Unplanned situations and emergencies inevitably arise in the best-managed obstetric units, but good organisation should be able to reduce these to a minimum. Anaesthetists are present in most labour wards for a majority of the working week, are involved in the care of the complex cases that test the organisational structure, and are accustomed to communicating with other medical and non-medical staff. They are therefore ideally suited to help in the planning of the various aspects of labour ward organisation.
Problems and special considerations
The labour ward is a potential hotbed of organisational problems. Workload may vary suddenly and dramatically, and the urgent nature of many admissions makes forward planning very difficult. A variety of specialists are intimately involved with the care of the patients, and conflicts, although regrettable, are inevitable. Priorities are often difficult to establish, and prolonged periods of routine work may be suddenly interrupted by an extreme emergency. All of this makes careful organisation essential but very difficult.
Maternity care is by far the largest source of medicolegal litigation in Europe and the USA, and analysis of claims commonly implicates communication and other organisational factors - for example, failure to notify the anaesthetist of an impending caesarean section until the last minute, resulting in inappropriate anaesthetic decisions or excessive delay.
In many labour wards in the UK and elsewhere, mothers identified as low-risk are frequently cared for solely by a midwife. This situation, although not hazardous in itself, calls for careful guidelines to ensure early communication of potential problems to relevant medical staff. The problem can be exacerbated if independent practitioners are allowed to admit their clients to the labour ward.
Although the role of the anaesthetist is more widely appreciated by midwives and obstetricians than in the past, there is still a tendency in some units to regard him/her as an ‘outsider’, only to be summoned when required. This attitude fosters poor communication and should be discouraged.
Management options
There should be a consultant anaesthetist responsible for the provision of the obstetric anaesthetic service. A labour ward working party or equivalent, meeting on a regular basis, is an ideal forum in which to raise concerns and maintain communication, and there must be an anaesthetist on this body.
Guidelines and protocols should be drawn up to cover both routine care and the management of difficult cases and emergencies, and must be agreed by all parties involved. These guidelines should be updated frequently, be readily available on the labour ward and be distributed to all new staff, who should undergo a formal familiarisation programme before being allowed ‘on call’. Standards laid down in guidelines should be the subject of regular audit. Independent practitioners who require admitting rights must also agree to abide by the unit guidelines.
A formal scheme for reporting all critical incidents and ‘near-misses’ must be in place, and a blame-free culture established to encourage staff to utilise the system. Regular multidisciplinary morbidity meetings are useful to identify potential organisational problems. Information from these should pass to a risk management committee (also multidisciplinary), responsible for ensuring good practice and minimising risk to patients.
Good communication is the most important factor in a well-managed labour ward. A system should be in place to ensure that potentially difficult cases are referred to an anaesthetist early in the antenatal period, and that the anaesthetist is also notified when they are admitted. Management plans and other relevant clinical information should be easily accessible to the care team at all times. The anaesthetist should be familiar with all the patients on labour ward, and this is best achieved by participating in joint ward rounds with the obstetricians and midwives. The duty anaesthetist must be rapidly contactable at all times; ‘bleep’ systems should not be relied upon as a sole means of contact. The names and methods of contacting consultant staff should be visible at the central desk. In general, anaesthetists should ensure that they are regarded as part of the ‘team’, rather than as someone to be called when the situation is desperate.
Extreme emergencies such as cardiorespiratory arrest are very uncommon on the labour ward, but a successful outcome depends on a rapid, efficient response - and this can be threatened by the very rarity of such events. National guidelines on the management of common emergencies such as anaphylaxis should be posted in a visible place. The whereabouts of resuscitation equipment and drugs must, of course, be known to all staff, and regular ‘drills’ for emergencies such as maternal collapse and massive antepartum haemorrhage should be carried out to ensure that the system works smoothly. Robust systems for data collection should be in place to enable the conduct of clinical audit, the identification and follow-up of complications, and the assessment of outcomes.
Detailed guidelines covering the above points, and more, have been published by the Obstetric Anaesthetists’ Association, the Association of Anaesthetists of Great Britain and Ireland, and the Royal Colleges of Midwives and of Obstetricians and Gynaecologists. These documents serve as useful reminders of the various aspects of labour ward organisation that need attention, and also serve as tools for ongoing audit.
Key points
• Poor organisation results in unnecessarily hasty, and sometimes incorrect, decision making.
• Anaesthetists should be involved in labour ward management.
• Good, early communication will help prevent many disasters.
Further reading
Obstetric Anaesthetists’ Association, Association of Anaesthetists of Great Britain and Ireland. OAA/
AAGBI Guidelines for Obstetric Anaesthetic Services, 3rd edn. London: AAGBI, 2013. www .aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf (accessed December 2018).
Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press, 2007. www.rcog.org.uk/globalassets/documents/guidelines/wprsaferchildbirthreport2007.pdf (accessed December 2018).