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Re: Non-reassuring tracing in latent phase Family doc and Head nurseFrom: Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C. (johnprov@sympatico.ca)Tue Apr 28 11:38:26 2009
At Tue, 21 Apr 2009, Charlie Chambers wrote: > >Along those lines, how many of you practice in hospitals where >guidelines for consultation are explicitly spelled out, or for >comanagement or assumption of care? We currently do not have anything >that guides those situations and it scares the heck out of me when I >later find out about some of the things that mid level providers were >managing without me being in the loop. > >****************************************************************************** I am pretty sure we got these guidlines from discussion of what the local teaching hospitals do. And for the midwives. As a primary care provider, the Midwife together with the client is fully responsible for decision making. The Midwife is responsible for writing orders and carrying them out or delegating them in accordance with the standards of the College of Midwives of Ontario. The Midwife discusses care of a client, consults, or transfers primary care responsibility according to the Indications for Mandatory Discussion, Consultation, and Transfer of Care. The responsibility to consult with a family Physician/General Practitioner, Obstetrician and or specialist Physician lies with the Midwife. Consultation should occur within an appropriate time after detection of an indication for consultation. The severity of the condition and the availability of Physician(s) will influence these decisions. DEFINITIONS Category 1: Discussion with another Midwife or with a Physician It is the Midwife’s responsibility to initiate a discussion with or provide information to another Midwife or Physician with whom care is shared, in order to plan care appropriately Category 2: Consultation with a Physician It is the Midwife’s responsibility to initiate a consultation and to clearly communicate that she is seeking a consultation. A consultation refers to the situation where a Midwife in light of her professional knowledge of her client, and in accordance with the standards of practice of the College of Midwives, requests the opinion of a Physician competent to give advise in this field. As per College of Midwives of Ontario standards: “The Midwife should expect that the consultation involves addressing the problem that led to the referral, an in-person assessment of the patient, and the prompt communication of the finding and recommendations to the patient and the referring professional” Following the assessment of the patient by the consultant(s), discussion can occur between the Midwife and consultant regarding future patient care. It is expected that when a consultation is initiated, from the discussion of the health care professionals, the consultant estimates the urgency of the consult and responds appropriately. The consultation can involve the Physician to their level of expertise providing advice and information, and/or providing therapy to the woman/newborn or prescribing therapy for the Midwife to administer to the woman/newborn. After consultation with a Physician, primary care of the client and responsibility for decision-making (together with the client) either CATEGORY: Policy and Procedure PAGE: 2 of 6 Subject: MIDWIFERY INDICATION FOR MANDATORY CONSULTATIONS a) Continues with the Midwife (consults for interest or courtesy), or b) Is temporarily/permanently transferred to a Physician. The consultant may be involved in, and responsible for, a discrete area of the client’s care, with the Midwife maintaining overall responsibility within her scope of practice. Responsibility could be transferred temporarily to another health professional, or be shared between health professionals according to the patient’s best interests and optimal care (“consult and follow with me” situations). Transfer or sharing of care should only occur after discussion and agreement among patients, referring health professionals and consultants. Areas/duration of involvement in client care must be clearly agreed upon and documented immediately following the consultation. It is the Midwife’s responsibility to ensure that the client understands which health professional will have responsibility for primary care. Category 3: Transfer to a Physician for primary care When primary care is transferred from the Midwife to a Physician, the Physician, together with the client, assumes full responsibility for subsequent decision making. When primary care is transferred to a Physician the Midwife may remain in supportive care within her scope of practice. As per Sudbury Regional Hospital Medical Staff By-Laws (82.3), Whenever the responsibility for the care of a patient is transferred (voluntarily) to another member of the medical staff, a written notation shall be made and signed on the patient’s record. It is the responsibility of the initial Physician to arrange and ensure transfer to another Physician willing and able to assume care and to inform the patient. The Physician to whom responsibility has so been transferred shall, on notification, accept immediate and continuous responsibility for and supervision of the patient’s care. In Category 2 and 3 of the policy on Midwifery Indications for Mandatory Discussion, Consultation and Transfer of Care with the Department of Obstetrics, the consultant and Midwife will decide between themselves who should deliver the baby and the patient will then be advised of the decision. CATEGORY 1 DISCUSSIONS Indications: Initial History and Physical Examination Adverse socio-economic conditions Cigarette smoking Age less that 17 years or primapara over 35 years History of genital herpes History of one late miscarriage (after 14 weeks) or preterm birth History of one low birth weight infant History of serious psychological problems Less than 12 months from last delivery to present due date Obesity Poor nutrition Previous antepartum hemorrhage Previous postpartum hemorrhage One documented previous low segment c-section Grand multipara (para 5) CATEGORY: Policy and Procedure PAGE: 3 of 6 Subject: MIDWIFERY INDICATION FOR MANDATORY CONSULTATIONS History of infant over 4500 g Primipara over 40 years History of uterine malformations or fibroids in lower segment of uterus History of pregnancy induced hypertension Indications: Prenatal Care Presentation other than cephalic at 4 weeks prior to due date No prenatal care before 28 weeks gestation Uncertain expected date of delivery Indications: During Labour and Delivery No prenatal care Thin (non-particulate) meconium CATEGORY 2 CONSULTATIONS Indications: Initial History and Physical Examination Current medical conditions e.g. cardiovascular disease, pulmonary disease, endocrine disorders, hepatic disease, neurological disorders Family history of genetic disorders Family history of significant congenital anomalies History of cervical cerclage History of repeated spontaneous abortions History of more than one low birth weight infant History of significant medical illness Previous myomectomy, hysterotomy, or cesarean section other than one documented previous low segment cesarean section Previous neonatal mortality or stillbirth Rubella during first trimester of pregnancy Significant use of drugs or alcohol History of essential hypertension on medication or eclampsia Age less than 14 years Indications: Prenatal Care Anemia-unresponsive to therapy Documented post-term pregnancy 42 completed weeks Fetal anomaly Inappropriate uterine growth Medical conditions arising during prenatal care, e.g. endocrine disorders, hypertension, renal disease, suspected significant infections, hyperemisis Placenta previa without bleeding in third trimester Polyhydramnios or oligohydramnios Pregnancy induced hypertension Isoimmunization Serious psychological problems Sexually transmitted disease CATEGORY: Policy and Procedure PAGE: 4 of 6 Subject: MIDWIFERY INDICATION FOR MANDATORY CONSULTATIONS Vaginal bleeding other than transient spotting Presentation other than cephalic at 3 weeks prior to due date Preterm pre-labour rupture of membranes (PPROM) CATEGORY 2 CONSULTATIONS Indications during labour and delivery Preterm labour 34 - 37 completed weeks Prolonged active phase defined as dilatation less that ½ cm per hour over a 2 hour period when patient in active labour (where active labour is defined as > 3cm dilated, contractions 5 min apart or less and membranes ruptured) Prolonged ruptured membranes - greater than 12 hours Prolonged second stage – multipara 1 hour, primipara 2 hours Retained placenta (i.e. after 30 minutes) Suspected placental abruption and/or previa Third or fourth degree tear Unengaged head in active labour in primipara Non-reassuring fetal heart rate patterns Hypertension > 140/90 on more than 1 occasion > 4 hours apart Indications Postpartum (maternal) Breast infection Wound infection Uterine infection Signs of urinary tract infection Temperature over 38° C (100.4°F) on more than one occasion Persistent hypertension Vaginal postpartum bleeding requiring continuous infusion IV oxytocin therapy Serious psychological problems CATEGORY 3 TRANSFERS OF CARE Indications: Initial History and Physical exam Any serious medical condition e.g. cardiac or renal disease with failure, or insulin dependent diabetes mellitus Indications: Prenatal Care Multiple pregnancy including twins Cardiac or renal disease with failure Insulin dependent diabetic Pre-eclampsia or eclampsia with proteinuria Symptomatic placental abruption Vaginal bleeding, continuing or repeated CATEGORY: Policy and Procedure PAGE: 5 of 6 Subject: MIDWIFERY INDICATION FOR MANDATORY CONSULTATIONS Indications: During Labour and Delivery Abnormal presentation including breech Multiple pregnancy including twins Non-reassuring fetal heart patterns unresponsive to therapy Active genital herpes at time of labour Placental abruption and/or previa Vasa previa Preterm labour (less that 34 completed weeks) Prolapsed cord Proteinuric pre-eclampsia or eclampsia Severe hypertension – defined as a diastolic BP > 110 mm Hg Thick (particulate) meconium Uterine rupture Uterine inversion Hemorrhage during labour Obstetric shock Indications Postpartum (maternal) Hemorrhage unresponsive to therapy Obstetric shock Postpartum eclampsia Thrombophlebitis or thromboembolism Uterine prolapse INFANT: CATEGORY 1 DISCUSSIONS Feeding problems Failure to pass urine or meconium within 24 hours INFANT: CATEGORY 2 CONSULTATIONS 34 to 37 weeks gestational age Infant less 2,500g Less than 3 vessels in umbilical cord Excessive moulding and cephalhematoma Abnormal findings on physical exam Excessive bruising, abrasions, unusual pigmentation and/or lesions Birth injury requiring investigation Congenital abnormalities, for example: cleft lip or palate, congenital dislocation of hip, ambiguous genitalia Abnormal heart rate or pattern Abnormal cry Persistent abnormal respiratory rate/or pattern Persistent cyanosis or pallor Jaundice in first 24 hours Suspected pathological jaundice after 24 hours CATEGORY: Policy and Procedure PAGE: 6 of 6 Subject: MIDWIFERY INDICATION FOR MANDATORY CONSULTATIONS Temperature less than 36°C, unresponsive to therapy Temperature more than 37.9°C, unresponsive to non-pharmaceutical therapy Vomiting or diarrhea Infection of umbilical stump site Significant weight loss (more than 10% of body weight) Failure to regain birth weight in three weeks Failure to thrive Failure to pass urine or meconium within 36 hours of birth Suspected clinical dehydration INFANT: CATEGORY 3 TRANSFERS OF CARE Apgar lower than 7 at 5 minutes Suspected seizure activity Major congenital anomaly requiring immediate intervention, for example: omphalocele, myelomeningocele Temperature instability
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Take care, John
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