Pre-Obstetric Emergency Training E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Advanced Life Support Group
- Sprache: Englisch
Pre-Obstetric Emergency Training: A Practical Approach, 2nd Edition
Fully revised and now in full colour, the new edition of Pre-Obstetric Emergency Training (POET) will help practitioners identify and manage a range of time-critical obstetric emergencies, specifically in the pre-obstetric department setting.
Providing structured examination and assessment techniques as an aid to determine what treatment should be provided before transport, this practical manual equips the practitioner with the knowledge necessary to save the mother and fetus in life-threatening circumstances before admission to the hospital. New to the second edition are chapters covering non-technical skills and communication, as well as complicated labour and delivery.
Designed to accompany the associated Advanced Life Support Group training course, Pre-Obstetric Emergency Training serves as an authoritative guide for a range of pre-hospital practitioners dealing with specialist situations.
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Veröffentlichungsjahr: 2018
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Table of Contents
Cover
Foreword to second edition
Preface to second edition
Preface to first edition
CHAPTER 1: Obstetric services
1.1 Organisation of obstetric services, epidemiology of obstetric emergencies and role of the ambulance service, general practitioner and midwife
1.2 Using patient hand‐held notes
CHAPTER 2: Legal and ethical issues
2.1 Impact of litigation claims
2.2 Consent and capacity
2.3 Confidentiality
2.4 Recognition of death
2.5 Medical errors and negligence
2.6 Cultural issues
2.7 Professional accountability
2.8 Documentation
CHAPTER 3: When things go wrong – a review of the MBRRACE‐UK and Ireland Maternity Mortality Reports 2014–17
3.1 Introduction
3.2 Background
3.3 MBRRACE‐UK report 2014 – highlights and take‐home messages
3.4 MBRRACE‐UK report 2015 – highlights and take‐home messages
3.5 MBRRACE‐UK report 2016 – highlights and take‐home messages
3.6 MBRRACE‐UK report 2017 – highlights and take‐home messages
CHAPTER 4: Getting it right – non‐technical skills and communications
4.1 Introduction
4.2 Extent of healthcare error
4.3 Causes of healthcare error
4.4 Human error
4.5 Learning from error
4.6 Communication
4.7 Team working, leadership and followership
4.8 Situation awareness
4.9 Improving team and individual performance
CHAPTER 5: Anatomical and physiological changes in pregnancy
5.1 Anatomical and physiological changes in pregnancy and implications for management
5.2 Relevant laboratory tests – differences in the ‘normal range’ in pregnancy
CHAPTER 6: Structured approach to the obstetric patient
6.1 Structured approach
6.2 Obstetric primary survey
6.3 Positioning the patient
6.4 Taking and evaluating an obstetric history
6.5 Obstetric secondary survey
6.6 Handover of the obstetric patient
CHAPTER 7: Collapse, cardiac arrest and shock in pregnancy
7.1 Cardiac arrest in pregnancy
7.2 Management of cardiac arrest
7.3 Resuscitative hysterotomy/perimortem caesarean section
7.4 Shock in pregnancy
CHAPTER 8: Emergencies in early pregnancy (up to 20 weeks)
8.1 Miscarriage
8.2 Cervical shock
8.3 Ectopic pregnancy
8.4 Pre‐hospital management of complications in early pregnancy
CHAPTER 9: Emergencies in late pregnancy (from 20 weeks)
9.1 Hypertension in pregnancy
9.2 Antepartum haemorrhage
9.3 Placental abruption
9.4 Placenta praevia
9.5 Uterine rupture
9.6 Amniotic fluid embolus
9.7 Pre‐hospital management of shock in late pregnancy
CHAPTER 10: Trauma, surgical and medical emergencies
10.1 Cardiac disease in pregnancy
10.2 Epilepsy in pregnancy
10.3 Venous thromboembolism in pregnancy
10.4 Diabetes in pregnancy
10.5 Respiratory disease in pregnancy
10.6 Trauma in pregnancy
10.7 Substance misuse in pregnancy
10.8 Carbon monoxide poisoning in pregnancy
10.9 Rape and sexual assault in pregnancy
10.10 Perinatal psychiatric illness
CHAPTER 11: Normal labour and delivery
11.1 Normal labour and delivery
11.2 Fetal skull
11.3 Stages of labour
11.4 First stage of labour
11.5 Second stage of labour
11.6 Normal mechanism of labour
11.7 Third stage
CHAPTER 12: Complicated labour and delivery
12.1 Preterm labour
12.2 Abnormal presentations and lies
12.3 Breech presentation
12.4 Occipitoposterior position
12.5 Face presentation
12.6 Brow presentation
12.7 Compound presentation
12.8 Transverse and oblique lies
12.9 Multiple pregnancy
12.10 Shoulder dystocia
12.11 Umbilical cord prolapse
12.12 Umbilical cord rupture
12.13 Other cord problems
CHAPTER 13: Emergencies after delivery
13.1 Primary postpartum haemorrhage
13.2 Secondary postpartum haemorrhage
13.3 Trauma to the birth canal
13.4 Acute uterine inversion
13.5 Postpartum infection and puerperal sepsis
13.6 Wound dehiscence
CHAPTER 14: Resuscitation of the baby at birth
14.1 Introduction
14.2 Normal physiology of transition at birth
14.3 Pathophysiology
14.4 Equipment
14.5 Strategy for assessing and resuscitating a baby at birth
14.6 Response to resuscitation
14.7 Tracheal intubation
14.8 Supraglottic airway device
14.9 Preterm babies
CHAPTER 15: Assessment and management of the post‐gynaecological surgery patient
15.1 Hysterectomy
15.2 Laparoscopy
15.3 Large loop excision of transformation zone
15.4 Pelvic floor repair
15.5 Surgical uterine evacuation
15.6 Common complications of gynaecological surgery
Abbreviations
Glossary
References
Further reading
Index
End User License Agreement
List of Tables
Chapter 01
Table 1.1 Roles of healthcare staff
Chapter 03
Table 3.1 Summary of maternal mortality statistics, 2009 to 2014
Chapter 04
Table 4.1 Types of errors
Table 4.2 Elements of communication
Chapter 05
Table 5.1 Ranges of values for laboratory tests
Table 5.2 Summary of key points
Table 5.3 Interpretation of abnormal values
Chapter 07
Table 7.1 Differential diagnosis of shock in the obstetric patient
Chapter 12
Table 12.1 Classification of breech presentations
Chapter 13
Table 13.1 Sepsis: recognition, diagnosis and early management for persons aged 12 years and over.
List of Illustrations
Chapter 01
Figure 1.1 Example of national patient hand‐held records.
Chapter 04
Figure 4.1 The ‘Swiss cheese’ model
Figure 4.2 Similar package design of two different medications
Chapter 05
Figure 5.1 Full left lateral position
Figure 5.2 Patient in RIGHT lateral position to avoid facing saloon wall
Chapter 06
Figure 6.1 Obstetric primary survey – global overview
Figure 6.2 Estimating obstetric blood loss. *Multidisciplinary observations of estimated blood loss revealed that scenarios (e–f) are grossly underestimated (>30%).
Figure 6.3 Fundal height estimation
Figure 6.4 Patient in semi‐recumbent position
Figure 6.5 Patient on spinal board with left lateral tilt
Chapter 07
Figure 7.1 Manual uterine displacement (‘cupping’ technique)
Figure 7.2 Manual uterine displacement (push technique)
Figure 7.3 Advanced life support algorithm.
Figure 7.4 Shock algorithm
Chapter 08
Figure 8.1 Possible sites of ectopic implantation
Chapter 09
Figure 9.1 Management of convulsions in pregnancy
Figure 9.2 (a) Concealed abruption: here all of the bleeding is under the placenta, pain is significant and the uterus tender, with no revealed bleeding. (b) Placental abruption where bleeding is most revealed
Figure 9.3 Major placenta praevia: low lying placenta
Chapter 10
Figure 10.1 Correct and incorrect seatbelt wearing
Chapter 11
Figure 11.1 Anatomy of the female pelvis
Figure 11.2 Anatomy of the fetal skull
Figure 11.3 Internal rotation
Figure 11.4 (a) Extension and (b) internal rotation
Figure 11.5 Axial traction
Figure 11.6 Change in direction of axial traction
Figure 11.7 Cutting the cord
Chapter 12
Figure 12.1 Most common lies
Figure 12.2 Most common presentations
Figure 12.3 Most common positions
Figure 12.4 Manual rotation into the sacroanterior position
Figure 12.5 Flexion of the knee and abduction of the hip
Figure 12.6 Løvset’s manoeuvre
Figure 12.7 Adapted Mauriceau–Smellie–Veit manoeuvre
Figure 12.8 Extended head or nuchal arms
Figure 12.9 Algorithm for breech birth
Figure 12.10 Mentoanterior face presentation
Figure 12.11 Mentoposterior face presentation
Figure 12.12 (a) McRobert’s manoeuvre; (b) McRobert’s with suprapubic pressure
Figure 12.13 ‘All fours’ position
Figure 12.14 Delivery of the shoulder that is nearer the maternal back (mother in ‘all fours’ position)
Figure 12.15 Trendelenburg position
Chapter 13
Figure 13.1 ‘Rubbing up’ a uterine contraction: the left hand is cupped over the uterus and massages it with a firm, circular motion in a clockwise direction
Figure 13.2 Bimanual uterine compression
Figure 13.3 Replacing an inverted uterus
Chapter 14
Figure 14.1 Response of a mammalian fetus to total, sustained asphyxia starting at time 0.
Figure 14.2 Effects of lung inflation and a brief period of ventilation for a baby born in early terminal apnoea but before failure of the circulation.
Figure 14.3 Response of a baby born in terminal apnoea. In this case lung inflation is not sufficient because the circulation is already failing. However, lung inflation delivers air to the lungs and then a brief period of chest compressions ( CC) delivers oxygenated blood to the heart, which then responds. IPPV, intermittent positive pressure ventilation.
Figure 14.4 Neutral position in babies
Figure 14.5 Airway opening in a newborn
Figure 14.6 Hand‐encircling technique
Figure 14.7 Newborn resuscitation algorithm.
Guide
Cover
Table of Contents
Begin Reading
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Pre‐Obstetric Emergency Training
A Practical Approach
SECOND EDITION
Advanced Life Support Group
EDITED BY
Mark Woolcock
This edition first published 2019 © 2019 by John Wiley & Sons Ltd
Edition HistoryWiley‐Blackwell (1e, 2009)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
A catalogue record for this book is available from the Library of Congress and the British Library.
9781119348382
Cover images: © ideabug/iStockphoto; Jade and Bertrand Maitre/Getty Images; sturti/Getty Images; Mark Woolcock, NHS Cornwall 111Cover design by Wiley
Note to text
Drugs and their doses are mentioned in this text. Although every effort has been made to ensure accuracy, the writers, editors, publishers and printers cannot accept liability for errors or omissions. The final responsibility for delivery of the correct dose remains with the practitioner administering the drug.
Working group
Sam Fournier
Paramedic, Educator, Ecole Supérieure d'Ambulancier et Soins d'Urgence Romande, Lausanne, Switzerland
Kim Hinshaw
FRCOG
Consultant Obstetrician and Gynaecologist, Director of Research & Innovation, City Hospitals Sunderland NHS Foundation Trust
Visiting Professor, University of Sunderland
Paul Holmes
MRCOG
Consultant Obstetrician and Gynaecologist, NHS Forth Valley
Denise Mace
MSc Advanced Clinical Practice, BSc(Hons) Midwifery
Delivery Suite Coordinator, City Hospitals Sunderland NHS Foundation Trust
Faye Rodger
FRCOG
Consultant Obstetrician and Gynaecologist, NHS Borders
Fiona Scarlett
BSc (Hons) Healthcare Practice, MCPara
Emergency Practitioner (Paramedic), Surrey and Sussex Healthcare NHS Trust
Helen Simpson
MRCOG
Consultant Obstetrician, South Tees Hospitals NHS Foundation Trust
Martin Smith
FRCEM
Consultant Emergency Medicine, Salford Royal NHS Foundation Trust, Salford
Martin Thomas
MD FRCS(A&E)Ed. MRCP FRCEM
Consultant in Emergency Medicine, Emergency Department, Salford Royal NHS Foundation Trust, Salford
Aarti Ullal
MRCOG
Consultant Obstetrician and Gynaecologist, City Hospitals Sunderland NHS Foundation Trust
Susan Wieteska
CEO, Advanced Life Support Group, Manchester
Mark Woolcock
Consultant Paramedic, Cornwall
Contributors
Contributors to second edition
Sally Buller
Registered Nurse RM Registered Midwife RM
Senior Specialist Midwife/Project lead for Maternity notes, Perinatal Institute
Brigid Hayden
FRCOG
Obstetrician & Gynaecologist, Member of MOET Working Group, Member of POET Working Group
Amanda Mansfield
Consultant Midwife
Medical Directorate, London Ambulance Service
Jonathan Wyllie
FRCPCH FRCP
Professor of Neonatology and Paediatrics, University of Durham
Consultant Neonatologist, Clinical Director of Neonatology, South Tees NHS Foundation Trust
Vice President Resuscitation Council UK
Contributors to first edition
Sally Evans
Midwifery,
Middlesbrough
Kim Hinshaw
Obstetrics and Gynaecology,
Sunderland
Helen Simpson
Obstetrics and Gynaecology,
Middlesbrough
Mark Woolcock
Pre‐Hospital Care,
Truro
Malcolm Woollard
Pre‐Hospital Care,
Coventry
Jonathan Wyllie
Neonatology,
Middlesbrough
Dedication
With thanks to our families and friends for their tolerance, support and understanding during the review and rewriting of this second edition manual and its associated course.
Foreword to second edition
I am privileged to have been asked to write this introduction to the second edition of the POET manual. Over the last 9 years POET has offered pragmatic advice and skills training to a wide range of practitioners working in the pre‐hospital environment. The manual and course encompass the full range of situations found in maternity care, from normal delivery to complex antenatal and intrapartum complications which put both the mother and fetus at risk.
In total more than 1500 professionals have benefited from this training and this has included paramedics, ambulance technicians, midwives, emergency department teams, primary care physicians and others. The first edition of the manual has been translated into Polish (2011) and Japanese (2014) and courses are run regularly in the UK, the Netherlands and Switzerland under the auspices of the Advanced Life Support Group (ALSG), Manchester, UK. The Working Group is also multi‐national with members from across the UK and Europe. Experienced faculty now includes ambulance personnel working closely with obstetricians, neonatologists and midwives to deliver high‐quality practical training to increase both confidence and skills to the multidisciplinary team in the pre‐hospital setting. The dedication of faculty ensures the ongoing success of the course, with many teaching enthusiastically in their own time.
The manual has been comprehensively updated. It now includes a review of the UK maternal mortality reports produced annually by MBRRACE (https://www.npeu.ox.ac.uk/mbrrace‐uk) and highlights the importance of non‐technical skills (clear communication, decision making and team working) in the area of pre‐hospital maternity care. This new edition continues to offer clear and practical advice to all professionals involved in pre‐hospital maternity care – congratulations to the wider POET team.
Kim Hinshaw FRCOGConsultant Obstetrician & Gynaecologist; Director of Research & InnovationCity Hospitals Sunderland NHS Foundation TrustVisiting ProfessorUniversity of Sunderland2018
Acknowledgements
Many people have worked hard to produce this book and the accompanying course. The editor thanks all the contributors for their efforts and all POET providers and instructors who took the time to send their comments during the reviews of the text and the course, in particular Brigid Hayden who completed a very detailed review of the manual.
We are all greatly indebted to Kate Wieteska for producing the line drawings that illustrate the text, and Kirsten Baxter at ALSG for her support and organisational skills. We thank the ALSG/CAI Emergency Maternal and Child Health (EMCH) programme, the ALSG Managing Obstetric Emergencies and Trauma (MOET) course and the Resuscitation Council for the shared use of some of their line drawings and algorithms. We gratefully acknowledge the written information and guidance received from the Perinatal Institute. Also, we thank the Consultant Midwife Amanda Mansfield from London Ambulance Service and Matthew Davis Clinical Fellow in Primary Care from South Western Ambulance Service for sharing their organisations’ photographs.
We would like to thank all of those in advance who attend the POET course and others using this text for their continued constructive comments regarding the future development of both the course and the manual.
Preface to second edition
2009…
Looking back at the preface to the first edition, a clear picture was painted depicting a distinct gap in the paramedic curriculum and the paucity of exposure to bespoke obstetric training and education. The 2009 manual was thus intended to support those working in the pre‐hospital arena. The principles were set firmly in the didactic realms of paramedic practice and whilst this assisted those working in the 999 services, it had less appeal to other healthcare professionals working in unscheduled and urgent care settings, and an increasing amount who worked ‘in‐hospital’.
Some 9 years later, the paradigmatic shift of paramedic education from in‐house training schools to academic institutions is producing highly autonomous, degree‐educated practitioners who demand detailed, evidence‐based texts and materials to underpin focused learning.
Concurrently, the centralisation of obstetric services has placed an increasing requirement on Emergency Department staff to manage patients with obstetric emergencies without any specialised cover. The need has never been greater for a multidisciplinary course that prepares healthcare professionals to promptly recognise and effectively manage a wide range of obstetric emergencies.
Now…
As hinted above, the term ‘pre‐hospital’ in the title of the manual and course suggested a narrow field of practice. The working group has spent many hours debating what the most descriptive title would be, enabling immediate acknowledgement of what and whom this manual is for. It was tremendously difficult to settle on a title that recognises midwives, paramedics, nurses and doctors, who may encounter patients in their own houses, in ambulances or in hospitals without any obstetric services. It was decided that the term ‘pre‐obstetric emergency training’ was most encompassing and would provide guidance for managing patients when no obstetric staff or facilities were available.
The future…
The face of modern healthcare is changing rapidly. In primary care and out‐of‐hours services, the models are now GP lead as opposed to exclusively GP delivered and the use of advanced nurse and paramedic practitioners is burgeoning. It is expected that within the next 5 years one‐third of all registered paramedics will be working outside of ambulance trusts in a range of settings and roles never previously associated with this profession.
The second edition manual, the updated course and powerful e‐learning have all been updated and revamped to assist the modern generalist clinician develop confidence when dealing with specialist situations, building a foundation for future safe practice.
Mark Woolcock2018
Preface to first edition
Pre‐hospital obstetric incidents make up a significant proportion of the more costly litigation claims against UK ambulance services. These claims are based either on an alleged failure to identify and manage a problem or lack of appropriate equipment for the treatment of a preterm baby.
For a number of years after the UK national paramedic curriculum was introduced in the UK, it included no specific training on the management of obstetric emergencies at an ‘advanced life support’ level. Most staff received only a half‐day of lectures during their initial ambulance technician training at the beginning of their career. Since 1999, advanced obstetrics and gynaecology became a mandatory part of the paramedic course for new entrants but with the expectation that existing paramedics would receive update training. Our experience has indicated, however, that paramedics in many parts of the UK have not had the opportunity to do so.
A confidential enquiry into maternal and child health (CEMACH) report has indicated that many of the pregnant women dying ‘had chaotic lifestyles and found it hard to engage with maternity services’. The ambulance service may be the initial contact with the health service for these patients and their peers who become unwell but are fortunate enough to survive. The CEMACH report identifies the need for a widened awareness of the risk factors and early signs and symptoms of potentially serious problems in pregnancy, and makes a number of key recommendations that could be addressed in part by appropriately trained pre‐hospital practitioners. For example, it states:
All clinical staff must undertake regular, written, documented and audited training for:
The identification, initial management and referral for serious medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers
The early recognition and management of severely ill pregnant women and impending maternal collapse
The improvement of basic, immediate and advanced life support skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies
There is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance.
This manual and its associated Advanced Life Support Group training course (also called POET) hope to meet these educational needs for a range of pre‐hospital practitioners. Both the text and the course have been developed by a multi‐disciplinary team of senior paramedics, consultant obstetricians and midwives, all of whom are practicing clinicians and experienced educators. POET course teaching teams have a similar multi‐professional membership with a shared philosophy of combining pre‐hospital and obstetric expertise. Although we anticipate that paramedics and pre‐hospital physicians will make up the bulk of our readership and course candidates, POET will also be of value to nurses working in walk‐in and unscheduled care centres and to midwives and to GPs – particularly those working at a distance from further support.
It is our sincere hope that POET will build the confidence and competence of pre‐hospital practitioners and thus contribute to reducing the incidence of maternal and fetal mortality and morbidity.
Malcolm WoollardHelen SimpsonKim HinshawSue WieteskaNovember 2009
Contact details and website information
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:Advanced Life Support GroupALSG Centre for Training and Development29–31 Ellesmere StreetSwinton, ManchesterM27 0LATel: +44 (0) 161 794 1999Fax: +44 (0) 161 794 9111Email: [email protected]
Updates
The material contained within this book is updated on approximately a four‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for updates (www.alsg.org/uk/poet).
References
To access references visit the ALSG website www.alsg.org – references are on the course pages. To access country‐specific Legal and Ethical Issues for POET, visit the ALSG website www.alsg.org/legal.
On‐line feedback
It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after his or her course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.
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CHAPTER 1Obstetric services
Learning outcomes
After reading this chapter, you will be able to:
Discuss the relationship between the different professional groups involved in the management of the obstetric patient
Describe the function and importance of hand‐held records and how to use them effectively
1.1 Organisation of obstetric services, epidemiology of obstetric emergencies and role of the ambulance service, general practitioner and midwife
Organisation
Around 700 000 women a year use obstetric services. The birth rate in the United Kingdom (UK) has slowed in recent years following a rise throughout the last decade. Multidisciplinary teams provide maternity services with midwifery and obstetric medical staff working together to provide optimal care. Community midwives perform the majority of care in the out‐of‐hospital setting. Inpatient antenatal care is now uncommon and not usually for long periods. Similarly, the postnatal length of stay for all women, including those delivered by caesarean section, has been reduced with the majority of care occurring in the community.
General practitioners (GPs) have in recent years become less and less involved in all aspects of pregnancy care, although there are still a small number who are involved in care in labour.
Place of delivery
The Maternity Matters report confirmed that women should be the central focus of obstetric care, emphasising the need for those providing obstetric services to support women in making informed choices and to provide easy access to care (DoH, 2007). Women undergo a risk assessment prior to delivery to help them choose where to deliver. This assessment is undertaken by their midwife in conjunction with medical staff, if required, and will involve assessment of previous medical history, previous obstetric history and the progress of the current pregnancy. The women will then be offered advice to help them choose the place of birth.
A woman may choose to have a home birth; deliver in a midwife‐led unit, which may be either ‘stand‐alone’ or attached to a consultant‐led unit (co‐located); or deliver in a consultant‐led unit. Women may also choose to ‘free birth’: a growing phenomenon in which the baby is delivered unassisted and unattended by a healthcare professional. Whilst this is perfectly legal, one should note it is illegal for someone without midwifery qualifications to assist in the birth unless in an emergency.
The 2011 Birthplace in England study identified that nulliparous women (those having their first baby) were more at risk for adverse perinatal outcomes (stillbirth, neonatal encephalopathy, brachial plexus injury, clavicle fracture, etc.) with a planned home birth than multiparous women (BECG, 2011). There was no statistical increase in risk for adverse outcomes for nulliparous women delivering in a midwife‐led unit. It was found that for multiparous women, there is no increased risk for adverse outcomes between each planned place of delivery. It was also found that women who plan to deliver at home or in a midwife‐led unit are more likely to have a ‘natural’ birth with reduced interventions compared with those who deliver in an obstetric unit. Choosing an appropriate place of delivery relies on effective communication between healthcare professionals and women regarding any specific risk factors.
In the majority of cases, women choose the appropriate place to deliver their baby. Midwives have a duty of care to support the woman’s final choice of place for delivery even if there are factors that make this a high‐risk decision. Occasionally this causes difficulties, for example, in home delivery where access is poor, there is no phone signal or the home environment is less than ideal. Some women with a high‐risk pregnancy also request home delivery. As long as the woman has capacity (see Chapter 2), is informed of the risks to herself and her baby and is not under duress, she is entitled to make that decision.
Mode of delivery
The majority of deliveries are uncomplicated, however the national caesarean section rate is 26.2% of births. In contrast, the rate in 1990 was only 12%. Caesarean section delivery requires major surgery and can have significant associated risks for both mother and baby.
Common pre‐hospital emergencies
Labour +/− delivery (term or preterm)
Bleeding antenatally or postnatally (including miscarriage) and postoperative vaginal haemorrhage
Abdominal pain other than labour
Pre‐eclampsia and eclampsia (this is now less common: 2:10 000 cases due to the use of magnesium sulphate in hospital in at‐risk cases; however, this does mean that one of the more common places to have a convulsion will be in the community)
Prolapsed umbilical cord
Transfer
Transfer may be necessary where risk factors develop before or during labour and after birth that necessitate moving the woman or baby from one location to another. Transfer may be required from all places of delivery.
In the 2011 Birthplace in England study, it was found that for the three non‐obstetric unit settings (home, stand‐alone midwifery unit and co‐located midwifery unit), transfer rates were much higher for nulliparous women (36–45%) than for multiparous women (9–13%).
Common reasons for transfer from home or from a midwife‐led unit are concerns about the progress of labour, fetal or maternal well‐being, or neonatal well‐being. A common reason for transfer between consultant‐led obstetric units is the need to access a neonatal cot for the baby either because the unit they are in does not have the appropriate neonatal facilities or all the cots are full. In these situations, the outcome is better for the baby if they are transferred while still in utero rather than after delivery. Occasionally, women need to be moved to other units for maternal specialist care.
Generally, a midwife (or medical staff) will accompany the woman and will be an invaluable source of advice and knowledge if problems occur during transfer. See Table 1.1 for the roles undertaken by clinical staff.
Table 1.1 Roles of healthcare staff
Paramedic
Midwife
GP (if on scene)
Obstetrician (via telephone)
Clinical condition
Assess
Assess
Assess
Initiate holding treatment
Advanced life support (ALS) Obstetric support
Assist with ALS Obstetric expertise
Assist with ALS Obstetric support
*
Advise on treatment
Transfer
Provide transportation Liaise with receiving unit Confirm exact location of receiving obstetric unit within hospital
Advise on most appropriate receiving unit Liaise with receiving unit Advise on timing/need for transfer
Advise on most appropriate receiving unit Liaise with referring crew Advise on timing/need for transfer
Advice
Transportation options/positioning in the ambulance
Obstetric expertise
General issues
Obstetric expertise
*Some GPs have specific expertise in obstetrics.
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Many features of the clinical management of an obstetric patient during secondary transfer are similar to that required in the home or during primary hospital admission. For example, remember to transport the patient who is unable to maintain their own position in the 15–30° left lateral tilt position or manually displace the uterus.
Further information on the management of inter‐hospital transfers generally and neonatal transfers specifically can be found in the Neonatal Adult Paediatric Safe Transfer and Retrieval (NAPSTaR) manual (Fortune et al., 2019).
Admissions procedures
These depend on local policies. Obstetric patients are usually admitted directly to the obstetric service via a triage assessment unit or delivery suite. In the case of major trauma, obstetric patients should be transferred to the emergency department or major trauma centre depending on the systems in place locally. In the case of medical problems admit via urgent care pathways.
In many units, women with problems in early pregnancy will be admitted to the gynaecology department via an early pregnancy assessment unit.
1.2 Using patient hand‐held notes
Most maternity units in the UK provide women with their own maternity hand‐held notes. Figure 1.1 shows an example of the national pregnancy notes that are currently used by approximately 60% of obstetric units in England (produced by the Perinatal Institute www.preg.info; accessed February 2018).
Figure 1.1Example of national patient hand‐held records.
(Reproduced with kind permission of the Perinatal Institute)
The pregnancy notes aim to facilitate a partnership between the mother, her family and the care provider, placing emphasis on patient safety and informed choice. They are designed to ‘support comprehensive history taking, promote effective communication between the mother and the multidisciplinary care team and between members of that team’. The notes are given to the woman by her midwife at her booking appointment in early pregnancy, enabling the expectant mother and her family to be informed and involved in decisions that affect her and her baby. To deal with special issues during pregnancy, a personalised management plan will outline specific outline specific treatment and care agreed between the mother and her care team. This plan will be reviewed at each antenatal contact and updated if the mother’s risks/needs change.
The woman’s medical/obstetric and social details are available to all healthcare professionals who may care for her during her pregnancy.
The notes enable effective communication within the multidisciplinary team, including ambulance clinicians who may attend the woman in her home or the community. All clinicians should document clinical care in these notes when they attend a woman during pregnancy if she is not transferred. Contemporaneous record keeping is a fundamental component of good clinical practice. Therefore the hand‐held pregnancy notes are an important link for healthcare professionals to improve care and reduce error.
Although there is variation in maternity hand‐held notes throughout the UK, the same general principles apply throughout:
The front cover will display the woman’s name, address, named midwife, consultant and GP, next of kin and emergency contact
Information within the notes for the woman to read, including appropriate support groups/advice line numbers, screening tests, pregnancy complications and routine visits
The notes will identify whether the woman is on the low‐ or high‐risk pathway of care. This is dependent on factors identified at the beginning of the pregnancy. The pathway may change during the pregnancy if complications arise, e.g. gestational diabetes, pre‐eclampsia, obstetric cholestasis
The antenatal section will display all screening tests/investigations performed, routine antenatal visits, scan results and fetal growth monitoring
There will be a section for the woman to complete a birth plan, in discussion with her midwife
There is a labour and postnatal section, which also includes detailed information regarding the baby, such as condition at birth, findings on the neonatal examination and details on feeding
Most hand‐held notes have an alert/special features section
. This will identify any complications or potential complications, and may show a plan of care to address these complications. A plan of care could also be documented in the management plan section.
Any healthcare professional can and should annotate this page
There will be a section for correspondence between healthcare professionals, identifying potential problems and formulating plans of care.
Any healthcare professional can and should annotate this page
Ambulance clinicians attending an obstetric patient who has not been transported to hospital should leave a copy of their patient report form in the hand‐held records. If a written or printed copy cannot be left, the hand‐held notes must be annotated
It is paramount that the hand‐held notes accompany the woman for all hospital admissions and routine antenatal visits. However, the notes may not have been issued to a woman in very early pregnancy if she has not booked through her midwife.
Summary of key points
It is important that you are aware of the roles of other healthcare professionals in the care of the obstetric patient
Remember that any health professional can and should annotate the alert page in the patient’s hand‐held notes
CHAPTER 2Legal and ethical issues
Learning outcomes
After reading this chapter, you will be able to:
Discuss the impact of obstetric‐related incidents on litigation claims
Describe the principles of gaining consent from adult patients and minors
Discuss the principles of maintaining patient confidentiality and the legal context
Debate the appropriateness of recognising death in obstetric cases
State the common causes of complaints
Define clinical negligence and describe the components necessary to demonstrate its proof
Discuss the impact of varied cultural issues on the provision of obstetric care in the pre‐hospital setting
State the professional responsibilities of pre‐hospital practitioners
This chapter outlines the principles involved in law and ethics. The specifics of legal and other frameworks for specific countries is available on‐line (www.alsg.org/uk/le).
2.1 Impact of litigation claims
The NHS Litigation Authority (NHSLA) report Ten Years of Maternity Claims (NHSLA, 2012) identified that maternity claims were the second largest group of claims and accounted for the highest value (49%) of the total value of claims under the Clinical Negligence Scheme for Trusts (CNST). A significant proportion of the more costly litigation claims made against UK ambulance services arise from pre‐hospital obstetric incidents. Although in a 10‐year period, obstetric cases consisted of only 13 of the total 272 claims, the average value of these cases was £815 000. Four were valued at more than £1 million. Claims were based on either an alleged failure to identify and manage a problem or a lack of appropriate equipment for the treatment of a preterm baby. The largest claim was for £3 375 000 and related to an alleged lack of equipment to care for a baby born at 26 weeks (Dobbie and Cooke, 2008).
Although the numbers of women and babies dying as a result of obstetric emergencies in the UK are small, some of these deaths might be prevented if effective training in the prompt recognition and management of these cases is undertaken by pre‐hospital providers (Woollard et al., 2008). Although it could be argued that antenatal provision of preventative obstetric care is more effective than treating problems after they arise, the Confidential Enquiry into Maternal and Child Health (CEMACH) report of 2007 suggested that many of the pregnant women who died ‘had chaotic lifestyles and found it hard to engage with maternity services’ (CEMACH, 2007a). One of its ‘top ten’ recommendations stated:
All clinical staff must undertake regular, written, documented and audited training for the
Identification, initial management and referral for serious medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers
Early recognition and management of severely ill pregnant women and impending maternal collapse
Improvement of basic, immediate and advanced life support skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies
There is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance (CEMACH, 2007a).
All registered healthcare professionals are ultimately responsible for identifying and achieving their own training needs and maintaining their own competence. This extends into post‐registration training and particularly through continuing professional development activity. A strong motivation for doing so, other than the obvious one of being able to meet patients’ needs, is individual accountability for practice. A failure to provide acceptable standards of care not only risks the patient’s welfare but also challenges the practitioner’s fitness to practice and their right to maintain professional registration. Although obstetric emergencies are rare, the consequences of mishandling them can be particularly severe for mother and baby, as well as for the pre‐hospital practitioner.
2.2 Consent and capacity
Healthcare professionals should understand the legal framework within their field of practice, including:
The legal rights of the mother
The legal rights of the fetus
The legal rights of the child
Consent prior to providing treatment: in particular informed consent and the capacity of the patient to give this. Check the legal framework in your organisation for details of express, implied or presumed consent and ensure that you fulfil the requirements with regard to obtaining this and documenting it
There are often specific caveats in the legal framework where patients are unable to consent and their situation is life threatening. It is important that you understand how this works in your domain.
Capacity and competence of mothers who are minors is a further area that should be well understood by practitioners.
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For consent to be valid the following must pertain:
Consent must be given voluntarily
There should be no duress
The patient must have capacity
Any information regarding risks, benefits, side effects and alternatives must be presented in order that the patient can make an informed decision
The patient must be able to communicate their choice
When obtaining consent from women in labour, take care if they are in pain or under the influence of narcotic analgesics (RCOG, 2015a).
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Remember – patients are allowed to withdraw consent to treatment at any time.
2.3 Confidentiality
All healthcare practitioners have both a professional and a legal duty of confidentiality to their patients.
Guidance and frameworks are produced by relevant professional bodies, employers and data protection legislation.
These apply to all forms of records, not just those stored on computer media.
Consider confidentiality when providing a handover in the emergency department or obstetric unit – never verbally present such information in the presence of relatives or anyone else without the patient’s consent. Be particularly vigilant when passing information to colleagues via telephone or radio in the pre‐hospital setting.
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When considering confidentiality, you should:
Take all reasonable steps to keep a patient’s information safe
Obtain the patient’s informed consent if you are passing on their information
Only disclose identifiable information if it is absolutely necessary, and, when it is necessary, only disclose the minimum amount necessary
Tell patients when you have disclosed their information
(Adapted from HCPC,2012.)
2.4 Recognition of death
The recognition of death is an integral part of healthcare professional practice. Usually, the ‘recognition of life extinct’ or ‘confirmation of death’ status is applied when a patient meets the criteria for not attempting cardiopulmonary resuscitation or where attempts at cardiopulmonary resuscitation have failed. Additionally, an advanced decision to refuse treatment or a decision to withdraw life‐sustaining treatment may also have been made.
The main aim of perimortem caesarean section (also known as resuscitative hysterotomy) is to increase the woman’s cardiac output, thereby improving her chances of survival. Delivery of a live infant may, or may not, also occur. Similarly, in the absence of gross deformities incompatible with life, practitioners should initiate and continue resuscitation attempts for babies that have no signs of life after delivery until handover to emergency department staff.
2.5 Medical errors and negligence
All serious untoward events or potential serious untoward events (‘near misses’) should be reported in accordance with the employer’s policy for incident reporting. This ensures that lessons can be learned from mistakes and changes made to training, policy or systems to avoid them being repeated.
Measures are often in place to facilitate lessons learned at the local level being applied on a national scale and this forms an important part of quality control in health services.
All healthcare practitioners are regularly required to deal with situations or people that they consider unpleasant or difficult. If a practitioner inadvertently offends someone, they should use the highly effective strategy of apologising. However, practitioners should not admit to making a clinical error without first taking further advice.
In the event of a complaint being received, practitioners should know the local and national standards set up to handle them, and in particular the time scale within which a response should be provided. They should also understand the appeals process that should be made available to the complainant should they be unhappy with the response.
As has been implied previously, pre‐hospital practitioners are accountable for their clinical acts, as well as any clinical omissions. A negligent practitioner is one who has:
Failed to exercise that degree of care which a person of ordinary prudence with the same or similar training would exercise in the same or similar circumstances.
(Woollard and Todd, 2006)
The case of Bolam v. Friern Hospital Management Committee (1957) established the precedent that to avoid being considered negligent, a practitioner should provide care to ‘the standard of an ordinary man professing to have that special skill …’.
2.6 Cultural issues
Pre‐hospital healthcare providers should consider themselves as guests in their patients’ homes (or lives). As such they should respect the cultural values of the patients they are asked to attend. They should not expect patients to adhere to other people’s personal values.
In many communities it is not normal or acceptable for women to be examined by men, and this can be particularly difficult for patients in the context of gynaecological and obstetric emergencies. Wherever possible, female practitioners should be available to care for such patients and circumstances may require that male providers are not present when intimate examinations or procedures take place. If male practitioners are tempted to take offence in such situations, they should remember that patients have the right of autonomy and self‐determination and if such a compromise is necessary to obtain consent to treatment this is well within the patient’s rights. If no female practitioners are readily available in an emergency situation, male practitioners should explain the procedures that need to be carried out, and the consequences of delaying them, but ultimately a competent patient has the right to decline them.
2.7 Professional accountability
Registered healthcare practitioners are personally accountable to their registrant body for the care that they provide to patients and have a number of responsibilities set out in their respective codes of conduct. These are similar across professional groups, but the following list is taken from the Health and Care Professions Council’s Standards of Conduct, Performance and Ethics (HCPC, 2016):
You must promote and protect the interests of service users and carers
You must communicate appropriately and effectively
You must work within the limits of your knowledge
You must delegate appropriately
You must respect confidentiality
You must manage risk
You must report concerns about safety
You must be open when things go wrong
You must be honest and trustworthy
You must keep records of your work
2.8 Documentation
A continual thread through this chapter – as well as in following chapters – reminds the practitioner of the importance of accurate and robust clinical documentation. After any patient consultation, which may be either face‐to‐face, over the telephone or even when providing advice to a colleague, a record should be made either in writing or electronically in the patient’s notes. This includes the ambulance patient care record (electronic or paper), the out‐of‐hours GP record or the patient’s hand‐held notes.
If the patient is not hospitalised, their patient record should be updated and, where possible, a copy of any written or printed notes included. If a patient is transferred to hospital it is entirely acceptable to complete the patient record after the handover, particularly when managing a clinically unstable patient.
The most important factor is not when the notes were written, but what was recorded. Always strive to maintain the highest level of clinical documentation, as this supports safe and effective patient care. This is not only a requirement of professional registration, but it may also help in your defence against a complaint or allegation of poor practice.
MBRRACE‐UK provided a ‘very strong recommendation’ to ambulance services around patient positioning during transfer with respect to relieving aortocaval compression, and specifically the need to document the woman’s position and whether any tilt was used during the journey (MBRRACE‐UK, 2014). See Chapter 3.
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Clinical documentation should:
Be written in a clear, accurate and legible manner
Record whether consent was obtained or not
Detail all clinical findings, decisions made and actions taken
