Vaginal Birth Clinical Pathway Department Of Health

State of Queensland (Queensland Health) 2015Licensed under: u/deed.enContact: Clinical Pathways Program@health.qld.gov.au(Affix identification label here)URN:Family name:Vaginal Birth Clinical PathwayGiven name(s):Address:Facility:.Date of birth:Sex:MFI»» Clinical pathways never replace clinical judgement.»» Care outlined in this clinical pathway must be altered if it is not clinically appropriate for the individual client.»»»»»»»»»»DRG O60C Vaginal Delivery without Complicating Diagnosis A (ALOS 1.83) B (ALOS 1.84)DRG O60B Vaginal Delivery with moderate complicating diagnosis A (ALOS 2.68) B (ALOS 2.51)DRG O60A Vaginal Delivery with severe complicating diagnosis A (ALOS 4.41) B ( ALOS 3.65)The A and B refer to hospital groups, with A being the major tertiaries and B the major regionalsAR-DRG V5 Hospital Benchmarking Funding Model 2004/05Documentation instructions:Initials - Indicates action / care has been ordered / administered.N/A - Indicates preceding care / order is not applicable.Crossing out - Indicates that there is a change in the care outlined.V - Indicates a variation from the pathway on that day, in that section. When applicable flag it in the “Variance column”, then document in the freetext area as instructed. If this variance occurs more than once daily, document the additional times of the variance in the variance free text area and inthe patient’s progress notes as applicable. KeyMidwife / NursingMedical / GP PhysiotherapistPharmacy Allied HealthQueensland Clinical Guidelines - available at http://www.health.qld.gov.au//qcg/Symbols guide care to a primary professional stream, it is a visual guide only and its direction is not intended to be absolute. A Vaginal Birth Clinical Pathway Ongoing Care (Additional Page) (SW233a) is available for extended treatment. A Vaginal Birth Clinical Pathway Clinical Events / Variances (Additional Page) (SW233b) is available if more space is required forclinical events and variances. Every person documenting in this clinical pathway must supply a sample of their initials and signature below.Signature logSignaturePrint nameSW233ÌSW233nÎMat. No.: 10253037InitialsRoleVaginal Birth Clinical Pathwayv13.00 - 07/2015Do Not Write in this binding margin Page 1 of 7

(Affix identification label here)URN:Family name:Vaginal Birth Clinical PathwayGiven name(s):Address:Date of birth:Sex:MFIEvery person documenting in this clinical pathway must supply a sample of their initials in the signature logEducation planKeyMidwife / NursingMedical / GP PhysiotherapistInterpreter ss and explain:Checking of the fundus and reason for checkingYesPharmacy Allied HealthQCGInitialCategoryNoDatePerineal careBreast changesBleeding up to 6 weeks after birthReturning to normal activitiesEmotional and social well being noted: .Postnatal follow upMidwife / EPPM / Medical Officer follow up in . .days / weeksCopy of ‘Pregnancy Health Record’ given to motherDiscuss last pap smear and when to have next oneVTE risk assessment completed and discussedDiscuss 13 Health (13 432 584) and 24 Hour help line 1800 686 268 numbers and communitysupportsChild Health Services Information - ‘Your guide to the first 12 months’ booklet identified anddiscussedReinforce: Seeking medical assistance immediately you experience fever, pain or increased bleedingPhysiotherapist Infant feedingDiscuss the importance of pelvic floor health and ask if mother understands and has practised herpelvic floor exercisesMother can demonstrate:Correct attachment breast feedingCorrect detachment for breast feedingCorrect positioning for infant feedingHand expressingDiscuss breast and nipple careDiscuss safe storage of breast milkDiscuss lactation and / or suppression (if applicable)When formula feeding, is mother able to perform decontamination of bottles, formulapreparation and understands transportation and storage techniquesPain managementDiscuss use of simple pain relief for pain management including “after birth pains”ContraceptionDiscuss contraception use (method of choice)Safe sleepingDiscuss measures to reduce SIDS / SUDIMother can demonstrate safe sleeping techniques as wrapping, positioning and settlingLifestyle adviceSafe car travelDiscuss co-sleeping surfaces, such as not sharing beds and lounges, plus smoke freeenvironments. Discuss risk of falling asleep while holding babyDiscuss healthy eating plan and lifestyle advice including review of smoking status / offer NRT ifrequiredDiscuss infant restraint for vehicleThe above education plan on self care, infants and siblings has been discussed with meYesNoI have received the Centrelink and Birth registration formsYesNoMother's name (please print):Signature:Page 2 of 7DO not write in this binding marginMother to make own appointment with local doctor / General Practitioner (GP) / TreatingSpecialist / Physician / EPPM, a hospital birth discharge summary will be sentPost natal contact phone call up to 5 days post dischargeDate: . and time: . arranged (if applicable)

(Affix identification label here)URN:Family name:Vaginal Birth Clinical PathwayGiven name(s):Address:Date of birth:Sex:MFIEvery person documenting in this clinical pathway must supply a sample of their initials in the signature logDischarge planInitialDischarge medications arrangedMothers own medications returnedAnti D givenMMR givenDiscuss Pertussis immunisation for parents and grandparentsDiscuss OGTT at 6 weeks postnatal (if applicable)Referrals initiated (for example)Do Not Write in this binding marginMedical Officer Specialist / Treating Physician / EPPM / Allied Health Professional / Indigenous Health Worker / QuitlineHospital discharge summary / copy of perinatal data report given to motherFaxed / sent to GP / Child Health Services (if applicable)Antenatal psychosocial screeningTransfer to other hospitalTime:Facility name:Further notes (including Criteria Led Discharge as per hospital protocol):Discharge ClinicianDate:Time:Designation:Page 3 of 7Signature:Date

(Affix identification label here)URN:Family name:Vaginal Birth Clinical PathwayGiven name(s):Address:Date of birth:Sex:MFIEvery person documenting in this clinical pathway must supply a sample of their initials in the signature logPostpartum vaginal birthInstructions: Initials - care attended to, Rule out - not applicable, V - variance (record and sign all variances on sheet provided or progress notes)KeyMidwife / Nursing0–2 hrsReviewMedical / GP PhysiotherapistDate:Hospital careMidwife / Medical OfficerPain relief orderedPharmacy Allied HealthTime:QCGInitialTimeVTimeVAVHome careVTE risk assessment reviewed and treatment commenced (if required)Rubella immune - vaccination not requiredNegative blood group - Kliehauer / cord blood test collected (anti D if required)Half hourly observations for 2 hoursID bands securedDocumentationBaby’s Personal Health Record commencedTime of transferOrientated to ward areaNil postnatal risks identified / alerts2–24 hrsEnter shift (that will occur predominately within the next 8 hours)Pain managementMinimal discomfort, provided with appropriate pain managementObservationsObservations of vital signs as per local protcol & recorded on Q-MEWTEpiduralDiabetesOther-specify: .IV therapy patent, running to timeFundusFirm and central, at or about the level of the umbilicusLochiaBright red, 1 pad / hourPerineumInfant feedingPerineum inspectedSafe feeding discussedBreast feeding - offered assistanceFormula feeding - offered assistance and able to make formulaDemonstrate feed chart recordingEliminationHas voided post birth, no dysuria, no urinary incontinence or voiding difficultiesNo HaemorrhoidsLegsNo calf tendernessNutritionTolerating diet and fluidsHygieneShowered independentlyFalls riskStandard falls prevention strategies implemented and recorded.Observe for ongoing effects of medications (e.g. epidural, sedation).Observe for hypotension and ongoing effects of blood loss (e.g. post partumhaemorrhage) - monitor BP.Mobilising independently.Pressure injuryConduct a comprehensive skin inspection within 8 hours of admission usingthe Adult Pressure Injurty Risk Assessment Tool.Infant careEmotional stateEducationDemonstration bath offered to parent / bathed by parentEmotional needs identified including labour and birthing concernsYesNoCommunication assistance required and utilised?State type: .Education plan updatedEarly dischargeUncomplicated birth - dischargedDischarge plan updated and completedExpectedoutcomesMother states: A - Achieved V - Variance1.1 Mother has her concerns addressed such as her personal requests, breast or formula feeding andher baby’s cares.Page 4 of 7DO not write in this binding marginPerinatal data report commencedTransfer to ward

(Affix identification label here)URN:Family name:Vaginal Birth Clinical PathwayGiven name(s):Address:Date of birth:Sex:MFIEvery person documenting in this clinical pathway must supply a sample of their initials in the signature logPostpartum vaginal birthInstructions: Initials - care attended to, Rule out - not applicable, V - variance (record and sign all variances on sheet provided or progress notes)KeyMidwife / Nursing24–48 hrsMedical / GP PhysiotherapistDate: . / . / . toHospital careReviewPharmacy Allied HealthDate: . / . / .QCGInitialTimeVTimeVAVHome careMidwife / Medical OfficerMedical Officer Specialist / Treating Physician referral requiredDischarge arrangedReferral to other Allied Health not requiredPhysiotherapistBladder / bowel function, posture / ergonomics / back care, rectus diastasis check andDo Not Write in this binding margin muscle co-activation / rehabilitation assessed with consentEnter shift that will occur predominately within the next 8 hoursPain managementMinimal discomfort, managed with prescribed / simple analgesiaObservationsObservations of vital signs as per local protcol & recorded on Q-MEWTEpiduralDiabetesOther-specify: .IV cannula patent, no signs of inflammationFundusFirm and central, 1–2cm umbilicusLochiaDark red - pink, 1 pad / 2 hoursPerineumPerineum inspectedBreasts / nipplesBreasts soft, nipples intactInfant feedingSafe feeding discussedBreast feeding - requires minimal assistanceFormula feeding - requires minimal assistance and understands increasingformula volumes required by infantEliminationNo dysuria, no urinary incontinence or voiding difficultiesNo haemorrhoidsBowels openedLegsNo calf tendernessNutritionSelf caringHygieneSelf caringFalls riskStandard falls prevention strategies implemented and recorded.Mobilising independently.Pressure injuryConduct a skin inspection if “at risk”.Standard pressure injury prevention and management strategiesimplemented and recorded.Emotional stateEmotional needs identified including labour and birthing concernsEducationEducation plan updatedDischargeDischarge plan updated / completedExpectedoutcomesMother states: A - Achieved V - Variance2.1 Mother has a sound understanding of care of herself and baby.Variance:Page 5 of 7

(Affix identification label here)URN:VaginalVaginal BirthBirth ClinicalClinical PathwayPathwayClinical Events / VariancesFamily name:Given name(s):Address:Date of birth:Clinical events / variancesDateTimeVarianceSex:MFIExpand on variances to clinical pathway for clinical relevance, clinical history, consultations and datacollection. Document as Variance / Action / Outcome. (Include name, signature, date and Initialsstaff category with all entries)DO not write in this binding marginContinue documentation on next page Page 6 of 7