The Labour Ward Handbook, second edition

Leroy Edozien, Leroy Edozien

• Publisher: CRC Press
• Year: 2010
• Print ISBN: 9781138457003
• eBook ISBN: 9780429586088
• Edition: 2
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

The Labour Ward Handbook, second edition, is a succinct manual that provides detailed clinical practice guidelines for the care of women in labour. Dealing more with the practice than the theory of labour ward management, this book is designed to be a ready guide for use in the delivery suite by the busy clinician.The format has been specifically d

PART I

Approach to care

‘… a shift in attention from what is done to patients to what is accomplished for them’

Committee on Quality of Healthcare in America. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001: 44

1 Communication

For efficient delivery of care, it is important that lines of communication are well defined. The consultant under whose care the mother is booked is ultimately responsible for her care. For each shift on the delivery suite, one midwife of appropriate seniority and experience will be designated Coordinator and will be responsible for coordinating the work of the delivery suite, providing necessary support, guidance and supervision of midwives and medical staff. The Coordinator should be informed regularly of each mother’s progress. The names of the Coordinator and the obstetric, anaesthetic and paediatric medical staff on duty should be on the designated notice board.

The lines of communication for the midwife are through the Coordinator and the resident medical staff. However, any midwife or other member of staff who has concerns about a woman’s care may contact the ST or consultant (obstetric or anaesthetic) directly.

All members of the duty obstetric team should ensure that they are readily accessible and available at all times.

Early identification and communication of risk

For women at high risk, a plan of management should be made antenatally and written in the handheld and hospital records, with a clear signature. Early identification of risk factors, anticipation of problems and effective communication are key factors for good management.

If a non-duty consultant has an interest in the management of a particular patient then this should be marked clearly in the case notes; the senior midwife or ST will need to contact this consultant when the woman is admitted and if problems arise afterwards.

All high-risk patients admitted to the labour ward must be seen by the doctor on duty as soon as possible.

The ST should be informed immediately of any untoward problems and of any of the following conditions (note that this is not an exhaustive list):

• APH

• PPH

• malpresentation

• cord prolapse/cord presentation

• severe pre-eclampsia/eclampsia

• multiple pregnancy

• preterm labour

• PROM

• abnormal fetal heart rate

• diabetes mellitus

• cardiac disease

• intrauterine death

• large baby

• previous CS

• any pregnancy identified as high-risk in the case notes

If there is any delay in response in cases such as prolapsed cord or if the registrar is unavailable because of another emergency, then the consultant on call should be called immediately.

It is recommended that the consultant should be physically present for the following:

• eclampsia

• maternal collapse (resulting from placental abruption, septic shock or other abnormality)

• CS for major placenta praevia

• PPH of more than 1.5 L where the haemorrhage is continuing and a massive obstetric haemorrhage protocol has been instigated

• return to theatre – laparotomy

Handover

There should be a personal handover of patient care at the shift/on-call changeover of both midwifery and medical staff. There should be ward rounds at 0830, 1300 and 1700 and a telephone review with the consultant at 2200.

There should be a professional approach to the ward rounds – which means no distractions such as telephone or side conversations. At each ward round, but particularly at the morning and evening rounds, there should be an assessment of the number and experience of the available workforce, identification of any threats to the service (e.g. non-availability of cots in the neonatal unit) and a review of patient safety incidents from the outgoing shift. The handover offers an opportunity to identify risks, make contingency plans and develop shared mental models for the challenges ahead. This helps to maintain situational awareness.

Communication with anaesthetists

In anticipation of events, the anaesthetist should be informed at an early stage of any of the following:

• APH

• twin pregnancy in labour

• breech vaginal delivery

• previous CS

• woman at risk of PPH

• pre-eclampsia

• obese patient who may require operative intervention

• medical conditions such as diabetes, sickle cell and heart disease

• history of anaphylaxis

‘Anaesthetists responsible for obstetric services should liaise with midwives, obstetricians and physicians to agree management for successful delivery. The anaesthetist must become involved in the management of the “at risk” patient at an early stage …’

Hibbard BM, Anderson MM, Drife JO, et al. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991–1993.

London: HMSO, 1996: Chapter 9: 101

‘Obstetricians failed to give adequate warning of impending problems to anaesthetic departments in at least six of the maternal deaths in this triennium. The lack of consultation with anaesthetic colleagues contributed significantly to a number of these deaths.’

Thomas TA, Cooper GM. Anaesthesia. In: Lewis G, ed. Why Mothers Die, 1997–1999. The Fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG

Press, 2001: 139

‘A good working relationship between the multidisciplinary team (midwives, medical, ancillary, managerial staff) and the women in their care is crucial to ensure optimal birth outcomes. This is best achieved with a team approach, based on mutual respect, a shared philosophy of care and a clear organizational structure for both midwives and medical staff with explicit and transparent lines of communication. Clear, accurate and respectful communication between all team members and each discipline is essential, as well as with women and their families.’

Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Anaesthetists, Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, Report of a Working Party. London: RCOG Press, 2007: 10

2 Documentation

All records should be written in black ink, and handwriting must be legible. The care given should be documented carefully and thoughtfully. All examinations, results, clinical communications and maternal requests should be documented accurately on the labour notes, partogram and CTG trace as appropriate.

All entries to the records must be clearly signed, dated and timed (use the 24-hour clock). Illegible signatures are not acceptable. Always print your name and grade below your signature.

Use abbreviations sparingly, and only those in standard use (eg CS, FH).

Every loose-leaf sheet in the notes must have patient identification. The responsibility for this rests with the first person who writes on that page.

Consent for examination, CS and other interventions must follow standard policy and practice (see Appendix 1).

Every operative delivery should be written up in detail, with the date, time, indication(s), findings and any complications stated clearly. Instructions for postoperative care should be itemized. Proformas for CS, instrumental vaginal delivery and repair of perineal tears help to raise the quality of documentation.

The time of decision to perform a CS, and the degree of urgency (see p. 82), should be documented. The time of commencement of CS, i.e. ‘knife to skin’, should be recorded in the theatre log book.

Before filing any results, check that they belong to the correct patient, annotate any action required or taken, and append your signature.

Every CTG trace should bear the patient’s identification label and the date and time of commencement and completion. The maternal pulse should be recorded regularly on the trace (not just at the beginning), along with any key events in care. Any loss of contact or discontinuation should be annotated on the trace.

Sign and date all CTGs, and file them securely with the clinical records.

The standard setting of 1 cm/min should not be altered on the CTG monitor.

Never try to alter existing notes. If corrections are necessary, draw a line through the incorrect entry and sign and date the additional note.

All midwifery records must comply with standards set by the Nursing and Midwifery Council (see Further reading, p. 16).

The statutory limitation on obstetric litigation is not until the child is 21 years of age, so notes relating to pregnancy care must be maintained intact...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Preface
• Acknowledgements
• Abbreviations
• Glossary
• Bleep/crash calls
• PART I: Approach to care
• PART II: Normal and low-risk labour
• PART III: Abnormal and high-risk labour
• Appendices
• INDEX