Fetal (3F)
Prolonged second stage of labour with a normal CTG
Fetal (4F)
Meconium staining of liquor in the presence of a normal CTG
Additional to the skill of prioritization is the ability to allocate the most appropriately skilled member of staff to the individual patients. To achieve the most efficient use of the resources available, initial assessment of the labour ward requires detailed handover of the workload, together with knowledge of skills and experience of the staff on duty. Once the initial priorities have been defined and staff distributed appropriately, good communication, regular reviews and comprehensive ward rounds are needed to summarize and reassess the workload and changing priorities. Regular ward rounds also provide an opportunity to identify potential future problems and encourage positive decision making, with clear plans outlined for each individual, including timing of examinations and stepwise decisions based on their findings, documented in the case notes. Problems tend to accumulate if decisions are deferred, resulting in simultaneous emergencies. Multidisciplinary ward rounds, including obstetric and anaesthetic medical staff and the midwifery shift leader, promote good communication between members of the team and enable planning of interventions which may require regional anaesthesia or analgesia, matched against the ongoing workload of the labour ward.
Within the systems of prioritization and triage in obstetrics there must always be the ability to deal with unexpected and unpredictable emergencies. Some obstetric emergencies can be anticipated, such as a large postpartum haemorrhage following a prolonged dysfunctional labour with oxytocin augmentation. If anticipated, these emergencies may be averted or, at least, planned for. For example, additional intravenous access prior to delivery and active management of the third stage with additional uterotonic agents can prevent or minimize postpartum haemorrhage. The outcome from other obstetric emergencies can be altered with swift identification of the problem and rapid intervention. For example, the use of continuous electronic fetal monitoring in women labouring after a previous CS can identify scar complications early and allow rapid intervention and emergency delivery. For emergencies that are often unpredictable, regular rehearsal drills and detailed departmental guidelines enable all staff to be familiar with the actions needed and their individual role.
Good communication on the labour ward is paramount, between patients, relatives and staff, and between members of staff. It is not possible to anticipate and recognize problems within individual delivery rooms without being fully aware of what is going on in that room. Ward rounds by the shift leader and medical staff should review each room occupied, although not all women need to be reviewed personally unless clinically indicated. An update from the midwife looking after the woman is enough, as long as there is good ongoing communication with the shift leader. Following ward rounds, the labour ward board, detailing all the women on the department, should be revisited and the cases summarized. Potential problems should be communicated to the anaesthetic staff, theatre staff and the neonatal unit, as they also form part of the team needed to coordinate safe practice. If this communication and teamwork is not well established it will lead to errors and conflicts between members of staff. For example, if the correct category of urgency for an emergency CS is not communicated to the anaesthetist and theatre team, they may not attend quickly and will delay the time to delivery. Both national and local enquiries looking at poor obstetric outcomes frequently highlight problems with communication being prominent in the series of events leading to the outcome. Multidisciplinary ward rounds, rehearsal drills and teaching sessions will help to improve teamwork and communication and should be encouraged. Clear lines of communication are required in emergencies, with calm and precise coordination from a single leading individual. These lines of communication can be established and practised during drills.
Clinical Scenarios
The following clinical scenarios (Tables 28.4, 28.5) have been designed to represent the workload of a busy labour ward. Read through the tables as if you were receiving handover for your shift. Consider how you would prioritize the cases and how you would allocate the staff you have available, which are described at the bottom of the table. Initially the workload may seem impossible to manage, but use the obstetric triage system outlined in Table 28.3 then check your ideas with those suggested below.
| 1 | 24 years, 28/40, nulliparous, chest pain and cough O2 saturation 93% on air | 7 | 32 years, G2P1 previous stillbirth at 38/40 36/40; decreased fetal movements |
| 2 | 28 years, 41/40, nulliparous; Cx 2 cm dilated at 02:30; Cx 3 cm dilated at 06:30; ARM | 8 | 36 years, nulliparous insulin-dependent diabetic; prostin induction at 38/40; last BM 4.1, 90 min ago |
| 3 | 18 years, 40/40, nulliparous, transferred from birth centre, APH 150 ml | 9 | 31 years, G3P2; previous LSCS; followed by SVD; Cx fully dilated at 06:30 |
| 4 | 27 years, para 1 SVD at 06:30; awaiting suturing of second-degree tear | 10 | 28 years, nulliparous, 31/40 dichorionic twins; IVF; painless PV bleeding |
| 5 | No case | 11 | 33 years, nulliparous; Cx 7 cm dilated at 04:30; Cx 9 cm dilated at 07:30 |
| 6 | 22 years, G2P1; Cx 4 cm dilated at 05:30; meconium-stained liquor; variable decelerations of FHR | 12 | 34 years, G2P1; maternal lupus BP 160/90, 1+ proteinuria; abdominal pain; no fetal movement |
| HDU1 | 37 years, nulliparous, 34/40, BP 175/112 3+ proteinuria, headache | HDU2 | No case |
| Rec 1 | 33 years, para 1 emergency LSCS at 9 cm dilated; vaginal bleeding; estimated blood loss 1100 ml | Rec 2 | 35 years, para 3; manual removal of placenta; oxytocin infusion, PR misoprostol; tachycardia HR 128 bpm |
Notes:
08:30 handover
Two elective LSCS – first case: maternal congenital heart disease, needs HDU
Three prostin inductions
Staff available:
Two ST1/2 (SHO)
Eight midwives – three senior who suture and cannulate
One shift leader midwife
One recovery nurse
One ST 3–7 – obstetrics (registrar)
One ST 3–7 – anaesthetics (registrar)
Anaesthetic and obstetric consultants available at 10 a.m. after risk management meeting.
| 1 | 22 years, nulliparous, transferred from birth centre; Cx 9 cm dilated since 03:30 | 7 | 29 years, G2P1; hepatitis B; Cx 3 cm dilated at 06:30 |
| 2 | 38 years, nulliparous; undiagnosed breech; contracting 2:10; Cx 1 cm dilated 07:30 | 8 | 36 years, G10P8; Cx 6 cm dilated at 07:30; thick meconium; fetal bradycardia of 90 bpm for 4 min |
| 3 | 32 years, G3P2; previous LSCS; followed by SVD; Cx 5 cm dilated at 06:30; meconium-stained liquor | 9 | No case |
| 4 | 31 years, nulliparous; prostin induction at 40+12/40; Cx 3 cm dilated at 04:00; variable decelerations of FHR | 10 | 24 years, nulliparous, 40+4/40; APH 200 ml |
| 5 | 28 years, G4P2+1 33/40; abdominal pain | 11 | 33 years, G3P0+2; previous stillbirth at 40/40; prostin induction at 38/40; awaiting ARM |
| 6 | 34 years, nulliparous, 40/40; spontaneous labour; Cx 4 cm dilated at 00:00; Cx 4 cm dilated at 04:00; ARM Cx 5 cm dilated at 08:00 | 12 | 41 years, G2P1; dichorionic twins, 34/40; backache; small PV bleed |
| HDU1 | 35 years, para 1; epileptic 2 seizures following spontaneous vaginal delivery | HDU2 | No case |
| Rec 1 | 32 years, para 1; forceps, third-degree tear PPH 1800 ml | Rec 2 | 29 years, para 2; emergency LSCS for fetal tachycardia; prolonged SROM pyrexial; HR 112; O2 saturation 93% |
Notes:
In theatre with LSCS + hysterectomy, massive PPH 3500 ml
08:30 handover – two elective LSCS, two prostin inductions
Staff available:
Two ST 1/2 (SHO)
Eight midwives – four senior who suture and cannulate
One shift leader midwife
One recovery nurse
One ST 3–7 – obstetrics (registrar)
One ST 3–7 – anaesthetics (registrar)
Anaesthetic and obstetric consultants available if requested.
Clinical Scenario A
Having allocated a priority to all cases, staffing needs to be reviewed to allow staff allocation. The first priority when faced with a number of complex problems requiring intervention simultaneously is to ask available staff to attend. The consultant obstetrician and consultant anaesthetist should be contacted and asked to attend immediately (patient care has to take priority, so the meeting can continue without them or be postponed).
1. The immediate priority is the woman in room 1 (priority 1B), who is hypoxic and needs full assessment and investigation for pulmonary embolus. She should be seen by the obstetric ST 1/2, as this is primarily a medical problem rather than an obstetric problem. She needs oxygen and anticoagulation with subcutaneous low molecular weight heparin, and investigations instituted to confirm the diagnosis. Midwife 1 should stay with her once medical staff have left.
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