ALARM Course Manual

942 Pages·2015·20.11 MB·English

Advances in Labour and Risk Management
22nd Edition — 2015–2016
ALARM
Course Manual
The ALARM Course Manual is published by the SOGC.
Copyright SOGC 2015-2016. All rights reserved.
Reproduction of this material is not permitted without explicit written consent of the SOGC.
Views expressed in the document do not necessarily reflect those of the SOGC members.
Canadian Cataloguing in Publication Data
Main entry under title:
ALARM Manual 22nd edition
ISBN 978-1-897116-53-1
1. Health Care – Obstetrics
2. Labour – Risk Management
22nd Edition ALARM Course Manual
Purpose
This course arose out of our work in the care of women in labour, their babies, and their families. Our single overriding objective
is to improve the outcome and the process of intrapartum care. One way to achieve that objective is through our continuing
education. The ALARM course is one means of that education. The course is maintained and taught by family physicians,
nurses and midwives and obstetricians. It has had the administrative support and backing of the Society of Obstetricians and
Gynaecologists of Canada. It is based on the best current evidence we have about what works to improve care, and incorporates
Canadian practice guidelines.
We hope that the course helps you as we learn together.
The information and recommendations in this syllabus reflect the emerging clinical and scientific advances
as of the date of issue and are subject to change without notice. The information should not be construed
as dictating an exclusive course of treatment or procedure to be followed. Correct drug dosages should be
verified before administration.
Purpose 1
22nd Edition ALARM Course Manual
Recognition
This 22nd edition of the course syllabus was revised under the direction of the 2015 ALARM Committee members.
2015 ALARM Committee Members:
Kim Butler (Co-Chair), MD, Fredericton, New Brunswick Caroline Delisle, MD, Greenfield Park, Québec
Jonathan Hey (Co-Chair), MD, Saskatoon, Saskatchewan Stephen DiTommaso, MD, Montréal, Québec
Heather Baxter, MD, Calgary, Alberta Sharon Dore, RN, PhD, Hamilton, Ontario
Carol Cameron, RM, Markham, Ontario Veronique Mareschal, MD, Chicoutimi, Québec
Virginia Clark, MD, Golden, British Columbia Marie-Jocelyne Martel, MD, Saskatoon, Saskatchewan
Richard Claveau, MD, Hearst, Ontario Judy Scrivener (ALARM Coordinator), Ottawa, Ontario
Catherine Cowal, MD, Oakville, Ontario
2015 Obstetrical Content Review Committee Members:
P. James Ruiter (Co-Chair), MD, London, Ontario Robert Gagnon, MD, Verdun, Québec
Suzanne Toni Wong (Co-Chair), MD, Toronto, Ontario Michael Helewa, MD, Winnipeg, Manitoba
Haim Arie Abenhaim, MD, Cote-St-Luc, Québec Jonathan Hey, MD, Saskatoon, Saskatchewan
Amanda Ashe, RM, Antigonish, Nova Scotia Andrew Kotaska, MD, FRCSC, Yellowknife, Northwest Territories
Christine Bloch, MD, Stratford, Ontario Dean C. Leduc, MD, Ottawa, Ontario
Sheri DeMeester, RN, BScN, London, Ontario Diane Sawchuck, RN, PhD, Vancouver, British Columbia
Sharon Lynn Dore, RN, PhD, Burlington, Ontario Courtney Green (OCR Coordinator), Ottawa, Ontario
William Ehman, MD, Nanaimo, British Columbia
The ALARM Program acknowledges the contributions of the original ALARM members:
Peter Beresford, MD, New Westminster, British Columbia Cheryl Levitt, MD, Hamilton, Ontario
June Carroll, MD, Toronto, Ontario Jaelene Mannerfeldt, MD, Okotoks, Alberta
George Carson, MD, Regina, Saskatchewan J. Kenneth Milne, MD, London, Ontario
Anne Doig, MD, Saskatoon, Saskatchewan Jean-Marie Moutquin, Sherbrooke, Quebec
Lisa Graves, MD, Sudbury, Ontario Shelly Rechner, MD, Hamilton, Ontario
Owen Hughes, MD, Ottawa, Ontario John Smith, MD, Dundas, Ontario
Robert Kinch, MD, Westmount, Quebec Thirza Smith, MD, Saskatoon, Saskatchewan
André B. Lalonde, MD, Ottawa, Ontario Roger Turnell, MD, Edmonton, Alberta
Carolyn Lane, MD, Calgary, Alberta Carlos Brailovsky (educational consultant)
Bruno Lemieux, MD, LaSalle, Quebec
Recognition 1
22nd Edition ALARM Course Manual
Disclaimer
SOGC has done its best effort to provide a product that is useful in terms of providing educational information based on an
evaluation of scientific literature and medical experience. The educational content attempts to describe principles of practice
generally applicable in most circumstances.
This information should not be deemed inclusive or exclusive of all methods of care. The ultimate judgment regarding the care of
a patient must be made by the physician in an informed consultation with the patient, in light of all the circumstances presented
by the patient, the diagnostic and treatment options available, and access to the necessary support resources.
The ALARM program is provided for educational purposes only and is to be used as a tool in assessing the knowledge and skill
of the user. You are advised that it is one of the tools to be used to assess and assist you in upgrading your skills in the subject
matter provided by the program. SOGC makes every effort to provide current information but no representations are made or
implied that the information and materials are completely accurate at all times.
Disclaimer 1
22nd Edition ALARM Course Manual
List of Topics
Objectives
At the completion of this course, registrants will be able to:
• improve the outcome and process of intrapartum and immediate postpartum care
• apply knowledge and skills in their practices in the following areas:
Communication, Consultation, Documentation, and Disclosure
Evidence-Based Obstetrics
Bad News in the Birthing Room
Risk Management and Patient Safety
Women’s Sexual and Reproductive Health
Management of Labour
Induction of Labour
Umbilical Cord Prolapse
Fetal Well Being During Labour
Vaginal Birth
Assisted Vaginal Birth
Delivery of Twins
Vaginal Birth After Caesarean Section (VBAC)
Shoulder Dystocia
Breech Presentation and Delivery
Postpartum Hemorrhage
Hypertensive Disorders of Pregnancy
Preterm Labour and Preterm Birth
Prelabour Rupture of Membranes (PROM)
Prevention of Early-Onset Neonatal Group B Streptococcal Disease
Antepartum and Intrapartum Hemorrhage
List of Topics 1
22nd Edition ALARM Course Manual
Suggested Readings
The ALARM faculty has used a variety of sources including standard textbooks and articles from the usual journals. In particular,
we have relied on the following:
1. The Cochrane Pregnancy and Childbirth Database. (Distribution ceased after 1995)
2. The Cochrane Library (http://www.thecochranelibrary.com/). Free access (citation and abstracts only) is available
to all users; full-text access is available by subscription (existing provincial licenses currently provide free access to
residents of New Brunswick, Nova Scotia, and Saskatchewan).
3. Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hutton E, et al. A guide to effective care in pregnancy and childbirth.
3rd ed. Toronto: Oxford University Press; 2000.
4. Basket TF, editor. The essential management of obstetrical emergencies. 4th ed. Bristol (UK): Clinical Press; 2004.
5. Healthy Pregnancy and Infancy sections of the Public Health Agency of Canada website
(http://www.phac-aspc.gc.ca/hp-ps/index-eng.php).
6. Society of Obstetricians and Gynaecologists of Canada clinical practice guidelines
(http://www.sogc.org/guidelines/index_e.asp) (see also listing on USB).
7. Additionally we have used two video tapes.
• The Safe and Appropriate Use of Forceps in Modern Obstetrics (available from Janssen-Ortho)
• Term Breech Patient Selection and Intrapartum Management (available from Wyeth Pharmaceuticals)
Suggested Readings 1
22nd Edition ALARM Course Manual
Communication, Consultation,
Documentation, and Disclosure
Effective communication is key to inter-professional team work and quality patient care. Guidelines have been developed by
many professional bodies that provide principles to foster optimal care and positive professional communication. Ineffective
communication has been identified as the leading root cause of perinatal sentinel events reported to the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) between 1995-2005.1
An event is defined as an unexpected occurrence that either caused harm (a harm event), or had the potential to cause harm (a
no-harm event). Both of these are adverse events.2
© Joint Commission Resources: Sentinel event statistics. Oakbrook Terrace (IL):
Joint Commission on Accreditation of Healthcare Organizations; 2006.1 Reprinted with permission.
Several accreditation and professional organizations have noted that communication issues are the leading reason for
complaint investigation. The current emphasis on patient safety stemming from reports of avoidable harm has revealed intra
and inter-professional communication as a key focus. The first and essential step toward establishing a clinical world where
Communication, Consultation, Documentation, and Disclosure 1
22nd Edition ALARM Course Manual
teamwork is reality is in the development of effective team communication and mutual respect.3 A Cochrane review on
interventions to promote collaboration between nurses and doctors showed that increasing collaboration improved outcomes of
importance to patients and health care managers.4
Principles of Communication
Effective communication occurs when “a message is transmitted, received, comprehended and acted upon in a timely fashion”.5
The following is a list of enablers of effective communication:
• Mutual respect
• Language that is clear and precise
• Timely flow and transfer of relevant information
• Clear delineation of the roles of the communicators
• Respect for confidentiality
• Conducive environment
• Inclusion of all people to whom the information pertains6
Professionalism in communication requires that caregivers understand and acknowledge the perspective of other professionals
and the perspective of learners within those professions. There has been an historical hierarchy in health care. This hierarchy is
not useful in a health care system that requires disciplines to work as a team. No one profession can function in isolation. All
professions must utilize the expertise, skills, perspectives and information of other caregivers to provide comprehensive, co-
ordinated care.7
Lack of true interprofessional educational programs as a component of basic training makes the transition to an interprofessional
model of care challenging. Maintaining the focus on the patient and quality of care will foster this process.7
Strategies to facilitate interprofessional care and planning might include:
• Skill drills for emergency situations involving all caregivers (Rehearsing responses to emergencies as a team using
evidence-based, unit-specific protocols in mock drills—simulations either low or high fidelity—facilitates
efficiency, performance, and effectiveness in real emergencies. Drills also provide an opportunity to ‘practise’ effective
communication between caregivers.)
• Committee structure that involves all professions
• Care planning that incorporates input from a variety of disciplines
• Debriefing unusual events as a team
• Non-punitive interprofessional case reviews
• Development of interprofessional procedures
Communication, Consultation, Documentation, and Disclosure 2
22nd Edition ALARM Course Manual
Key Points Related to Communication
1. Non-verbal messages (“body language”) are five times more influential than verbal messages.
Non-verbal communication is unconsciously motivated and more accurately indicates a person’s meaning than the
words being spoken.8 The tone of the words and inflections constitute a major element of communication.
2. Precision in language is key.
The care team must use language that is clear and with agreed-upon abbreviations understood by all. Written
language must also be accurate – casual use of terms such as “fetal asphyxia” results in inappropriate labelling. Clearly,
it goes without saying that neat and legible must be the standard when handwriting messages in order for ‘precision
in language’ to be maintained.
Mutually agreed-upon language is essential for fetal heart rate (FHR) interpretation and documentation. The potential
for miscommunication between team members is decreased when everyone is speaking the same language as with
respect to electronic fetal heart monitoring data for example.9
Cognitive underspecification adds another dimension to precision. Cognitive underspecification was defined by James
Reason as communication style that leads to a gap in knowledge. The concept was extremely well explained by
Elizabeth Duthie in her work “Recognizing and Managing Cognitive Underspecification.” We quote a paragraph from
her paper:
Cognitive underspecification is ubiquitous whenever verbal communication occurs. It is frequently unrecognized and
may or may not lead to errors. An example of cognitive underspecification is seen in the following event from critical
care. In the ICU, in response to a nurse’s verbal report that a patient had a low potassium level, the resident said ‘‘let’s
give him a run of 10X4.’’ The nurse entered the order into the computer for potassium chloride 10 meq. IV Q1 hr X 4
doses. This was what the resident intended, despite the lack of a stated drug name, complete dose, route, or schedule.
The intended order and the executed order were identical. The lack of an error can be attributed to a well-known,
familiar communication pattern and a knowledge gap that was closed with matching, accurate information. If the
clinicians were asked if the communication was complete, accurate, and clear, they very well may have responded
‘‘yes’’ as they had no doubts about what course of action to follow. Techniques such as repeat/read back will not
necessarily correct cognitive underspecification. If the nurse repeats back ‘‘Give him 10X4’’ and the resident says ‘‘yes,’’
they have simply confirmed the incomplete communication.11
If we imagine the same conversation between the resident and a co-worker new to the unit, or vice versa, incomplete
communication leading to a serious knowledge gap could occur. We do not recognize the above example as a problem
when it occurs in our domain – as a result, we all do it.
Communication, Consultation, Documentation, and Disclosure 3