Student midwives must be able to demonstrate that they have the competence, knowledge and skills to be deemed fit to practise at the point of registration, not only in the performance of routine clinical skills but also in ‘managing obstetric and neonatal emergencies, underpinned by appropriate knowledge’ (Nursing and Midwifery Council (NMC), 2009: 4). The labour ward environment is dynamic and unpredictable in nature and, as a consequence, learning opportunities in relation to the management of obstetric emergencies cannot be anticipated. In such an environment the safety of women and babies is paramount, with the student's learning needs being a secondary consideration (Haigh, 2007).
Theoretical input at the start of a 3-year midwifery programme focuses on normality and typically students will study: anatomy and physiology; physiological changes as a result of pregnancy; low-risk antenatal, intrapartum and postnatal care; and care of the newborn. The rationale for this approach is that if you have a thorough underpinning knowledge of normality, you will be able to recognise the ‘abnormal’ and act appropriately, thereby demonstrating safe practice. Despite our best efforts to focus on normality, the reality of the labour ward environment does not match theoretical input, so it is not uncommon for students in their first placement to be exposed to complex clinical situations and obstetric emergencies for which they have received no formal theoretical education.
The majority of student midwives who participated in a study exploring their experiences of simulated learning with a focus on the management of obstetric emergencies (Power, 2010a) felt unprepared for their first labour ward placement, as they had not received any theoretical input in relation to the management of obstetric emergencies. Theoretical input at university until this time was focused on normality in childbearing. There was a common feeling of worthlessness, anxiety and vulnerability as students witnessed obstetric emergencies during their first placement. This was attributed to a lack of preparation in terms of orientation to the environment (which would have enabled them to be more useful if asked to locate vital equipment), and a lack of basic knowledge of common obstetric emergencies and how they could safely assist their mentors.
These findings led to the development of a ‘survival guide’ for students to take into their first labour ward placements, providing basic information on the two obstetric emergencies they were most likely to witness—shoulder dystocia and postpartum haemorrhage (PPH)—and suggesting how they could help, if their mentor felt it safe and appropriate. Hopefully this will help students to feel more prepared at the start of the placement and avoid the feelings of worthlessness experienced by students in the study (Power, 2010a).
This article summarises the Survival Guide for First Labour Ward Placements (Power, 2010b). It should be read in conjunction with your host site induction leaflet and local Trust policies and guidelines. The purpose of the guide is not to teach you to personally deal with the emergency, as this is outside of your sphere of practice. You will be there under the direct supervision of your mentor, who will manage the emergency as part of the multi-professional team. During your first shift, ask to be given a tour of the labour ward including: the location of equipment you may be asked to retrieve in an emergency; the mechanisms of the electric beds; how to use the emergency buzzer; and how the emergency fast bleep telephone system works.
If you are involved in an emergency situation, you should discuss events with your mentor in the first instance and, if you require further support, you have a named supervisor of midwives, your personal academic tutor and senior lecturer in practice. You will also be given the opportunity for group reflection at the end of your placement.
Shoulder dystocia
The incidence of shoulder dystocia is 0.58–0.7% of all vaginal deliveries (Royal College of Obstetricians and Gynaecologists (RCOG), 2012). It is defined as ‘a vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed’ (RCOG, 2012: 2). In some cases, the first signs of a potential shoulder dystocia are slow progress in the first stage of labour followed by the slow extension of the baby's head and the chin remaining tight against the mother's perineum (‘turtle-necking’).
There is a recognised procedure for managing a shoulder dystocia, following the HELPERR mnemonic (Table 1). You will not be expected to have the expertise to use the mnemonic, but with instruction you might be able to help your mentor under direct supervision.
| H: call for help (you can call for help using the emergency buzzer) |
| E: evaluate |
| L: legs in McRoberts' (you can assist with the McRoberts' manoeuvre) |
| P: pressure (suprapubic) |
| E: enter |
| R: remove posterior arm |
| R: roll over onto all fours |
The emergency buzzer will alert other members of staff to enter the room. If you have received comprehensive instruction at the start of your placement from your mentor, you may be able to help by assisting with the McRoberts' manoeuvre. The manoeuvre involves flexion and abduction of the woman's hips, positioning her thighs on her abdomen (RCOG, 2012).
Postpartum haemorrhage
Primary PPH is the most common form of major obstetric haemorrhage, affecting 5% of women in the UK (RCOG, 2011). The definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby (World Health Organization, 2003). Causes of primary PPH are (RCOG, 2011):
You will not be expected to have the expertise to manage the situation, but you might be able to help your mentor under direct supervision. The steps in managing PPH are listed in Table 2.
| Arrest the bleeding |
| Resuscitate the mother |
| Replace the fluids (you might be asked to fetch the PPH trolley/tray) |
| Prevent complications |
| Call for appropriate help (you can call for help using the emergency buzzer) |
| Assess ABC (airway, breathing, circulation) |
| Rub up a contraction (if you have received comprehensive instruction at the start of your placement from your mentor, you may be able to do this, under direct supervision) |
| Repeat oxytocic |
| Catheterise |
| Two large bore cannulas 14 or 16 gauge |
| Take bloods |
| Drugs |
| Bimanual pressure if required |
| Theatre |
Preparing for placement
This is a very basic guide. For more detailed information you should refer to the Green-top guidelines on shoulder dystocia (RCOG, 2012) and PPH (RCOG, 2011). You can supplement your learning by accessing appropriate midwifery textbooks. Enjoy your placement!