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Open Access Highly Accessed Research article

Clinical decision-making: midwifery students' recognition of, and response to, post partum haemorrhage in the simulation environment

Julie Scholes1, Ruth Endacott23*, MaryAnne Biro3, Bree Bulle4, Simon Cooper5, Maureen Miles39, Carole Gilmour6, Penny Buykx7, Leigh Kinsman7, Rosemarie Boland8, Jan Jones39 and Fawzia Zaidi1

Author Affiliations

1 Centre for Nursing and Midwifery Research, University of Brighton, Mayfield House, Village Way, Brighton, UK

2 Faculty of Health and Social Work, University of Plymouth, Drake Circus, Plymouth, UK

3 School of Nursing & Midwifery, Monash University, Clayton Campus, Victoria, Australia

4 The Royal Women's Hospital, Melbourne, Victoria, Australia

5 School of Nursing (Berwick), Monash University, Berwick, Victoria, Australia

6 School of Nursing and Midwifery, Monash University, Peninsula Campus, Frankston, Victoria, Australia

7 School of Rural Health, Monash University, Bendigo, Victoria, Australia

8 Nurse Educator: NETS (Victoria), PhD Scholar, University of Melbourne, Melbourne, Australia

9 School of Nursing and Midwifery, Monash University, Gippsland Campus, Churchill, Victoria, Australia

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BMC Pregnancy and Childbirth 2012, 12:19  doi:10.1186/1471-2393-12-19

Published: 23 March 2012



This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration.


Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis.


The students' clinical management of the situation varied considerably. Students struggled to prioritise their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error.


The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could be done whilst they awaited the emergency team. They did not necessarily serve to prompt the students' or help them plan care prospectively. The limitations of the study are critically explored along with the pedagogic implications for initial training and continuing professional development.