COLLEGE OF MEDICINE AND

HEALTH SCIENCE
SCHOOL OF NURSING AND MIDWIFERY

STUDENT CLINICAL PORTFOLIO

MODULE: CLINICAL PRACEMENT V

Department: MIDWIFERY Program: ADVANCED DIPLOMA IN MIDWIFERY

Academic Year:2021-2022 Semester: III Year/Level:

THREE

Clinical area: KACYIRU HOSPITAL Clinical Period: 19th December, 2022-24th February,
2023

Student name: Fulgence UMHOZA Student number: 217054218

SUPERVISOR: Baudouine NDIMURUKUNDO

Francoise MUJAWAMARIYA

Fulgumuhoza20@gmail.com
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Table of Contents

GENERAL INTRODUCTION...........................................................................................................................2

CLINICAL STUDENT SELF ASSESSMENT..................................................................................................3

STUDENT CLINICAL LEARNING CONTRACT...........................................................................................6

REFLECTIVE JOURNALS.............................................................................................................................16

First reflective journal...................................................................................................................................16

References.........................................................................................................................................................18

Second reflective journal..............................................................................................................................19

Third reflective journal..................................................................................................................................20

References.........................................................................................................................................................21

Fourth reflective journal................................................................................................................................21

References.........................................................................................................................................................23
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GENERAL INTRODUCTION

A clinical placement is defined as any arrangement in which a health caregiver student is presented in an
environment that provides healthcare or related services to patients or the public. It develops our confidence
to practice and assist the public or patients in managing any doubts they have about their skills and
knowledge.

I, Fulgence UMUHOZA with REGISTRATION NUMBER: 217054218, a midwifery student in University

of RWANDA, college of medicine and health sciences CMHS, at HUYE Campus in Year III, write this
portfolio regarding my clinical placement at KACYIRU HOSPITAL. This clinical portfolio contains all
detailed information of what I have done during this clinical placement started from 19 th December, 2022 and
end on 24th February, 2023. According to the clinical placement objectives, in these 10 weeks we have to
rotate in different services of maternity ward, pediatric and neonatology
The key elements of this portfolio are general introduction, clinical self-assessment; clinical learning
contract, reflective journals, conclusion, proof and evidence of signed code of conduct and group clinical
report.
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CLINICAL STUDENT SELF ASSESSMENT

CLINICAL LEARNING ACTIVITIES COVERED NOT EVIDENCE PROVIDED

COVERED IN THE PRESENT
PORTFOLIO
Receive and admit the client Achieved Patient files
Recognize emergency and act accordingly. Achieved Patient files
Perform infection control techniques. Achieved Patient files and signed
logbook
Perform infection control techniques. Achieved Patient files and signed
logbook
Document all findings. Achieved Patient files and signed
logbook
Assess for lower Limbs Achieved Patient files and signed
logbook
Conduct examination of the pregnant Achieved Patient files and signed
logbook
woman including physical, obstetrical
examination
Assess and manage Emotional condition Achieved Patient files and signed
and after pains logbook
Conduct health education … Achieved Patient files and signed
logbook
Carry out wound care for caesarian Achieved Patient files and signed
deliveries logbook
Administer drugs Achieved Patient files and signed
logbook
Carry out general examination of child Achieved Patient files and signed
logbook
Take child anthropometric Achieved Patient files and signed
logbook
Able to detect congenital malformation Not Achieved Patient files and signed
logbook
Able to guide the clients in the decision Achieved Observed by senior
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CLINICAL LEARNING ACTIVITIES COVERED NOT EVIDENCE PROVIDED

COVERED IN THE PRESENT
PORTFOLIO
making according to the available family midwives and clinical
planning methods supervisor
Documented in patient file
Perform different family planning Not Achieved Patient files and signed
procedures logbook
Provide the adequate knowledge about Achieved Patient files and signed
reproductive health logbook
Detect malpresentations and malpositions Achieved Patient files and signed
logbook
Conduct health education … Achieved Patient files and signed
logbook
Monitor the woman in the 1st and 2nd Achieved Observed by senior
stage of labor using the Partogram (50 midwives and clinical
Partogram, at least 30 well completed) supervisor
Documented in patient file
Detect and manage high risk pregnancies Achieved Patient files and signed
logbook
Detect and manage macrosomia and the Achieved Patient files and signed
babies with abnormal conditions logbook
Manage abnormal deliveries Achieved Patient files and signed
logbook
Perform and repair episiotomy/tear where Achieved Patient files and signed
necessary. logbook
Perform active management of the 3rd Achieved Patient files and signed
stage of labor logbook
Carry out neonatal general examination Achieved Patient files and signed
logbook
Monitor mother and baby in post-partum Achieved Patient files and signed
using Partogram. logbook
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CLINICAL LEARNING ACTIVITIES COVERED NOT EVIDENCE PROVIDED

COVERED IN THE PRESENT
PORTFOLIO
Carry out wound care for caesarian Achieved Patient files and signed
deliveries logbook
Able to detect uterine tumors (leiomyoma, Not Achieved Patient files and signed
polyps…) logbook
able to advocate and manage the mothers Achieved Observed by senior
with post-partum mental illnesses midwives and clinical
supervisor
Documented in patient file
Draw at least one nursing care plan per day Achieved Patient files and signed
for one mother logbook
Monitor clients with pregnancy related Achieved Patient files and signed
problems logbook
Management of antepartum haemorrhage Not Achieved Patient files and signed
logbook
Carryout nursing care of client with Achieved Observed by senior
abortion midwives and clinical
supervisor
Documented in patient file
STUDENT SIGNATURE

Date: 19th December, 2022

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STUDENT CLINICAL LEARNING CONTRACT

Student’s Identification: Fulgence UMUHOZA

Student registration number: 217054218
Department: MIDWIFERY
Module name/code: CLINICAL PLACEMENT V
Year of study: YEAR THREE
Semester/Trimester: III Period of clinical placement: from 19/12/2022 to 24/02/2023

A learning contract is an agreement between student and clinical supervisor/mentor, which determine the
explicit of what a student has to achieve. It is completed before the starting of clinical placement by the
student with supervisor/mentor's help and then signed after agreement by both sides.
Purpose: To engage the students in clinical learning process that provides opportunities to make behavioral
improvements and meet nursing/academic standards.

The table below indicates the key elements of the learning contract
Student’s Clinical learning Timeline Indicators Means of Observation/
learning goals activities verification comment of the
supervisor/ Mentor
Receive and history taking: Two 20 Patients Clinical
admit the client obstetrical, weeks midwifery
gynecological, logbook and
medical, surgical patients files
family, GBV
Recognize Doing Triage 8 weeks At least 20 Clinical
emergency and clients midwifery
act accordingly. logbook and
patients files
Conduct Leopold’ maneuver, Two 50 clients Clinical
examination of descent of the fetal weeks midwifery

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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
the pregnant head, fundal height, logbook and
woman including fetal heart patients files
physical, auscultation, pelvic
obstetrical assessment; bishop
examination score and be able to
identify abnormalities
and propose solutions.
Perform Hand washing, putting Two 100% Clinical
infection control on gloves, respect weeks midwifery
techniques. sterility, environment logbook and
safety. patients files
Document all To record all clients' Eight 100% Clinical
findings. information weeks midwifery
logbook and
patients files
Monitor the Physical assessment, Two 50 clients Clinical
woman in the 1st Vaginal examination, weeks midwifery
and 2nd stage of abdominal assessment, logbook and
labor using the performing SVD. patients’
Partogram (50 files
Partogram, at Inspection
by clinical
least 30 well
supervisor/
completed) nurse
Detect Perform gynecological 8 weeks 10 clients Inspection
malpresentations examinations by clinical
and malpositions supervisor/
nurse
Detect and Diabetes mellitus type 8 weeks 5 clients
manage high risk II, pre/eclampsia,
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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
pregnancies HIV/AIDS, asthma,
cardiopathies
Detect and Cleft palate, spina 8 weeks 5 clients
manage bifida, omphalocele
macrosomia and
the babies with
abnormal
conditions
Manage Abnormal deliveries 4 weeks 5 clients Clinical
abnormal midwifery
deliveries logbook and
patients files
Perform and Injection of anaestasia, Two 10 clients Clinical
repair suturing. weeks midwifery
episiotomy/tear logbook and
where necessary. patients files
Perform active Controlled cord Two 20 clients Clinical
management of traction(CCT), weeks midwifery
the 3rd stage of Placenta examination, logbook and
labor uterine massage, patients files
administration of
oxytocin
Apply ART administration, Two 5 clients Clinical
PPTCT/PMTCT health education weeks midwifery
management logbook and
where necessary patients files
Carry out Neonatal general Two 20 client Clinical
neonatal general assessment weeks midwifery
examination logbook and
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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
patients files
Administer vitamin K1, Two 100% Clinical
routine drugs to tetracycline eye weeks midwifery
the neonatal. ointment logbook and
patients files
Monitor mother Evaluation of lochia, Two 20 clients Clinical
and baby in post- breast examination, weeks midwifery
partum using vital sign monitoring logbook and
Partogram. patients files
Perform Breast colostrum, Two 30 clients Clinical
examination engorgement, mastitis, weeks midwifery
cracked nipple, logbook and
inverted nipple patients files
Perform Monitor Bowel Two 40 clients Clinical
Abdomen function (bowel weeks midwifery
examination sound) logbook and
(shape, scar, patients’
wound…) files
perform Bladder Inspection
examination by clinical
(fullness, urinary supervisor/
bag[input/output] nurse
Observe Lochia (type, amount, color, Two 30 clients Clinical
discharge odor) weeks midwifery
logbook and
patients files
Examine (tear, redness, edema, Two 30 clients Clinical
perineum approximation of weeks midwifery
suture) logbook and
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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
patients files
Assess and Uterine involution Two 30 clients Clinical
monitor Uterine measurement, weeks midwifery
involution logbook and
patients files
Assess for lower pain, edema, varicose Two 20 clients Clinical
Limbs veins weeks midwifery
logbook and
patients files
Assess and Explain physiological Two 30 clients Clinical
manage changes of uterine weeks midwifery
Emotional function logbook and
condition and patients files
after pains
Conduct health breastfeeding, family Two 30 clients Clinical
education … planning, nutrition, weeks midwifery
perineal exercise, logbook and
hygiene, patients files
immunization, danger
signs and harmful
practices
Carry out wound Post-natal Two 30 clients Clinical
care for care(assessment) weeks midwifery
caesarian logbook and
deliveries patients files

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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
Able to detect Detect uterine Four 5 clients Clinical
uterine tumors tumors(leiomyoma, weeks midwifery
(leiomyoma, polyps…)and act logbook and
polyps…) accordingly patients files
Administer drugs - Checking the 8 weeks 50 clients Clinical
prescribed
midwifery
Drug, its dose and
route of logbook and
administration.
patients files
-Administration of the
drug as prescribed by
the doctor.
able to advocate advocate and manage Two At least 5 Clients files
the mothers with post-
and manage the weeks clients
partum mental
mothers with illnesses
post-partum
mental illnesses
Draw at least one Draw nursing care Two 97% Clinical
plan (Assessment,
nursing care plan weeks midwifery
nursing diagnosis,
per day for one planning, intervention, logbook and
rationale and
mother patients files
evaluation)
Monitor clients Pre-eclampsia, 8 weeks 15 clients Clinical
eclampsia,
with pregnancy midwifery
hyperemesis
related problems gravidarum logbook and
patients files
Management of Placenta abruption, 8 weeks 10 clients Clinical
placenta praevia,
antepartum midwifery
haemorrhage logbook and
patients files
Carryout nursing Pre and post obstetric 2 weeks 6 clients Clinical
abortion
care of client midwifery

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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
with abortion logbook and
patients files
Advocate and Assessment 4 weeks 5 clients Observation
manage mothers by clinical
with post-partum supervisor
mental illnesses
Monitoring a Provide adequate in 2 To perform Signed
antibiotics and
client with weeks it on 75% logbook
dexamethasone
PPROM and according to gestation under
week
PROM supervisor
Neonatology During the First two to in 2 To perform Signed
six hours after birth
Assess new born weeks it on 87% logbook
under
supervisor
Care of the new By weighing, bathing, in 2 To perform Signed
vital sign
born from weeks it on 77% logbook
admission to under
discharge supervisor
Care of new born By monitoring in 2 To perform Signed
temperature
in incubator weeks it on 88% logbook
under
supervisor
Use of oxygen By covering well in 2 To perform Signed
genital organ
therapy and weeks it on 98% logbook
phototherapy under
supervisor
Perform venous By performing aseptic in 2 To perform Signed
procedure
puncture weeks it on 60% logbook
under
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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
supervisor
Calculate drug As prescribed in 2 To perform Signed
and weeks it on 75% logbook
administration under
supervisor
Monitoring new- Continuous positive in 2 To perform Signed
airway and pressure
born under weeks it on 57% logbook
CPAP under
supervisor
Teach and assist By avoiding infection in 2 To perform Signed
transmission
mother in weeks it on 99% logbook
expression of under
breast milk supervisor
Assist client in Show them its in 2 To perform Signed
importance
kangaroo weeks it on 88% logbook
under
supervisor
Feeding new- By gavages, in 2 To perform Signed
breastfeeding
born baby weeks it on 99% logbook
under
supervisor
Paediatric B using nursing in 2 To perform Signed
process
Assess and care weeks it on 78% logbook
child under
supervisor

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Student’s Clinical learning Timeline Indicators Means of Observation/

learning goals activities verification comment of the
supervisor/ Mentor
Assess physical, By history taking, and in 2 To perform Signed
head to toe assessment
psycho social, weeks it on 74% logbook
and cognitive under
development supervisor
Identify paediatric emergency in 2 To perform Signed
paediatric weeks it on 67% logbook
emergency under
supervisor
Calculate drug As prescribed in 2 To perform Signed
and weeks it on 73% logbook
administration under
supervisor
Health education Appropriate education in 2 To perform Signed
and counselling
weeks it on 87% logbook
under
supervisor
documentation Document finding in 2 To perform Signed
appropriate
weeks it on 87% logbook
under
supervisor
Deliver nursing Using nursing care in 2 To perform Signed
plan
care weeks it on 80% logbook
under
supervisor
Assess Provide education, and in 2 To perform Signed
calculate calories
nutritional needs weeks it on 79% logbook
under
supervisor

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I, Fulgence UMUHOZA, commit to comply with the above commitments and code of Professional Conduct
for Nursing/Midwifery. Failure to do so, the CMHS academic regulation and clinical training guidelines will
be applied.
Date and signature of student Date and signature of Clinical Supervisor
19th December, 2022

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REFLECTIVE JOURNALS

Student’s Identification: Fulgence UMUHOZA

Student registration number: 217054218
Department: MIDWIFERY
Module name/code: Clinical placement V
Level/year: III

First reflective journal

Introduction
Fever is an elevation in body temperature that exceeds the normal daily variation and occurs secondary to an
increase in the hypothalamic set point. As such, fever is regulated in the same manner that normal
temperature is maintained in a normal environment, the difference being that the body's thermostat (the
hypothalamus) has been reset at a higher temperature (a higher hypothalamic set-point). This shift from a
normothermic to a febrile set point is analogous to resetting a thermostat to raise room temperature. Fever is
one of the most common chief complaints in pediatric patients presenting to the emergency department,
accounting for up to 20% of pediatric ED visits. Fever tends to be of a higher clinical importance in neonates
and infants younger than 3 months, as they are immunologically immature and incompletely vaccinated.
Children younger than 3 months have unique risks for serious bacterial infection, bacteremia and occult
bacteremia, making the recognition of fever and transport to an ED for evaluation extremely important.
Situation
On 22nd December, at KACYIRU HOSPITAL in neonatology, there was a mother who had girl with 3.630kg
born weight newborn with high temperature of 38.4 oC on day 3 of life. A baby was diagnosed jaundice with
neonatal infection.
Affect
Really, it was my first time to face neonatal infection. It also helped me to know more about causes of high
temperature, and how to manage it.
Interpretation
According to (Scott R. Snyder, 2011), Fever is not necessarily a bad thing. On the good side, it enhances the
body’s immune response, making it more effective at fighting infection; it may have direct antimicrobial
activity; and it can be a valuable diagnostic aid to the healthcare provider. On the bad side, fever can make

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an infant uncomfortable, and it increases metabolic activity, resulting in increased oxygen consumption,
carbon dioxide production and water loss.

There is a distinct difference between an elevated body temperature caused by fever and an elevated body
temperature caused by hyperthermia. Hyperthermia is characterized by an uncontrolled increase in body
temperature that exceeds the body’s capacity to lose heat, in contrast to a fever caused by the release of
endogenous pyrogens secondary to infection. Causes of hyperthermia in infants include exposure to a hot
environment and excessive swaddling. The vast majority of pediatric fever is due to infections, and the vast
majority of infections are due to viral sources. Common viral and bacterial infections are often benign in
healthy neonates and infants and respond well to simple supportive or antimicrobial treatment. Examples of
common bacterial illnesses include otitis media, urinary tract infections, appendicitis, pharyngitis and
sinusitis. Examples of common viral illnesses include gastroenteritis, upper respiratory infections,
bronchiolitis and flu-like illnesses common in the fall and winter months. Infections like sepsis or meningitis,
however, can have significant morbidity and mortality if left untreated. Compared with viral infections,
bacterial infections are a more serious cause of infection in children, as they can be difficult to identify and
are associated with high mortality.

Neonates (less than 28 days old) and young infants (28–90 days old) have traditionally been discussed as
subsets of febrile pediatric patients because of differences in the type and severity of infections they
encounter. Children under 3 months may present with an apparent viral syndrome and still harbor serious
bacterial illness (SBI). In children less than 3 months of age, the urinary tract is the most common site of
SBI, followed by bacteremia and meningitis. Bacteremia is the presence of pathogenic (harmful) bacteria in
the bloodstream. Occult bacteremia describes the presence of pathogenic bacteria in the bloodstream of a
well-appearing febrile child in the absence of an obvious source (focus) of infection. Prior to the widespread
use of vaccines against Haemophilus influenzae type B (HIB) and S. pneumoniae, the incidence of
bacteremia in this population was approximately 5%. While the current rate of occult bacteremia is about
1%, the risk is real. It can be argued that all febrile children under the age of 3 months should be transported
to the ED for evaluation, as the risk of occult bacteremia, though low, is real and the associated mortality is
high.

To better understand why the neonate and young infant are at high risk of developing a SBI that can lead to
bacteremia and occult bacteremia, it is necessary to understand the two different types of immunity and how
these systems mature in this population (Scott R. Snyder, 2011).
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For the neonate or infant who presents with a fever but otherwise appears healthy and is hemodynamically
stable, no management other than monitoring and transport is required. If a fever results in patient irritability
or discomfort, an antipyretic like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can be administered
per protocol (Scott R. Snyder, 2011). If your newborn is younger than 2 months with a rectal temperature
greater than 100.4 degrees Fahrenheit (38 degrees Celsius), go to an emergency department immediately
(Julie Kardos, 2020).

Decision
After this experience, to become a better midwife I have decided always to be there for detecting all
problemsby reaching all clients as individuals in order to promote the health of mother and babies as well as
explained above.

References

Cleverland Clinic, 2022. Cleverland Clinic. [Online]

Available at: https://my.clevelandclinic.org/health/diseases/22263-jaundice-in-newborns
[Accessed 2 January 2023].
Julie Kardos, M. F., 2020. Fever in a Newborn. [Online]
Available at: https://www.chop.edu/conditions-diseases/fever-newborn
[Accessed 2 January 2023].
NHS, 2022. Causes - Newborn jaundice. [Online]
Available at: https://www.nhs.uk/conditions/jaundice-newborn/causes/
[Accessed 16 March 2022].
Santina A Zanelli, M., n.d. What are the adverse effects of hyperthermia in infants with hypoxic-ischemic
encephalopathy (HIE)?. [Online]
Available at: https://www.medscape.com/answers/973501-106519/what-are-the-adverse-effects-of-
hyperthermia-in-infants-with-hypoxic-ischemic-encephalopathy-hie
[Accessed JULY 2022].
Scott R. Snyder, B. N.-P., 2011. Fever in the Neonate and Young Infant. [Online]
Available at: https://www.hmpgloballearningnetwork.com/site/emsworld/article/10265095/fever-neonate-
and-young-infant
[Accessed 30 December 2022].

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Staff, M. C., 2022. Infant jaundice. [Online]

Available at: https://www.mayoclinic.org/diseases-conditions/infant-jaundice/symptoms-causes/syc-
20373865

Second reflective journal

Introduction
In this reflective journal, I am going to reflect on the management of preeclampsia, preeclampsia is defined
as hypertension after 20 weeks of gestation and proteinuria. New onset elevated blood pressure at least
4hours systolic blood pressure >=140mmHg, or diastolic blood pressure >=90mmHg at 2hours apart plus
proteinuria >=300mg of protein in 24 hours urine collection or 2+ dipstick Ina woman without history of
proteinuria.
Actual situation
It was on 7th January, 2023 I was in post-natal ward at King Faisal Hospital where I was with registered
midwife ,we had client M J She was a G4P2AB1 she was admitted on 5 th January, 2023 due to
preeclampsia with severe features on pregnancy of 25 weeks. vital signs were: BP :164/102 mmHg pulse :
134 BPM RR:28 cycles/min T:36.7 OC on while she was admitted she had received mgso4 roding of mgso4
8ml with 12 ml of water for injection intravenous and maintenance dose of mgso4 1g /hour in 500ml of
normal saline within 24 hours. On 7th January, 2023, she was on nifedipine with blood pressure of 140/99
mmHg, pulse 102 bt/min, like at 3 PM. The blood pressure start to rise to 151/80 mmHg, pulse 107 bpm, I
tried to call midwife immediately and then measure again, blood pressure became 178/104 mmHg, pulse:
138bpm. Then, she called Doctor immediately and told to start hydralazine, but blood pressure does not
lowered, after like 40min became 182/107 mmHg, pulse 143 bpm finally she also started other episode of
MgSO4 loading and maintenance dose with 24 hours, and doctor said; it doesn't lowered. They can start
contractions then, she may delivery but with lower chance of newborn to survive.
Affect me personally
I felt happy and confident to apply academic knowledge on the field. I realized that I have to be confident to
apply all academic knowledge because they are ones with evidence. In addition, influenced me positively to
read more the effects of preeclampsia that lead to make decisions of staring contraction if it doesn't lowered.
What I learned from experience
According to (Medline plus, 2019), they show different risk of having preeclampsia during pregnancy if the
blood pressure is not controlled, Decreased blood flow to the placenta, If the placenta doesn't get enough

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blood, baby might receive less oxygen and fewer nutrients. This can lead to slow growth intrauterine growth
restriction, low birth weight or premature birth, Prematurity can lead to breathing problems, increased risk of
infection and other complications for the baby.
The next, Placental abruption Preeclampsia increases your risk of this condition in which the placenta
separates from the inner wall of your uterus before delivery. Severe abruption can cause heavy bleeding,
which can be life threatening for you and your baby. Furthermore, poorly controlled hypertension can result
in injury organs like your brain, heart, lungs, kidneys, liver and other major organs. The last preeclampsia
increase risk of having Future cardiovascular disease. Especially for the one who had preeclampsia more
than once or who have had a premature birth due to having high blood pressure during pregnancy.
Decision
I had decided to apply nursing care procedure as how we had educated in order to provide quality care to our
clients and obey the physician medical prescription time and other nursing care procedure recommended
because are the one that can help mother and foetus to survive.

References

https://Medlineplus.gov/high_blood_pressure_in_pregnancy
Charles R.B et al. 1998. Obstetrics and gynecology, 3rd ed. Williams &Wilkins
https://www.mayoclinic.org
https://www.who.int

Third reflective journal

UTERINE RUPTURE

Introduction

A uterine rupture is a complete division of all three layers of the uterus: the endometrium (inner epithelial
layer), myometrium (smooth muscle layer), and perimetrium (serosal outer surface). Clinicians must remain
vigilant for signs and symptoms of uterine rupture. Uterine ruptures can cause serious morbidity and
mortality for both the woman and the neonate. Most uterine ruptures occur in pregnant women, though it has
been reported in non-pregnant women when the uterus is exposed to trauma, infection, or cancer (Togioka &
Tonismae., 2022).
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Situation
On 19th January 2023, at Kacyiru Hospital in the maternity (labor ward), there was a G 3P2002 mother with 39
weeks of gestational age. She got monitored well, but at 8cm she got ruptured but we got it at time of
delivery where we saw too much blood and we ask for assistance to gynecologist and he concluded uterine
rupture with ultrasound and in that range, foetal heart rate get missed. They concluded to do C/S with
hysterectomy.
Affect
Really, I got embarrassed due to G3P2 monitored mother get a uterine rupture at 8 cm of dilatation. Moreover,
it affected me negatively because it was my first time to face uterine rupture.
Interpretation

According to (Togioka & Tonismae., 2022) A uterine rupture requires simultaneous delivery and treatment
of maternal haemorrhage. A second large-bore intravenous line should be placed, and blood should be
ordered and brought to the operating room. If large-bore intravenous access cannot be obtained, central
venous access with a large bore sheath introducer should be considered. Initial resuscitation is often provided
by infusing Lactated Ringers electrolyte solution. Brisk and large volume blood loss should prompt early
blood transfusion. If bleeding is not quickly controlled, an arterial line will improve the accuracy and
frequency of blood pressure monitoring, lead to a shorter response to hypotension, and facilitate serial
laboratory tests.

Complications for a mother, Excessive blood loss (haemorrhage), losing the ability to get pregnant due to
hysterectomy, Stillbirth (Cleverland Clinic, 2022.). As we detected that, it is uterine rupture.

Decision
As a new coming Midwife, I decided to report any questionable finds on FHR early to prevent any risk that
may be raised like that of missing FHR unnecessarily.

References

Cleverland Clinic. (2022., November 30). Uterine Rupture. Retrieved January 23, 2023, from Cleverland
Clinic: https://my.clevelandclinic.org/health/diseases/24480-uterine-rupture#:~:text=A%20uterine
%20rupture%20is%20a,to%20support%20a%20developing%20fetus.
Togioka, B. M., & Tonismae., T. (2022, June 27). Uterine Rupture. Retrieved January 24, 2023, from
National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK559209/
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Fourth reflective journal

INTRODUCTION
Retained products of conception is among the main causes of post-partum hemorrhage and infection.
Placenta is Thick, blood-rich tissue that lines the walls of the uterus during pregnancy and nourishes the
embryo. Placenta and its membranes (amnion and chorion) should be examined as soon as possible after
delivery to ensure that there is no part of placenta or membranes has been retained to cause post-partum
haemorrhage. Placenta examination may provide a unique opportunity to explore and understand intra-
uterine environment. (Benirischke K et al.., 2012). Reflective journal bellow is going to summarize topic of
placenta examination.
SITUATION
When I was on the day duty in labor ward, I was with midwife caring mother who underwent spontaneous
vaginal delivery. The mother was G5P4004, admitted for monitoring of active phase of labor, with cervical
dilatation of 7cm, descent 0f 2/5. I monitored the labor and only after ten minutes of monitoring, mother
complete with cervical dilatation of 10cm, descent: 1/5 and so, we decided to monitor second stage of labor.
Immediately I took action to conduct delivery and with only 5 minutes, we delivered baby boy with 3400
grams APGAR of 9-10-10. After delivery of baby, we managed the third stage of labor and we did active
management of third stage of labor, here I surprised by the professional of midwife we were together, she
managed the procedure as well as indicated. She did placenta examination in ways which was interested to
access she took kidney dish, and she put on placenta, weigh and measure it and examined maternal and fetal
parts of placenta. Because it is my first time to see midwife who did well procedure of placenta examination,
I asked why she did it and replied that because mother was having precipitated labor, she was at risk of
placenta retained as well as postpartum hemorrhage. By examining, the placenta we found there was missing
membranes, and performed manual removal of them.
AFFECT
The situation made me to feel happy, because when I was trying to examine placenta as we saw in theories
some senior midwives told me that I am wasting my time. Only I have to look completeness of placenta and
membranes. I felt courageous because we discuss together and find out importance of placenta examinations
after delivery, which was crucial.
INTERPRETATION

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This situation made me realize importance of placenta examination, which was ignored by some midwives.
Many literatures wrote about placenta examination. According to the journal of (Benirschke K, et al. 2012),
they said the rationale behind placenta examination where this procedure might be done early to identify and
diagnose cause of postpartum hemorrhage. Placenta checked for completeness, consistency, size, shape, and
parts. Hemorrhage, accessory lobes, placental infracts and nodules should be noted. On umbilical cord
length, insertion, vessels, thrombosis, knots and Wharton’s jell should be accessed. In addition, color, luster,
valamentous (large vessels) and odor of fetal membranes should be evaluated. (McArthur, N & Harding,
2018) those examinations can yield on prevention of postpartum hemorrhage and infection. According to
McArthur, N & Harding. The procedure done in the following ways; inspect umbilical cord vessels, observe
fetal side for irregularities, lift placenta up to observe completeness. Return placenta to the surface to look
extra vessels and lobes, separate amnion and chorion, turn placenta over and inspect maternal surface,
examine cotyledons, weigh and measure cord and placenta, swab it in case of placenta infection, lastly
inform the findings to the mother. By comparing to literatures, we did as supposed to perform it.
DECISION
Inspection and examination of placenta should be performed as soon as possible after delivery. As midwife
the situation I faced encourage me to change the practice of doing my professional without basing to others.
Because client has no problem, doesn’t mean that you have to escape routine procedure or perform it
partially, sometimes it can help to diagnose problem early.

References

Benirschke K, Burton G J & Baergen R N (2012), placenta and its importance in evaluating an unexplained
intra uterine fetal demise, journal of fetal medicine, vol. 2, viewed 24 January, 2023. Available at
https://link.springer.com/chapter/10.1007/978-3-642-23941-0-1
McArthur, N & Harding, C (2018), placenta examination after birth – practice guideline, royal Berlshire
NHS Foundation trust viewed on 24 January, 2023. Available at
https://www.royalberkshire.nhs.uk/downloads/gps/gp%20protocols%20guidelines/maternity%20guildelines
%20and%20polices/intrapartum/placenta-examination-guideline-v.3.0-GL-NOV18.Pdf.

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