●
You are the registrar on call for the labour ward. You have just arrived for the handover at 08.30 h.
●
Attached you will find a brief résumé of the 10 women on the delivery suite as shown on the board.
●
The staff that are available today are as follows:
– a SSHO in her 12th month of career training
– a third-year specialist anaesthetic registrar
– six midwives:
– DB is in charge
– DB, JR and BB can suture episiotomies
– JR, DB and MM can insert an i.v. line.
●
NB – the consultant on call is doing his operating list and is not keen on being disturbed unless absolutely necessary.
READ THE BOARD CAREFULLY. You have 15 minutes to decide:
●
what tasks need to be done
●
the priority of the cases
●
who should be allocated to each task.
At the next station you will meet the examiner with whom you will discuss your decisions and your reasoning.
YOU WILL BE AWARDED MARKS FOR YOUR ABILITY TO MANAGE THE
DELIVERY SUITE
16
PRIORITIZATION ON DELIVERY SUITE
Discussion
What is the station testing?
The examiner wants to assess whether you can prioritize the problems and safely manage the labour ward. You must demonstrate an organized and confident approach and be able to defend all your decisions. Do not keep on saying that you would ask the consultant’s advice, as the examiner wants to know what your decisions would be. However, clearly it would be prudent to mention that you would call the consultant and check that he was happy with any operative decisions. There may be different answers to this station but as long as your decisions are sensible, you’ll score well. A global score will be awarded for each room, and it is therefore important not to miss out any rooms in your conversation with the examiner. In this situation, a half mark will be rounded up.
Usually there will be one to three patients who will need urgent review, one to three who can be left for a while, and the rest will be those for whom the decision-making is important. You need to demonstrate to the examiner that you know what is important, that you have an organized mind and that you can hand responsibility over to other staff members, but you want to be informed of any problems they may encounter. Be clear and concise. Don’t just repeat what is written on the board!
What are the pitfalls?
You cannot do everything! You must determine where you are needed the most and where the staff can go depending on their experience. You must delegate but ensure that the staff will communicate with you if further problems arise.
Preparation
This is an easy station to practise. Each time you walk onto a labour ward there is an OSCE station set up for you. Ideally, ask one of your seniors to spend 15 minutes with you discussing your management priorities. Practise being able to delegate duties. If you are sitting the exam at a junior level, i.e. you have never taken charge of a labour ward, ask your registrar to role-play being your junior and you do the prioritization.
17
18
DELIVERY UNIT BOARD
Room
Name
Parity
Gestation
Liquor
Epidural
Syntocinon
Comments
Midwife
1
Barnett
1+1
32
–
Yes
Yes
LSCS at 0230 (PET)
DB
EBL 800 mL baby on SCBU
2
Lawson
3+0
T+9
Mec
Yes
No
8 cm at 0300
Com/MW
Transferred in from home
3
Tifou
0+0
39
Intact
No
No
Undiagnosed breech
DB
Spont. labour. 4 cm at 0730
Breech at spines
4
Smith
0+0
31
Dr to see
BB
Vaginal bleeding
CTG normal
5
Jones
0+0
41
Mec
Yes
No
Fully at 0700
VM
6
Patel
1+0
T+2
Clear
No
No
Trial of scar. ARM at 0300
JR
LSCS
FBS at 0600 pH 7.29
6 cm at 0600
7
Finch
2+0
14
Intact
No
No
Routine admission for cervical cerelage
VM
8
Allpress
0+0
39
Delivered. Awaiting suture
MM
9
Murphy
2+0
T+6
Intact
No
No
Spont. labour 3 cm at 0650
BB
10
Grant
0+2
32
Intact
No
No
Twins. Contracting. Ceph/breech
MM
IVF pregnancy
Review station 3
Examiner’s instructions
The candidate has 15 minutes to explain to you the following: A. The tasks, which need doing on the delivery suite; B. The order in which the candidate would do them; C. The staff he/she will allocated to each
These instructions may not be exclusive and a degree of flexibility is allowed in the marking.
Tasks required:
Room 1
Needs review post caesarean section as had severe pre-eclampsia. This review would involve pulse, blood pressure, amount of ongoing blood loss, hourly urine output and fluid status. Bloods should be repeated.
Room 2
Needs urgent review as she is a multiparous woman in her 3rd labour and should have delivered by now. She has meconium liquor and has been transferred in from home so is likely to have been in labour for a very long time.
Room 3
Needs urgent review to discuss mode of delivery and recommend epidural Room 4
Needs assessment as to the amount of bleeding, the cause and whether or not in pre-term labour. Must exclude abruptions.
Room 5
Needs review, as should have delivered by now.
Room 6
Needs review to assess progressing adequately and review CTG and repeat FBS if any CTG abnormalities.
Room 7
Needs non-urgent review and consent to be signed after fetal viability has been checked and dating of the pregnancy has been re-checked Room 8
Needs suturing.
Room 9
Needs review later in the morning when the other cases have been sorted out.
Room 10 Needs urgent review as may be in premature labour. If she is in premature labour, she will need steroids with tolcolysis.
The priorities for review are: Room 2 is the first priority, followed by Room 3 and Room 10 and then Room 4. It would be appropriate for the Registrar to see Room 2 and Room 10 and the SHO to see Room 4 and Room 3. The midwife could suture Room 8 and Room 9 could be assessed by the midwife later in the morning. After the urgent cases have been sorted out, then the medical staff should review Room 6
and Room 5.
19
REVIEW STATIONS
Mark sheet
Room 1
0
1
2
3
4
Room 2
0
1
2
3
4
Room 3
0
1
2
3
4
Room 4
0
1
2
3
4
Room 5
0
1
2
3
4
Room 6
0
1
2
3
4
Room 7
0
1
2
3
4
Room 8
0
1
2
3
4
Room 9
0
1
2
3
4
Room 10
0
1
2
3
4
Total
/40 → divide by 2
Final mark
/20
20