Maternity Minor operations/procedures protocols and... · BO Bowels open N.O.K Next of kin BP Blood...

Maternity Minor operations/procedures Patient likes to be known as Patients Name

NHS No. (Affix patient label)

Consultant

Planned date

Named Midwife

Date of admission

Ward

Known Allergies

CODE Paper colouring Midwives responsibility White Pre – op clerking & clinic visit TX Doctors responsibility Yellow Admission & Pre – op phase PAMS responsibility Pink Surgery Green Post op

Version 1.5 October 2019 Review before October 2021 Approval Group Date Maternity Clinical Governance 1st November 2019

Change History Version Date Author(s), Job title Reason Version 1.3 September

2015 Cathy Ma, Recovery Theatres Nurse

Reviewed

Version 1.4 September 2017

Cathy Ma, Clinical Lead Practitioner, P Bose Consultant Obstetrician

Reviewed – no change

Version 1.5 September 2019

Cathy Ma, Clinical Lead Practitioner, P Bose Consultant Obstetrician

Reviewed – minor change

©RBFT Maternity minor operations/procedures (V1.5) Nov 2019 of 12

All members of staff who are using this Pathway use black ink and fill in this section. You can then use initials when recording care

Print Name Designation Signature Initials

How to use an Integrated Care Pathway (ICP)

• Firstly, if you are going to write in the ICP you need to state your Name, Job Title and give a sample signature and initials on the front of the ICP cover

• If you are recording an event which is predicted by the ICP, then you just sign against that predicted intervention in the column provided.

• If your intervention is not in line with the pathway, you must record this as a variance in the variance column with the action you will take to try to bring the patient back onto the pathway.

• Care given by health care assistants and student nurses must be countersigned by a registered nurse.

• There are many ‘NOTES’ pages for you to write free text about the care given to the patient by you. These notes should always be dated and timed.

• The ICP has been colour coded to make it easier to document your aspect of care. Black background relates to Doctors, Clear background relates to nurses and grey backgrounds relates to PAMS, but check the key prior to writing.

• All ICPs are chronological so you should be able track the care given very easily Abbreviations BO Bowels open N.O.K Next of kin BP Blood pressure N/A Not applicable FBC Full blood count PU’d Passed urine HB Haemoglobin ROS Removal of sutures I.M Intra muscular SB Still born IV Intra venous TPR Temperature, Pulse ,Respiration IVAB Intra venous anti biotic TTOs Tablets to take out LOS Length of stay U& E’s Urea and Electrolytes N.B.M Nil by mouth


Pre-operative assessment

Gravida Para Gestation

Planned date for operation Date operation proposed / / Date decision made / / by whom: Maternal observations BP

Pulse

Temp Weight BMI MRSA screen Y � N �

Urinalysis Glucose Protein

TEDs Size………….

If weight greater than 130kg, theatres informed � Bariatric equip arranged � N/A �

Allergies (to include latex allergy)

Recent bloods: date taken……………… results:

Fetal observations

Heart rate CTG performed Y � N � Fetal movement felt

Assessment / treatment Initial Reason for variance and action taken. Base line observations are within normal limits

Specify areas of body piercing Expected LOS =

Ranitidine prescribed and given to woman with explanation on when and how to take

Blood taken/ form given Date and time of admission confirmed with woman

Has the woman any body piercing Y � N � If yes, is she willing to have it removed prior to C section Y � N �

Woman advised to remove jewellery, contact lenses, makeup and nail polish

Length of stay discussed with woman Woman advised to arrive on DAU at…………hrs

Has patient been seen and consented by SHO � Anaesthetist �


Medical Assessment

Proposed procedure:

Current medication Remember : inhalers/ nebulizers, eye drops, topical preparations, oral contraceptives, hormone replacement therapy, insulin, home oxygen, injections, herbal preparations / items bought from chemist / OCP / health foods

Drug history obtained from; GP letter � Patient � Relative � other…………..

Name Dose Frequency Route Name Dose Frequency Route

Relevant obstetric history Physical examination

Any signs of;

Jaundice Anaemia Cyanosis Clubbing Oedema Lymph

CVS:

Chest: Abdo:

Summary

Interventions Initial Reason for variance and action taken. Blood results are within normal range Consent Consent gained Medication DVT risk low � High � DVT prophylaxis prescribed

Should a DVT risk assessment be completed?

Advice Advice sought from surgeon Name:

Result

Advice sought from anaesthetist Name: Result


Day of operation. Pre-operative check list

Time Blood results

200 Blood group = 190 HB WBC Platelets 180 170

Pulse & Blood 160 Blood sugar pressure 150 Time Blood sugar Action

140 Fetal heart (red) 130

120 110

Additional information

Bowels last open………………

100 90 80 70 60 50 Temp

CTG performed Y � N � Reassuring Y � N � Initial Reason for variance and action taken Patient admitted on computer Latest G+S available on computer Theatre prepared for latex allergy N/A �

Date / time Multi-disciplinary free text

Sign

Pre-operative check list overleaf


Pre-operative check list

Allergies ( to include latex allergy)

Nil by mouth, food............hrs Fluid...................hrs Ward Theatre Specify Details Patient has taken x 2 doses of Ranitidine Y / N If blood X matched, available in Labour ward Y / N Bath / shower Y / N Wearing gown (opening at back) Y / N Consent form present and correct with second signature from midwife / Dr

Y / N Y / N

Name band and red allergy band insitu Y / N Y / N Drug Chart & relevant medication present Y / N Y / N Prosthesis removed if necessary Y / N Y / N Dentures / cap / crowns / tongue piercing (specify)

Y / N Y / N 8 7 6 5 4 3 2 1 / 1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1 / 1 2 3 4 5 6 7 8

Jewellery & body piercing removed / taped Y / N Y / N Nail varnish / makeup removed Y / N Y / N Contact lenses removed if applicable Y / N Y / N Hearing aid (left / right / insitu?) Y / N Y / N TED stockings insitu Y / N Y / N Prepared for theatre by :................................ Date

Received in Theatre by:........................... Date

Has the patient any pressure damage Y � N � At risk of pressure damage Y � N �

If yes to any of the following a Waterlow assessment needs to be completed and attached to the document


Theatre

Theatre ( No………………) Initial Reason for variance and action taken Patient position Lithotomy � Lloyd Davis � Supine � Trendelenburg � Right arm By side � Extended on board � Flexion onto chest �

Left arm By side � Extended on board � Flexion onto chest �

Pressure areas protected: Elbows � Sacrum � Calf muscles � Heels � Flowtron legging applied Y � N � Gel Pads �

Diathermy plate applied Thigh Right � left � Abdomen � Flank � Other……………..

Skin preparation used: Chlorhexidine in spirit � Alcohol Povidone Iodine � Aqueous Povidone Iodine � Aqueous chlorhexidine � Other �

Sutures: Soluble � Insoluble � Nylon � Prolene � Monocryl � Steristrips � Dexon � Vicryl � Silk � other…………… Interrupted � Subcuticular � Continuous �

Dressings applied: Mepore � Surgipad � Mat pad � Bioclusive � Pressure dressing � Other…………………….

Vaginal pack in situ: Y � N Diathermy plate clear: Specimens sent: Y � N � Nature……………… For microbiology � Histology � Cytology �

Drains in situ Y � N � site……………… Type: Redivac � Corrigated � other…………… Drains sutured in Y � N �

Blood loss during procedure………………..mls Swab, instrument count & sharp count correct Swabs � Instruments � Sharps � Catheters in situ Urethral � Suprapubic � Vygon � Instillagel � Size…… Volume of water ………

Operation performed Cervical clamps in-situ Y � N � Time on………. Time off…………..

Intra- operative analgesia Dose Time Given by Bupivacaine to wound Y � N � ……..% ……….mls Diclofenac Y � N � if yes route…………….

Time out of theatre……………..hrs Name of Surgeon

Name of Anaesthetist

Name of scrub person Name of circulator; Name of anaesthetic assistant


Recovery

Airway Management Endotracheal � Laryngeal mask � Oropharyngeal / Guedal � Manual support �

Self-maintaining �

Oxygen therapy Face mask/nasal specs..........L/min T. Bag………….L/min None � Time stopped…….. Artificial airway rejected at…………….hrs

Awake and responsive at……………hrs

Requires active warming Y � N � Extra blankets � Bair hugger � other …………………..

Nursed on: Trolley � Bed � (if Waterlow > 15, nurse on bed)

I.V Cannula site position Pain chart commenced Y � N � Peri-operative analgesia given Y � N � if yes record:

Drug name Dose Route Time given

Peri-operative anti - emetic given Y � N � if yes record:

Drug name Dose Route Time given

PCA in situ Y � N � Epidural in situ Y � N � PCEA in situ Y � N � If yes to any of the above, record pump number………

Invasive monitoring Arterial line � time removed……………… CVP line � chest x-ray requested Y � N �

Other special instructions e.g.O2 therapy, IV therapy, antibiotic

Criteria for safe discharge to be completed on page 10

Sterile ticket Sterile ticket Affix ticket

Or enter written format here

Affix ticket Or enter written

format here Affix ticket









format here


Recovery


Criteria for safe transfer to ward : Initial Reason for variance and action taken All post – operative medication prescribed: Analgesia including PCA / epidural � Anti-emetics � Antibiotics � IV fluids �

All documentation correct and completed; Operation sheet � Anaesthetic sheet � Drug chart � Discharge letter �

Oxygen saturation within patients normal range Oxygen therapy in situ on transfer from recovery to ward; Y � N �

Haemodynamically stable Pain score of <5 or acceptable to patient Minimal blood loss Answers simple questions coherently Temperature within 36 – 37.5ºC Nausea & vomiting under control Hand over to ward staff complete (to include review of post-op instructions)

Received by Ward nurse ……………………………………. Time………………….

Date / time

Free text Sign


Post op day of operation

Intervention Initial Reason for variance and action taken E L

Returned from theatre at..................... Clinical assessment Pain score of < 5 or acceptable to patient. (see page 2)

BP, pulse, and peripheral circulation are stable on return from theatre.

No signs of internal or external bleeding from wound and surrounding area

No complaints of nausea Treatment Analgesia given prn Anti-emetics given as prescribed

Discharge criteria for day case patients Initial Reason for variance and action

taken. Patient tolerating light diet. Patient has passed urine post op Patient is alert and orientated No excessive bleeding Patient aware of surgical outcome Patient states readiness to be discharged Responsible adult escort accompanying patient who will stay with patient for 24 hours

Cannula removed Discharge information leaflet and verbal explana given to patient and carer

TTO’s with verbal and written information given t patient and carer

Discharge letter given to Patient � to be sent to GP �

District nurse / Practice nurse aware Medical certificate given to patient for. . . . .wks Follow up appointment:- Given to patient � To be sent to patient � Not applicable �

Escort is confident to take patient home (Escort to sign) …………………………………….. Discharged by Time Goals for this phase Patient recovered safely from anaesthetic Patient up and mobilising, eating and drinking. Day case patients discharged home


Patients that are unfit for discharge Doctor informed Patient aware of outcome Relatives informed Transferred to……………… . .……….Ward Time . . . . . . . . . . . .

Reason for transfer

Date / time Multi-disciplinary free text

Sign


Maternity Minor operations/procedures protocols and... · BO Bowels open N.O.K Next of kin BP Blood...

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