Training, teamwork and the structure of the NHS Dr Lisa Joels MD FRCOG Royal Devon & Exeter NHS Trust Sept 2012 Royal College of Obstetricians and Gynaecologists Aims To understand the role of the O&G ST5 registrar in UK practice To understand teamwork and what a multidisciplinary team does To gain an insight into the structure of the NHS Homework: To work through the following clinical scenarios which will be discussed in the first virtual classroom answers to be sent to the RCOG as below Deadline: 4pm UK/8.30pm India time Fax to RCOG at 0044 207 7772 6388 or email to [email protected] The labour ward board You are the registrar (ST5) on call for the delivery unit. You have arrived for the hand over at 8.30am. Attached you will find a brief resume of the 10 women on delivery suite as shown on the
board. Decide on the priorities for managing each patient and delegate tasks as appropriate The labour ward board The staff that are available today are as follows: An O&G ST1, in post for 6 months A third year anaesthetic registrar (ST3) The on call consultant has been asked to deal with a problem on Intensive Care Unit. Six midwives: SW is in charge; SW, CK & MC can suture episiotomies; DB, SW & PL can insert IV lines. VM is newly qualified. Community Midwife CMW is available to come in from the community for low risk midwifery led care women if needed RM NAME GES LIQUO T R EPID SYNT COMMENT 1 MARSHA 0
LL 38 - YES YES LSCS for Breech yesterday afternoon, taken back SW to theatre for bleeding at 2am. Angle oversewn and drain sited. Blood loss 2500mls 2 FORD 2 41 Clear. NO NO 3
OLDHAM 0 20 Membr Intact NO NO Spontaneous labour 6cm at 3am. Cervagem TOP for Edwards Syndrome Stoppd contracting at . R/V for oxytocin COM MW CK 4 SCOTT 5 40
Clear NO NO MC 5 GRANT 0 26 Membr Intact NO NO Contracting Spontaneous labour 7cm at 8am? urge to push. Tightening, loin pain, abdominal discomfort CTG normal. Booked for ultrasound scan 6
CHOPRA 1 40 - NO NO MC 7 MURRAY 0 38 - NO NO 8 STOTT
0 39 - - - 9 BRYAN 3 + 1 41 - NO NO Diabetic insulin dependant For I.O.L. Contracting. 4cm at 0400h Repeat VE at 0700h still 4cm Delivered at 6am Awaiting suturing For elective CS. Now contracting
10 HUGHES 1 Blood NO Stained NO APH, Contracting 2 in 10 & complaining of pain between contractions Early decelerations on CTG. DB 38 MW CK VM PL VM Allocati on
RM NAME GES LIQUO T R EPID SYNT COMMENT 1 MARSHA 0 LL 38 - YES YES LSCS for Breech yesterday afternoon, taken back ST1 &Anae to theatre for bleeding at 2am. Angle oversewn sth and drain sited. Blood loss 2500mls 2
FORD 2 41 Clear. NO NO SW or ST5 3 OLDHAM 0 20 Membr Intact NO NO
Spontaneous labour 6cm at 3am. Cervagem TOP for Edwards Syndrome Stoppd contracting at . R/V for oxytocin 4 SCOTT 5 40 Clear NO NO VM 5 GRANT 0 26
Membr Intact NO NO Contracting Spontaneous labour 7cm at 8am? urge to push. Tightening, loin pain, abdominal discomfort CTG normal. Booked for ultrasound scan 6 CHOPRA 1 40 - NO NO Diabetic insulin dependant For I.O.L. 7
MURRAY 0 38 - NO NO Contracting. 4cm at 0400h Repeat VE at 0700h still 4cm 8 STOTT 0 39 - - - 9
BRYAN 3 + 1 41 - NO NO Delivered at 6am Awaiting suturing For elective CS. Now contracting DB & ST5 routine PL & ST5 semiurgent MC 10 HUGHES 1 Blood NO Stained
NO 38 APH, Contracting 2 in 10 & complaining of pain between contractions Early decelerations on CTG. ST5 semiurgent ST1 & PL CK & ST5 semiurgent DB & ST5 urgent The labour ward team Midwives: Independent practitioners Advanced skills: cannulation, suturing, prescribing
SHO Variable level of skills Need to be explicit in instructions for delegation Anaesthetist Epidural, spinal and GAs Input in managing critically ill obstetric patients e.g. Severe PET, massive obstetric haemorrhage Consultant 40 hour cover (or more) Effective handover EWTD means shift work hence the need for effective handover to minimise clinical risk SBAR tool for communication Situation Background Assessment Recommendation Written documentation at handover Ref: Improving patient handover. Good Practice guide 12 (Dec 2010) www.rcog.org.uk/ MEOWS chart Modified obstetric early warning score/system Respirations, saturations, pulse, BP, temperature, urine output, pain score, neuro response (AVPU)
Clinical governance Standardised risk management tool to recognise the sick patient in all clinical specialties Modified algorithm for use in obstetrics to reflect referral pathways in MDT Ref: Saving mothers lives 2003-05 page 247, Standards for Maternity Care RCOG 2008 (RCOG working party reports) Obstetric triage Option list You are triaging the referrals to the antenatal clinic. For each of the following clinical scenarios select the most single most appropriate pattern of antenatal care. Each option may be used once, more than once or not at all. A Consultant led care with 4 weekly scans from 24 weeks gestation B Consultant led care with 2 weekly scans from 22 weeks gestation C Consultant led care in a tertiary unit D General Practitioner led care E
Shared care between consultant obstetrician and consultant physician F Shared care between consultant and perinatal mental health team G Shared care between consultant and general practitioner H Shared care between midwife and consultant visits at 12 weeks and term I Shared care between midwife and consultant visits at 20 weeks and term J Shared care between midwife and perinatal mental health team K Midwifery led care throughout Obstetric triage 1. Dear Doctor, Please would you book Mrs Twigg for antenatal care. She is 28
years old and is currently 10 weeks gestation in her third pregnancy. The first was a normal delivery and the second was an elective caesarean section for breech. She would like to discuss vaginal delivery. 2. Dear Doctor, Please will you book Mrs Haldon for antenatal care. She is in her first pregnancy and was seen last week in the early pregnancy unit with a threatened miscarriage. She had a scan which confirmed a viable monochorionic, diamniotic twin pregnancy of 10 weeks gestation. 3. Dear Doctor, Please arrange antenatal care for Mrs Gwyn who is now pregnant for the third time. Both her children were born by normal vaginal delivery but after each pregnancy she suffered postnatal depression. She is no longer taking antidepressants and although a little anxious is coping well. 4. Dear Doctor, Please would you arrange antenatal care for Mrs Doublegood who finds herself pregnant again. This is her third pregnancy, her two children were born normally but this is a new relationship. She is a smoker and has a body mass index of 28. Obstetric triage 1. Dear Doctor, Please would you book Mrs Twigg for antenatal care. She is 28 years old and is currently 10 weeks gestation in her third pregnancy. The first was a normal delivery and the second was an elective caesarean section for breech. She would like to discuss vaginal delivery. Answer H Shared care, consultant visit 20/40 and term 2. Dear Doctor, Please will you book Mrs Haldon for antenatal care. She is in her first pregnancy and was seen last week in the early pregnancy unit with a threatened miscarriage. She had a scan which confirmed a viable monochorionic, diamniotic twin
pregnancy of 10 weeks gestation. Answer B Cons led care fortnightly scans Obstetric triage 3. Dear Doctor, Please arrange antenatal care for Mrs Gwyn who is now pregnant for the third time. Both her children were born by normal vaginal delivery but after each pregnancy she suffered postnatal depression. She is no longer taking antidepressants and although a little anxious is coping well. Answer I MLC + perinatal mental health team 4. Dear Doctor, Please would you arrange antenatal care for Mrs Doublegood who finds herself pregnant again. This is her third pregnancy, her two children were born normally but this is a new relationship. She is a smoker and has a body mass index of 28. Answer J Midwifery led care Summary Obstetric triage and prioritisation is very likely to be in the examination Need to understand the role of each team member in order to appropriately delegate Understand competence level of ST5 to call for help appropriately
Structure of midwifery led and neonatal care Unified standards and protocols across NHS Summary OSCE question preparatory station EMQ application of clinical knowledge to specific scenario given Your questions Homework: Online lectures on SAQs, EMQs &MCQs Refer to NICE guideline CG132: Caesarean section & submit answers to cases Deadline: Thu 4 Oct 2012, 4pm UK/8.30pm India time Fax to RCOG at 0044 207 7772 6388 or email to [email protected] Thank you for attending and see you next Sunday!
