Vaginal Birth Pathway Workshop: Evidence-Based Care Program

Education Workshop (click to go to the desired section) • Introduction to Workshop/Instructions • Evidence-Based Care Program • Vaginal Birth Pathway Workshop Vaginal Birth

Next Back Introduction • This interactive workshop is designed to go along with a workbook. Keep the workbook handy as you go through the workshop to engage in the required activities. • This is a web-based workshop, and thus has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic. • At the bottom of each page are navigational buttons to help you move through the workshop. • You can go through as much or as little of the workshop as you like at a time. • If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion. Back to Start of Workshop

Next Back Evidence-Based Care Program These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop clinical pathways and other evidence-based care tools based on clinical practice guidelines, that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, Grey Bruce Health Unit, and the Community Care Access Centre). It is hoped that these pathways will improve: • Coordination of care through more communication across professions; • Continuity of care, through increased linkages among hospitals and the CCAC; • Clinical outcomes, through increased usage of best practices; and • Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop

Next Back Vaginal Birth Pathway Package • This pathway is for patients who come to our hospital for a vaginal birth. • The pathway consists of 7 parts: • Clinical Practice Guideline • Pre-Printed Orders • Patient Pathway • Patient Education Booklet • Breast Latch Assessment Tool • Vaginal Birth Clinical Pathway • Newborn Clinical Pathway Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Practice Guideline • Two guidelines were used in the development of this pathway - “Family Centred Maternity and Newborn Care: National Guidelines”, Health Canada, and “Healthy Beginnings: Guidelines for Care During Pregnancy and Childbirth”, Society of Obstetricians and Gynecologists of Canada (SOGC). • These guidelines summarize the evidence used in the development of this pathway. • They can be found electronically on the GBHN website www.gbhn.ca . Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Pre-Printed Orders • There are four sets of pre-printed orders for this pathway package: • Admission orders • Postpartum orders • Newborn orders • Newborn Circumcision orders • These orders can be found on the unit. Back to beginning of VB section Back to Start of Workshop

Next Back Patient Materials • This package has a patient pathway, which explains to the patient what is happening to them while in hospital. It should be given to the patient in the pre-admission clinic. • In addition, there is a patient education booklet called “Having your baby in a Grey Bruce Health Network hospital”, which should also be handed out in the pre-admission clinic. • This booklet should be discussed at the pre-admission clinic to go over any questions before the patient arrives, and discussed again in the postpartum period before the patient is discharged. • There are also several accompanying education materials that should also be used for education of the caregivers. • There are three pieces – “Let’s Grow a Healthy Baby”, “Community Resources for Parents”, and “Hearing Screening for your New Baby” Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Pathway • This pathway is intended for patients who have come in for a Vaginal Birth. • The first page of the pathway is the Pre-Admission Page. It is to be used when the patient comes in for her pre-admission appointment. • At the right hand side of the sheet is a place to enter the date. There is also one column to enter the date of the clinic appointment. • The top two rows of some pathway pages have the patient outcome and performance indicators we are looking to achieve for that day. These indicators need to be inputted into the Variance Record as “met” or “not met”. Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Pathway • Then, using the column for your shift, tasks are initialed as they are completed, or enter N/A and initial if they are not applicable to the patient. For example, if it is the night shift and you are not doing any patient teaching, indicate N/A and initial in the section for Psychosocial/Education under “Review Patient Pathway”. • The next page of the pathway is Labour Triage with Admission. You will notice that for this page and all pages through to the end of labour, the column to the right has been omitted. This is because there are standard documentation forms used on the unit that duplicate these tasks. The task list is there for informational purposes. However, the indicators should still be noted on the variance record if not met by the end of the phase of labour. Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Pathway • Once the Postpartum period is reached, the columns to the right return to the pathway, and so tasks should be initialed when completed, or indicate N/A and your initial if the task does not apply to the patient. • You will notice a new task beginning Postpartum 3-24 hours that refers to a Latch Score. This refers to a Breast/Latch Assessment toolthat is to be used. • The Discharge Criteria, the second last page of the pathway, should also be checked daily. If any of the criteria have been met, these should be initialed and dated. Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Pathway • Once the baby is born, the Newborn Pathway should be started on the baby’s chart. • This pathway is a day-style pathway, and follows the baby’s stay for the 48 hours in hospital. • Like the mother’s pathway, tasks should be initialed as they are completed, or indicate N/A and initial if the task does not apply for the patient. For example, if the baby is female, circumcision will not be discussed under “Psychosocial Support/Education”, so this can be entered as N/A, and initialed. • The discharge criteria (2nd last page) should be checked daily and initialed if any of the criteria are met. • In addition, any indicators need to be entered on the Variance Record as “met” or “not met”. Back to beginning of VB section Back to Start of Workshop

Next Back Vaginal Birth Clinical Pathway • When all discharge criteria have been met for both baby and mother, they can be discharged home. • To do this, the Discharge Summary of the Variance Record for each pathway need to be filled in. Then the Variance Record can be pulled from the chart and sent to your Site Champion for evaluation purposes. Back to beginning of VB section Back to Start of Workshop

Next Back End of Vaginal Birth section This is the end of the general information for the Vaginal Birth pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the Vaginal Birth workshop. Test your knowledge of Vaginal Birth by doing the Vaginal Birth quiz. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Try it! Click hereto see the clinical pathway. Take a look at the clinical pathway. On the first page is a master signature sheet. Sign it, and then for the remainder of the pathway you can just initial as tasks are complete (if you have a Master Signature Sheet for your facility, this will not be on your pathway page). There are also some basic instructions on the first page on how to use the pathway. Each page will need a patient ID sticker, except the Variance Record. The Variance Record is for evaluation purposes only, and so does not need individual patient information on it. Flip to the first page of the pathway, “Pre-Admission Clinic””: On the first page of each pathway will be a section for comorbid conditions. Please list any conditions the patient has that may affect the care you are giving. This will help health records in coding Nancy appropriately. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d Our sample patient Nancy is pregnant and has arranged for a hospital visit and pre-admission appointment. During her visit, the nurse can refer to the pathway to ensure all topics are discussed, and initial as tasks are completed. In addition, she will initial the indicators, and input them into the Variance Record. (See sample page filled out) Nancy should also receive her patient education materials at this visit and instructed to bring these with her when she comes back in to have the baby. When Nancy arrives in hospital in labour, the Labour Triage With Admission page should be started. You will notice on this day and through all phases of labour through to postpartum, that there are no columns on the right hand side to fill out. This is because these tasks are already found on the standard corporate documentation used on your unit. However the pathway serves as a cue sheet for all tasks that should be completed during that phase. In addition, all indicator should be inputted in the Variance Record as “met” or “not met”. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d Once labour is complete, the pathway moves into the postpartum phase. The first page is the first two hours postpartum. There is one column to the right of all tasks at this point, and these are initialed as they are completed. You can use your corporate progress notes if you require further documentation. Some tasks are not appropriate for all patients or all time frames. In these cases, you can indicate an N/A and initial to show this. Take a look back at the indicators. Let’s assume that Nancy did not begin breastfeeding within the first hour postpartum. This needs to be indicated on the Variance Record. On the Variance Record, enter Nancy’s age, 29, Gender, and Admission Date along the top. Then look at the table below this area. Beside the indicator, tick off “not met”, date and initial. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d The next column is “Code”. Look on the back of the Variance Record. There is another table here, with common reasons for variances on it. Find the one that is most applicable to your variance, and put this on the front of the Variance Record in the “Code” section. If there were any corrective action that you could do to fix this variance, you would write it in the next section. If not, indicate N/A, and initial. At a later time, when the variance has been resolved (if it can be resolved), whoever finds the variance resolved will initial and date this. In this case, either breastfeeding was initiated or it wasn’t, there is no corrective action required. So, indicate this by putting “N/A” and initialing in the boxes to the right of “Code”. (see a sample page completed) Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d The next page of the pathway is the rest of the first postpartum day. You will see three columns on the right hand side (one for each shift – if there are only two 12 hour shifts, you will only need two of these) –write in today’s date at the top. Below the date, write in the hours you will be caring for Nancy. You will then use this column to initial as each task on that page is completed. (see a sample page completed). The rest of the sections are tasks that are to be completed for that day. Again, some tasks are not applicable to each patient, or to each shift. For example, if it is night shift, you may not be teaching Nancy, so under “Psychosocial Support/Education”, you can indicate “N/A” and initial “Review Patient Pathway”. On each day of all pathways, you will notice a referral to a Patient Pathway. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d Nancy should have her patient pathway from the preadmit clinic. If she does not, we can give her another one for teaching purposes. However, if Nancy is not ready for education, indicate N/A on the pathway in this section and initial this task until she is ready for education. The education materials, including the handout – Having Your Baby in a Grey Bruce Health Network Hospital and the other brochures and booklets listed on the first page of this booklet can be referenced to aid you in teaching. Also, the Patient Pathway should be referred to on a daily basis to help Nancy understand the plan of care. You will notice on the postpartum pages that there is a reference to a Latch Score assessment. This refers to the Breast/Latch Assessment tool, which helps document feeding and latching of the baby. See a sample filled out. . Back to beginning VB section Back to Start of Workshop

Next Back Simulation Cont’d At the end of each day, in the Discharge Planning section (last section of each page), you will notice it says “Assess Discharge Criteria Daily”. This means you will need to flip to the second last page, the Discharge Criteria, on a daily basis, at some point during the day, and check if any of these goals have been met. If they have, initial and date them. Once the baby is born, there is another pathway to be used for his/her chart, called the Newborn pathway. It works much the same as the Vaginal Birth pathway. The Newborn pathway follows the same format as the postpartum 3-24 hours and 24-48 hours. There are tasks to be initialed for each day, and indicators that should be met as well. Back to beginning of VB section Back to Start of Workshop

Next Back Simulation Cont’d Let’s assume it is the second postpartum day, and Nancy and her baby have now achieved all the Discharge Criteria. They are now ready to be discharged. Once Nancy is discharged, all that remains to be done is filling out the Discharge Summary on the Variance Record. Take a look at this. At the bottom of each Variance Record, there is some basic information we are looking to collect on each patient to help us evaluate the pathway. Fill this in, and then take the Variance Record off of the chart, and give to your site champion. (see a sample Summary Completed). This will be forwarded to the Evidence-Based Care Program Coordinator, who will use the information on the Variance Record for evaluation of the pathway. If Nancy is transferred to another hospital, there are instructions for this on the back of the Variance Record. Make sure the proper materials get forwarded to the receiving hospital, so they can continue using the pathway. Back to beginning of VB section Back to Start of Workshop

Back Vaginal Birth Quiz • What are the inclusion/exclusion criteria for this pathway? • What patient education materials are used for this pathway? When are they handed out? • When is this pathway started? • Where is the documentation done during the phases of labour? • What is the Breast/Latch Assessment tool and how is it used? Back to Start of Workshop Answers

Back Answers: Vaginal Birth Quiz • What are the inclusion/exclusion criteria for this pathway? This pathway is used for all women admitted for vaginal birth with no identified risk factors. • What patient education materials are used for this pathway? When are they handed out? There is the booklet – Having your baby in a Grey Bruce Health Network Hospital, as well as accompanying materials – Let’s Grow a Healthy Baby, Community Resources for Parents, and Hearing Screening for your Baby. These are all handed out in the pre-admission clinic. • When is this pathway started? This pathway is started in the preadmission clinic. • Where is the documentation done during the phases of labour? There is standard corporate documentation already in existence for the phases of labour, so documentation is done on these sheets rather than on the pathway to avoid duplication. • What is the Breast/Latch Assessment tool and how is it used? This tool is used to help us assess the mother’s breast, as well as how the baby is feeding and latching. • If you have had difficulty with any of these questions, go back through the material on this pathway and/or the general pathway information in this workshop, or ask your Site Champion any other questions you have. Back to beginning of VB section Back to Start of Workshop

Vaginal Birth Pathway Workshop: Evidence-Based Care Program