09:00 - 21:30
Labour Ward, Maternity Triage, Emergency Theatre (and Obstetrics Ward 31 after 5pm)
Labour Ward, Maternity Triage, Emergency Theatre and Obstetrics Ward 31
Attend Labour Ward Handover at 9am
- Be on time!
- You need to be in Scrubs and theatre shoes (if you don't have your own find a pair without a name on in the changing rooms)
- Ensure hair is off your shoulders and no lanyards!
- Take the 1st-On page (#56015) from the Night Team
- Grab an Ipad or Laptop and sign into Badger - Save all the patients as 'Favourites' to help the ward round move smoothly
- Join the Ward Round; the majority of jobs generated tend to quick and can be done on the way round
- If you have no urgent jobs and there is no-one waiting to be seen in Triage, feel free to join the Team as they head upstairs to the Obstetric Ward Round. You will always learn something and will be able to see what's happened to patients you admitted or managed the day before!
Duties of the Day
Your time will be split between
- Labour Ward
- Emergency Theatre
- Occasionally Early Pregnancy/ Daycare depending on the ebb and flow of activity
Typical duties include prescriptions, fluids, cannulae, ECGs, patient reviews. *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
Essentially A&E in pregnancy
You will likely spend most of your day here and at the weekend when you are being pulled in all directions, triage needs to be prioritised over non-urgent ward jobs.
If a woman has had an USS showing a viable intrauterine pregnancy (normally a Booking Scan at 10-12 weeks) they will usually attend Maternity Triage as their first port of call for acute complaints relating to their pregnancy
- Women can self-present or be referred by Community Midwives/GPs/A&E/ante-natal clinics. If they are unbooked they will need to be seen by EPAS or Gynae.
- Patients will have a Midwife assessment before you see them, consisting of;
- Maternal Observations
- Abdominal Examination
- Foetal Assessment (CTG if >26 weeks, FHR if <26 weeks)
- 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/consultant
- Please do not examine / make a plan if you are not confident with what you are doing – someone will always be there to help
- Please do not discharge any patients without discussing them first with registrar or consultant
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;
- 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
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
- 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?
- Category 1 - Immediate threat to the life of mother or baby - Decision-to-Delivery time = 30mins
- Category 2 - Urgent but no immediate threat to the life of mother or baby, often timing is dependant on Labour Ward pressures
- You will be paged from theatre to attend Emergency Caesarean Sections
- At this point the Spinal Anaesthesia is normally in and your presence is required immediately. Drop what you are doing, apologise to whoever you are with and explain you need to attend an emergency
- Head down to Theatre A/B. Normally the registrar/consultant is already there
- Make sure you are in scrubs, theatre shoes and have a theatre hat on before entering Theatre
- Before scrubbing, make sure there is gown and gloves open on the prep-table and you have a mask on (Normally, theatre staff are pretty good at getting this ready but often in an emergency it's up to you!)
- Scrub (presumed you can do this, if you need a refresher ask one of the midwives/theatre staff!)
- Assist in the C-section in the usual way, but be aware of the fact that the focus is on delivering the baby as quickly as possible so stay focused!
If in doubt, ASK!