labour ward manual

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EDITORIAL COMMITTEE

CHAIRMAN


* Dr Haris Njoo Suharjono FRCOG

MEMBERS

* Dr Rafaie Amin M MED O&G
* Dr Nicholas Ngeh MRCOG
* Dr Edawati Dahrawi Edrus M MED O&G
* Dr Sim Wee Wee MRCOG
* Dr Sukanda Jaili M MED O&G
* Dr. Lim Soon Hock MRCOG




























Updated 7.2.2012

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CONTENTS

1
Editorial Committee


2.
LR Protocol

2.2 Basic care

2.2.1 Documentation

2.2.2 Guidelines on general safety precautions

2.2.3 MOH Color code for high risk obstetric screening
2.2.4 Caesarean section - consent

2.2.5 Caesarean section - prophylaxis for acid aspiration

2.2.6 Ultrasound scan during labour


2.2.7 Thromboprophylaxis in pregnancy & puerperium

2.2.7.1 Guidelines for thromboprophylaxis in vaginal
deliveries

2.2.7.2 Guidelines for thromboprophylaxis in caesarean
sections.
2.2.7.3 Guidelines for prophylaxis again thromboembolism
pregnancy and puerperium
2.2.7.4 Guidelines for epidural anaesthesia in women
receiving heparin thromboprophylaxis


2.3 Pregnancy problems

2.3.1 PIH/PE
1.3.2 Antihypertensive therapy

1.3.2.1 Hydralazine Infusion Regime

2.3.2.2 Labetalol Infusion Regime

1.3.3 Eclampsia

1.3.3.1 Magnesium Sulphate Regime

2.3.3.2 Diazepam Infusion Regime


2.3.4 HELLP Syndrome

2.3.5 Cardiac Disease in Pregnancy

2.3.6 Bronchial Asthma woman in labour

2.3.7 Diabetic mother in labour

2.3.8 Rhesus negative mother

2.3.9 HIV in pregnancy

2.3.10 Breech/ECV
2.3. l1 Twins in labour

2.3.12 Trial of scar

2.3.13 Intrauterine death


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2.4
Childbirth
2.4.1 Induction of labour

2.4.1.1 Cervical scores

2.4.1.2 Augmentation of labour

2.4.1.3 Oxytocin augmentation / induction regime


2.4.2 Management of first stage of labour

2.4.3 Management of second stage of labour

2.4.4 Fetal monitoring in labour

2.4.5 Pain relief in labour

2.5
Childbirth problems

2.5.1 Episiotomy

2.5.2 Repair of cervical tears

2.5.3 Repair of vaginal and perineal tears

2.5.4 Instrumental delivery

2.5.5 Management of retained placenta

2.5.6 Preterm prelabour rupture of membranes

2.5.7 Prelabour rupture of membranes

2.5.8 Perinatal Group B Streptococcus Infection Prevention
2.5.9 Preterm labour


2.5.9.1 Tocolytic for preterm labour

2.5.9.2 Tocolytic regime: Ritrodrine

2.5.9.3 Tocolytic regime: Salbutamol

2.5.9.4 Tocolytic regime: Terbutaline

2.5.9.5 Tocolytic regime: Indomethacin

2.5.10 Antepartum haemorrhage

2.5.10.1 APH: Abruptio placenta

2.5.10.2 APH: Placenta praevia


2.5.11 Postpartum haemorrhage

2.5.12 Guidelines for transfusion in massive blood loss

2.5.13 Disseminated intravascular coagulation

2.5.14 Uterine inversion

2.5.15 Cord prolapse

2.5.l6 Shoulder dystocia

2.5.17 Acute fetal distress in labour







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3. Appendices for quick reference

3.1
Hydralazine infusion regime

3.2
Labetalol infusion regime

3.3
Magnesium Sulphate therapy

3.4
Diazepam infusion regime

3.5
Oxytocin augmentation / induction regime

3.6
Salbutamol regime

3.7 Heparin infusion regime

3.8
Red Alert

3.9
Indications for Pediatric referral

3.10 Indications for Caesarean Section
3.11 Guideline for Dating Ultrasound

Essential contact number
4.1
Contact numbers of Consultants / Specialists /
Medical Officers

4.2
Important extension numbers


























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DOCUMENTATION
ADMISSION CLERKING SHEET (88.H314.01)
1. All columns must be filled
2. Identified risk factors - write in RED
3. Ensure recording of salient information - such as blood group / rhesus factor
The follow up notes form is designed to allow recording of information of a particular
antenatal visit in a SINGLE row. Record new and current information obtained during a
particular visit.
WARD NOTES
1. Each review should include complaints, findings, results, assessment, diagnosis
working diagnosis and plan of management. In booked cases, this plan should be
stated clearly in the notes.
2. Specialist input is required in all patients with risk factors
3. All entry in the case notes must include:

3.1 Date (include the year)
3.2 Time (use the 24 hour clock)

3.3 Signature and name clearly printed or stamped
4. Self- inking rubber stamp is recommended (Compulsory for all house officers).
5. House officers to write "H.O" below their names.
6. When notes are written on behalf of others, the names of the senior doctor should
head the entry
6.1 S/B: SEEN BY
6.2 D/W: DISCUSSED WITH
6.3 S/W: SEEN WITH
7. Entry on behalf of the head of department / unit should be written in red.
8. Each review should include a short note regarding the case, salient features, risk
factors and working diagnosis.
9. Every patient who is admitted to the ward must have a written plan of management.




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OBSTETRIC OPERATIVE NOTES
1. Completeness is the responsibility of the surgeon.
2. Names of doctors should be in full.
3. All notes must end with the name and signature of the person writing the notes.
4. Blood loss 500ml and more must be written in red and include term 'PPH '.
5. Post operative orders should be tailored to the case including relevant investigations.
6. HPE Forms:

6.1 Must contain a short case summary of the patient.
6.2 Specimen must be identified and described correctly.
6.3 The name of the doctor requesting the examination should be that of the
Surgeon.
6.4 If the house officer writes the form, his/her name should follow that of the
Surgeon.
6.5 All forms especially for specimen suspicious of malignancy must be counter
checked by Specialist / Medical Officer before submission.
7. Indications for LSCS should follow the standard list, (refer appendix)



























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DISCHARGE SUMMARY
Antenatal Ward
A patient admitted and discharged should have a discharge summary of her admission
and to be clipped in her antenatal care booklet (Red Book). It should include the date
of admission, date of discharge, reason for her admission and the management
Postnatal Ward

In Caesarean sections / Hysterectomies, details on:

1. Indication
2. Operative difficulties / complications
3. Blood transfusion, if any
4. Post operative recovery
5. Plan for next delivery (mode)
6. Any contraindication for subsequent trial of scar should be included in the Red

Book/Patient Held record/Home Based Card
WEEKLY IN-PATIENT SUMMARY

Any patient managed as an in-patient for duration of five days or more should have a
weekly summary. A review of such patients by the ward consultant is compulsory.
NOTE: Every patient must have a written plan of management.














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GUIDELINES ON GENERAL SAFETY PRECAUTIONS
PROTECT YOURSELF
1. Wear gloves when setting intravenous lines and handling blood specimen.
2. Gown-up when conducting delivery or performing procedures (eg. MRP
exploration)
3. Use disposable sterile gown / visor / goggles / boots when conducting labour in a
biohazard case (positive for HBsAg / HIV)
4. Use long gloves / elbow length gloves when performing MRP.
5. Use of eye protection is recommended during delivery and episiotomies repair.
6. Use OT garment while on duty in labour room.
7. Use plastic gown during delivery.
8. Use sterile gown while doing MRP.

9. Report all needle prick injury and follow established protocols.
10. Test yourself for Hbs Antibody levels.
11. Obtain immunization against Hepatitis B.
PROTECT YOUR COLLEAGUE
1. Identify high-risk patients (eg. Positive for Hepatitis B) whenever a patient; is passed
over during shift changes or when a patient is transferred from one station / ward to
another.
2. Label all blood specimens from high-risk patients using the special biohazard stickers
stamp.
3. Personally dispose all sharps (injection needles / suture needles) into the "sharps
bin". Sharps should not be left unattended.












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PROTECT YOUR PATIENT
1. Label all blood specimen bottles. The venopuncturist must label all specimen bottles.
2. Wash your hands before and after examination of patients.
3. In the labour room, wear a mask before doing vaginal examination.
4. Swab the vulva with sterile water before doing a vaginal examination.
5. Drape (sterile) patient before delivery.
6 Use aseptic techniques to insert a Foley's catheter.
7. Use prophylactic antibiotics where applicable (eg. MRP)
8. Use sedation / local or general anaesthesia appropriately

8.1
Local anaesthesia (episiotomies)
8.2
Pudendal block (instrumental delivery).
8.3
MRP to be done in OT.

9. 'ALL OR NONE LAW'. The doctor who conducts the delivery is expected to
see the patient through till the end (till the episiotomy wound is repaired). This
should also be strictly followed in instrumental deliveries and Caesarean sections.
10. Inform patient of relevant details of current pregnancy, which may have a bearing
upon management of her future pregnancy (eg. Extended tear of uterus during LSCS).
This information should be reinforced once again to both couple upon
discharge
.
Details of such complications must be documented (in red pen) in the patient held
card / Red Book.





















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