfunctions of menstruation, contraceptive devices and information, sexually transmitted infections, how to perform a well-woman examination, and PAP smear interpretation. Also included is information about the female sexual response and various mental and emotional aspects of wellness and health. Case studies are utilized to demonstrate the application of clinical judgment and management within the scope of care of the Certified Professional Midwife. 
Screening Guidelines Throughout the Lifespan:
Clinic 2050: Phase Two Competencies
Students demonstrate practical skills and competencies necessary to begin acting as a primary midwife under supervision and prepare for Phase Two Assessment.
Outline of Newborn Exam Procedure:
After the completion of this course and a 1 day in person assessment, I completed all of the requirements for phase 2. I moved on from the assistant student role to the primary student role.
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