1. © 2004-2007 Grey Bruce Health Network Education Workshop (click to go to the desired section) Introduction to Workshop/Instructions Evidence-Based Care Program Vaginal Birth Pathway Workshop Vaginal Birth

2. © 2004-2007 Grey Bruce Health Network 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.underlined like this 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 NextBack

3. © 2004-2007 Grey Bruce Health Network 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 NextBack

4. © 2004-2007 Grey Bruce Health Network 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 Start of Workshop Back to beginning of VB section NextBack

5. © 2004-2007 Grey Bruce Health Network Vaginal Birth Clinical Practice Guideline Two guidelines were used in the development of this pathway - “Family Centered 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. www.gbhn.ca Back to Start of Workshop Back to beginning of VB section NextBack

6. © 2004-2007 Grey Bruce Health Network 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 Start of Workshop Back to beginning of VB section NextBack

7. © 2004-2007 Grey Bruce Health Network 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.patient pathway 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. (When printing booklet from GBHN website include the Pacifiers and Respiratory Syncytial Virus(RSV) handouts )Having your baby in a Grey Bruce Health Network hospital 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 4 pieces – “Let’s Grow a Healthy Baby”, “Community Resources for Parents” order from Public Health Unit at (519) 376-9420 x 433, and “Hearing Screening for your New Baby” Hearing Foundation at 866-HEAR-YOU) Back To Sleep (613) 954-5995 or visit the website at: www.hc-sc.gb.ca/hppb/childhood-youth Back to Start of Workshop Back to beginning of VB section NextBack

8. © 2004-2007 Grey Bruce Health Network 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 Labour Triage with Admission. It is to be used when the patient presents to hospital.Labour Triage with Admission At the right hand side of the sheet is a place to enter the date. The patient outcome and performance indicators we are looking to achieve need to be dated and inputted as “met” or “not met”. There is space on this page for your progress notes (use regular progress note sheets if more space is needed) Back to Start of Workshop Back to beginning of VB section NextBack

9. © 2004-2007 Grey Bruce Health Network Vaginal Birth Clinical Pathway The next two pages of the pathway cover Postpartum (3- 24hrs) and Postpartum 24-48hrs. Date and time 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. The patient outcome we are looking to achieve is to be initialed and inputted as “met” or “not met”. There is space available for progress notes on the bottom at the back of the page (add regular progress notes page if you require more space) Back to Start of Workshop Back to beginning of VB section NextBack

10. © 2004-2007 Grey Bruce Health Network Vaginal Birth Clinical Pathway You will notice a new task beginning Postpartum 3- 24 hours that refers to a Latch Score. This refers to a Breast/Latch Assessment tool that is to be used. Breast/Latch Assessment tool The Discharge Criteria, the last page of the pathway, should also be checked daily. If any of the criteria have been met, these should be initialed and dated.Discharge Criteria Back to Start of Workshop Back to beginning of VB section NextBack

11. © 2004-2007 Grey Bruce Health Network Newborn Clinical Pathway Once the baby is born, the doctor can use the Postpartum and Newborn order sets. The Newborn Pathway should be started on the baby’s chart.Newborn Pathway 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. Back to Start of Workshop Back to beginning of VB section NextBack

12. © 2004-2007 Grey Bruce Health Network Newborn Clinical Pathway  Indicators need to be entered as “met” or “not met”.  The discharge criteria (last page) should be checked daily and initialed if any of the criteria are met.  Space is available for progress notes on the bottom at the back of the page (add regular progress notes page if you require more space).  When all discharge criteria have been met for both baby and mother, they can be discharged home Back to Start of Workshop Back to beginning of VB section NextBack

13. © 2004-2007 Grey Bruce Health Network 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.Simulation Test your knowledge of Vaginal Birth by doing the Vaginal Birth quiz. Vaginal Birth quiz. Back to Start of Workshop NextBack Back to beginning of VB section

14. © 2004-2007 Grey Bruce Health Network Simulation Try it! Click here to see the clinical pathway.Click here 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. Flip to the first page of the pathway, “Labour Triage with Admission”: Back to Start of Workshop Back to beginning of VB section NextBack

15. © 2004-2007 Grey Bruce Health Network Simulation Cont’d Our sample patient Nancy is pregnant and has arranged for a hospital visit and pre-admission appointment. During her visit, Nancy should receive her patient education materials and be 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. It also includes the Performance and Patient Outcome Indicators for Active Labour and the 1 st 2hrs Postpartum. Back to Start of Workshop NextBack Back to beginning of VB section

16. © 2004-2007 Grey Bruce Health Network Assess the Patient Outcome and Performance Indicators Labour Triage with Admission 1. Patient received appropriate prenatal care □ Met □ Not Met □N/A 2. Patient meets criteria for admission □ Met □ Not Met □N/A 3. Fetal Heart rate measured by intermittent auscultation □ Met □ Not Met □N/A Do any documentation on the progress notes at the bottom of this sheet instead of your regular progress notes. Complete other documentation as per your corporation. Back to Start of Workshop NextBack Back to beginning of VB section

17. © 2004-2007 Grey Bruce Health Network Assess the Patient Outcome and Performance Indicators Active Labour 4. Fetal Heart rate measured by intermittent auscultation □ Met □ Not Met □N/A 5. IV or Saline Lock started for medication administration only □ Met □ Not Met □N/A Do any documentation on the progress notes at the bottom of this sheet instead of your regular progress notes. Complete other documentation as per your corporation. Back to Start of Workshop NextBack Back to beginning of VB section

18. © 2004-2007 Grey Bruce Health Network Simulation Cont’d Once labour is complete, the pathway moves into the postpartum phase first 2 hours. Assess the Patient Outcome and Performance Indicators 6. Immediate skin-to-skin Mother-Newborn contact 7. Breastfeeding initiated within 1 st hour postpartum Do any documentation on the progress notes at the bottom of this sheet add your regular progress notes sheet if you need more space. Complete other documentation as per your corporation. Back to Start of Workshop NextBack Back to beginning of VB section

19. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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 with postpartum first 24 hours and 24-48 hours. There are tasks to be initialed for each day, and indicators that should be met as well. 1. Prophylactic medications given after 1 hr post-birth 2. Breastfeeding assessed using latch assessment tool Back to Start of Workshop NextBack Back to beginning of VB section

20. © 2004-2007 Grey Bruce Health Network Simulation Cont’d The next page of the Vaginal Birth pathway is the rest of the first postpartum day(3-24 hrs). You will see columns on the right hand side (one for each shift ) –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. 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”. 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. Back to Start of Workshop NextBack Back to beginning of VB section

21. © 2004-2007 Grey Bruce Health Network Patient Pathway and Education Materials On each day of all pathways, you will notice a referral to a Patient Pathway. The Patient Pathway should be referred to on a daily basis to help Nancy understand the plan of care. 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.handout – Having Your Baby in a Grey Bruce Health Network Hospital. Back to Start of Workshop NextBack Back to beginning VB section

22. © 2004-2007 Grey Bruce Health Network 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 last page, the Discharge Criteria once a shift, and check if any of these goals have been met. If they have, initial and date them. Back to Start of Workshop NextBack Back to beginning of VB section

23. © 2004-2007 Grey Bruce Health Network 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. If Nancy is transferred to another hospital, there are instructions on what documents to send the receiving hospital, so they can continue using the pathway on the first page of the pathway under the heading “HOW TO USE THE CLINICAL PATHWAY” Back to Start of Workshop NextBack Back to beginning of VB section

24. © 2004-2007 Grey Bruce Health Network Vaginal Birth Quiz 1. What are the inclusion/exclusion criteria for this pathway? 2. What patient education materials are used for this pathway? When are they handed out? 3. When is this pathway started? 4. Where is the documentation done during the phases of labour? 5. What is the Breast/Latch Assessment tool and how is it used? Back to Start of Workshop Back Answers

25. © 2004-2007 Grey Bruce Health Network Answers: Vaginal Birth Quiz 1. 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. 2. 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. 3. When is this pathway started? This pathway is started in the preadmission clinic. 4. 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. 5. 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 or contact EBC program Back to beginning of VB section Back to Start of Workshop Back