Queen Elizabeth University Hospital

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Obstetric On-call

08:30 - 20:30

Labour ward emergency work and cover of obstetric wards after 16:30

Obstetric handover is followed by consultant-led ward rounds on Labour Ward and Ward 48.

During the week you will join the ward round on the labour ward and antenatal ward and assist in theatre when necessary.

Typical duties include prescriptions, fluids, cannulae, ECGs, patient reviews (these will usually be medical reviews e.g tachycardia, fever and you will not be expected to perform obstetric assessments or examinations). *Grey cannulas are required for all women in labour*

  • You will also be involved in Emergencies - post-partum haemorrhage, shoulder dystocia and pre-eclampsia to name a few ...
  • If you are called to an emergency, identify yourself and ask the registrar/consultant/Labour Ward Sister what you can do to help. Often this will be IV access, sending bloods, prescribing emergency drugs. It is good to have an understanding of how these Emergencies are managed to appreciate what is happening and how best to contribute
  • You will not be expected to carry out any obstetric assessments or examinations in the labour ward.

Where possible IDLs should be started on labour ward before the patient moves to the post natal ward. At the weekend, there is significant pressure in the post natal wards and it is often more appropriate for you to excuse yourself from the antenatal / labour ward rounds to start tackling the jobs in the post natal ward early

Consultants

Consultants work in a resident “hot day” capacity Monday to Friday (not including public holidays) between 0830-2030 on Labour Ward. The consultants will either do “hot days” Mon/Tues or Wed/Thurs

Weekend Consultant Obstetric on-call is covered Friday to Sunday by a separate day and night team, non-resident overnight and non-resident all day Saturday and Sunday

Obstetric Wards

08:30 - 16:30 

Ward 48 - Antenatal ward
Ward 47 - Postnatal ward 

There will be a daily consultant ward round. The timing of this depends on the activity in labour ward. The rest of the day will be; 

  • Clerking in patients
  • Organising and chasing investigations
  • Writing IDLs

The doctor covering the wards 47 and 48 is often very busy. There are diaries on the wards with lists of reviews and jobs, keep these up to date.

No patient should leave the hospital without an IDL – please make sure these are done timorously. IDL compliance is audited regularly and is expected to be 100% as per GGC policy. if the process starts is Labour ward, the IDL process will be easier and more effective.

Pre-op assessment

Often, the doctor covering ward 48 will also be covering the gynaecology pre-op assessment area. If you are covering both (should be clear from the rota) please check in at the pre-op assessment area first thing at 08:30 prior to heading to W48.

Post-natal reviews 
  • Day 2 reviews done by junior staff (FY/GPST/ST1-2) unless clinically indicated otherwise
  • Uncomplicated Ventouse, MCFD and elective c/section deliveries
  • Complicated SVD
    • Pre-eclampsia/Hypertension
    • PPH <2 litres
    • Sepsis
  • Uncomplicated emergency c/sections
  • Diabetes

If patients request a debrief as an inpatient, discuss with the postnatal registrar/on-call Obstetric registrar or Consultant who will support with this 

Registrar reviews 
  • Unwell patients
  • Day 1 post HDU
  • PPH >2 litres
  • Complicated elective/emergency c/sections
    • GA c/sections
    • Surgical complications
  • 3rd/4th degree tears
  • Readmissions 

N.B. Patients that do not routinely need medical review

  • Uncomplicated SVDs
  • Previous Obstetric cholestasis

Maternity Assessment Unit

10:00 - 18:00 

1800 - 1000 Covered by on call gynaecology
  • MAU is the first port of call for all pregnant women coming into the hospital in labour or with an acute complaint relating to their pregnancy.
  • You may be asked to see these women, take a history, bloods, gain IV access and in some cases examine and make a plan. We do not expect any of you to be experts in obstetrics and therefore we expect that initially you will need a lot of support and supervision from the registrar covering the MAU
  • Please do not examine / make a plan if you are not confident with what you are doing – someone will always be there to help
  • It is also important that you are aware that the agreed unit policy is that women presenting postnatally to MAU warrant a middle grade obstetrician review

Common Presentations in Triage

Women will present with a large range of clinical problems, some warranting admission or delivery (this will not be your call!) and others requiring simple investigations, risk assessment and reassurance +/- plans for follow up.

Below are a few of the most common presentations and important diagnoses to think about;

Headache
  • Extremely common in pregnancy due to hormonal change, stress and poor sleep
  • Exclude dehydration
  •  Severe headaches can be a sign of Pre-Eclampsia so be sure to exclude other symptoms including visual disturbance, epigastric pain, oedema. Always check BP and urine for protein
  • Common things are common, but make sure you take a good history and exclude any Red Flag symptoms; first & worst, sudden onset, neurological disturbance, postural link, systemic features of infection/inflammation
Abdominal Pain

Again, very common due to stretching of abdominal wall and displacement of intra-abdominal organs

  • Exclude regular uterine activity (contractions) and anything to suggest premature labour (backache, pelvic pressure and vaginal discharge)
  • Exclude associated PV Bleeding
  • Exclude any abdominal trauma and check Rhesus status
  • If epigastric, any other signs of Pre-Eclampsia?
  • If suprapubic, any associated urinary symptoms to suggest UTI?

Don't forget appendicitis, gallstones and constipation ... pregnant women can still have these!

Shortness of Breath

Oxygen consumption and tidal volume are increased in pregnancy and it is extremely common for women to feel a subjective shortness of breath, especially in the third trimester where the diaphragm is compressed by the enlarging uterus

  • Exclude infectious causes
  • Any other suggestive features of Pulmonary Embolus (pleuritic chest pain, calf swelling/oedema, risk factors, tachycardia, low SpO2) - Obstetrics generally has a low threshold for investigating PE's due to their relatively high morbidity/mortality index
Infections
  • UTIs - very common. Can stimulate pre-term labour so always treat if you suspect a UTI
  • LRTIs - common and can be more serious in pregnant women due to physiological changes and immunosupression
  • Sepsis - be on hot alert for Sepsis! If someone meets the criteria, perform the SEPSIS 6 and escalate accordingly
PV Bleeding and Discharge
  • Multiple causes for PV bleeding; exclude placenta praevia, placenta abruption, vasa praevia as these are serious and will often need urgent management 
  • Rule out associated pain, ensure patient happy that there has been no change in foetal movements
  • Has the bleeding been provoked ? Post-intercourse/ ? Abdominal trauma
  • Is the discharge 'Show'? Ruptured membranes? Odorous?

Postnatal readmission is a DATIX trigger – remember to fill in a DATIX form

 

Elective Caesarean Sections

08:30 - 16:30 

The Elective Caesarean Section team is lead by a named consultant or senior trainee (ST6/7) separate from the on-call team. You will be the surgical assistant for the elective caesareans

You should arrive in the labour ward recovery area for 0830 to see the patients with the surgeon prior to a team brief in the theatre.

After the operation it will be your job to start the IDL for the patient. This makes things easier for the team on the postnatal ward.

Gynaecology On-call

08:30 - 20:30

Handover on labour ward 

09:00 - Consultant-led ward round on W49 before reviewing Emergency Gynaecology patients in Gynaecology Emergency Department

Referrals

08:30 - 17:00 - All referrals will be triaged by on-call consultant and seen in Gynaecology Emergency Department

Out of hours - Referrals will be made to on-call registrar

GP referrals should go directly to Ward 49 to be assessed if they are deemed stable 

A&E referrals may need to be assessed in the Adult Emergency Department if it is unclear whether they need admission to Gynaecology 

Admissions 

Unnecessary admissions should be avoided. Some women will be able to be given an appointment for review (including Transvaginal USS) in the Emergency Unit the next working day or have their details passed onto EPAS. Please discuss individual patients with the On-call Consultant if unsure what to do. The same applies to women awaiting assessment in the A&E department

Reviews

If medical staff in the main adult hospital request review of a ward patient, please discuss this with the on-call Gynaecology Consultant. It may be appropriate to transfer the patient to the Gynaecology Emergency Department for review (same day or next day) or for the patient to be given an urgent appointment at a GOPD. In some cases the registrar/consultant will want tor review the patient on the ward.

Whiteboard

Keep the whiteboard on Ward 49 updated on a daily basis including any HDU/ITU/ward outliers. This is located in the doctors’ room behind the ward clerkess’ desk.

Gynaecology Referrals and Follow up

Referrals

Emergency Gynaecology to routine out-patient clinic
  • Many Emergency Gynaecology referrals are not emergencies at all and can easily be seen at the earliest outpatient clinic
  • Ask the referring GP or ward doctor if this is appropriate. If you know the patient’s postcode, then they can be referred to the appropriate clinic within their catchment
  • Always put the on-call consultant’s name on any investigations and use the consultant team system to establish clinic and follow-up arrangements for emergency patients. Referrals will be scanned through the vetting process appropriately.
Urgent outpatient clinic
  • If urgent OP attendance is required, give the appropriate secretary a letter and they will scan onto Clinical Portal/contact Outpatient Appointments
  • Contraception of STI should be given details of the Sandyford Clinic or advised to see their GP. If positive Chlamydia results come back, then write to the patient with an appropriate action plan, copying the letter to the GP and sending a referral to the Sandyford

Discharge

  • Most patients seen through gynaecology emergencies will go home. Few require follow-up.

An electronic discharge letter to the GP must be completed following every review in Gynaecology Emergencies. This includes all patients who are seen on Ward 49 out of hours. This is very similar to completing an IDL and is just as important. This should be completed by the doctor who sees the patient.

  • Within Trakcare, select the ward attender patient episode from either SGH-Emergency Gyn or SGH49-Gynaecology. All patients being seen must be ward attended – nursing or clerical staff will do this
  • From options above, select Discharge Letters then New OPCL
  • In clinical notes, select New and complete the main body of the letter
  • It’s important to also complete Additional OPCL info – New (just add in NA/Nil if no follow up required)
  • You must then Update and Authorise in order for the letter to be complete which will then send to GP electronically and be uploaded on to Clinical Portal

MDT

For patients who are being referred to the regional gynaecology MDT:

  1. When you submit a case for MDT discussion, copy Dr Hardie (local lead Gynaecology Oncology) into the referral as it is helpful for her to look over the cases before MDT Meeting
  2. If an inpatient on ward 49 is submitted for MDT discussion, please put a copy of the completed MDT referral form in the notes and document that submission has been done
  3. If you submit an MDT form for a patient elsewhere in QEUH, it would be helpful to upload the referral onto Portal so that we know the form has been completed across specialties

 

Early Pregnancy Assessment Service

Monday – Friday @ QEUH 8:00 - 16:00 for referrals
Saturday @ QEUH 08:30 - 16:30 for referrals 
Sunday @ PRM (EPAS provided by PRM on Sundays) 08:30 - 16:30. You will need to liase with PRM staff to refer any patient after 16:30 on a Saturday

The contact numbers for PRM EPAS are 0141 211 5317 and 0141 211 5323.

Night shifts

20:30 - 08:45

Monday - Thursday
Friday - Sunday 

Overnight, there will always be two registrars resident within the hospital and two junior doctors (FY2 / GPST2 / ST1)

Handover

The whole team should start at handover in the Labour Ward at 20:30 which will also be attended by the night Obstetric Consultant. The Gynaecology team will then visit Ward 49 to assess all patients who have been to theatre that day and any other patient who is causing concern.

Workload

It is important that the on-call overnight work as a team with equal share of the workload. If Gynaecology and MAU are quiet, the Gynaecology team may help out on Labour Ward, but their priority is to Ward 49 and Emergency Gynaecology at all times. There will also be some nights where there will also be an ST2 shadowing the more senior registrar overnight.

  • Out of hours, all calls from MAU will come to the Gynaecology page

It should be stressed that there is to be no use of a bed or a Parker Knoll chair for sleeping purposes overnight whilst on-call

We are in the process of trying to improve the current rest facilities/doctors room. If anyone would like to be involved with moving this forward, please contact Dr Hardie

Education & Teaching

Portfolio

  • Educational supervisors will be allocated at the beginning of the block
  • Keep ahead with your Portfolio, check what is required and get started early!

Junior Teaching 

Departmental Teaching

A calendar of teaching events is available here

 

Hospital Layout and Sister sites

Queen Elizabeth University Hospital

You will be based within the Queen Elizabeth University Hospital Maternity Building but may work “off site” for some clinical sessions. The unit is spread over 4 floors.

Ground floor 

- Labour ward (including obstetric theatres),

- Gynaecology theatres

- Maternity assessment

- Day care

- Antenatal and gynaecology outpatient clinics

- Pre-assessment

- Gynaecology emergency department, early pregnancy assessment service and gynaecology day ward.

- Seminar room for teaching and training (see later).

First floor

- Administration corridors including the secretaries, consultant offices and doctors’ room.

Second floor
- High risk postnatal ward (47) 

- Antenatal ward (48) 

Third floor 

- Gynaecology ward (49) 

- Low risk postnatal ward (50) 

Victoria ACH (VACH)

The VACH is the day hospital opposite the (now closed) site of the original Victoria Infirmary.

  • Gynaecology Outpatient/ Ultrasound/ Colposcopy clinics here
    • Clinic K, 1st floor
  • Day Surgery Unit lists, 1st floor
Parking

Basement car park, visitors/patients ≤4 hours or on the street.

Gartnavel General Hospital (GGH)

  • Day Surgery Unit is located on the ground floor 
Parking

Restrictions as above 

 

Parking and Sustenance

Parking 

Parking in the hospital is limited. Staff parking permits are not available for trainees. There are some non-permit holder areas where you can park in the hospital (map enclosed in induction pack) but these tend to fill up quickly in the morning.

People also park on the roads outside or in the visitor parking spaces. If you use these spaces for >4 hours, you are at risk of being given a parking ticket.

Don’t park in the ambulance bays at the side of the maternity building or in the consultant emergency spaces. There are lots of spaces in the multi-storey car park behind the maternity building.

Sustenance 

The WRVS shop is situated at the main entrance of the maternity building. This is open daily (0900-2000 Mon-Fri & 1200-1600 Sat/Sun). Hot drinks, soup, toasties etc can be bought in addition to sandwiches, snacks and cold drinks.

There are also vending machines outside labour ward. You are welcome to use the tea rooms on MAU and LW. If you drink tea/coffee/use their milk, you should offer a donation.

There is a small doctors office next to the labour ward coffee room with access to a computer. There is also a kitchen next to the 1st floor admin corridor doctors’ room with a kettle and microwave but there is minimal crockery/cutlery.

A small quiet room next to the coffee room in the 1st Floor Admin Corridor is available for use as either a Prayer Room or for Breastfeeding needs. If anyone wishes to use these, then let us know.

The QEUH Canteen/Aroma café is on the first floor of the main adult hospital. There are also shops on the ground floor including M&S, various food outlets and a cash machine.