Sentinel 4G Death of a baby (twin) Review completed. Causal findings The induction process for new medical following emergency around staff is reviewed and adjusted to ensure caesarean section. there is suitable orientation to the facilities, the need for a more support services and to the likely impact of comprehensive programme of these on clinical practice adjustment and orientation for Obstetric Specialists to the rural Ensure best evidence guidelines specific environment, to the WCDHB are developed, disseminated and available within the unit the need for a local guideline for on; the management of twins to assist electronic fetal monitoring - staff when unexpected events including mention that where occur, continuous fetal monitoring is the absence of multidisciplinary indicated but unable to be training in Greymouth to facilitate obtained, Fetal Scalp Electrode communication between disciplines in (FSE) should be used complex clinical situations - may have the management of twin labour resulted in staff not effectively sharing and delivery including delivery in – their knowledge of local procedures, theatre for all twins not questioning decision making nor A course specifically to improve suggesting the use of additional management of obstetric emergencies is procedures/equipment. run at the WCDHB as a way of improving multidisciplinary teamwork between Obstetricians, Midwives, Anaesthetists, Duty Nurse and Midwife Managers etc That consideration is giving to transferring women with multiple pregnancies to a tertiary centre at an appropriate gestational age.
Sentinel 4G Death of a baby (twin) following emergency caesarean section. Review completed. Causal findings around the need for a more comprehensive programme of adjustment and orientation for Obstetric Specialists to the rural environment, the need for a local guideline for the management of twins to assist staff when unexpected events occur, the absence of multidisciplinary training in Greymouth to facilitate communication between disciplines in complex clinical situations - may have resulted in staff not effectively sharing their knowledge of local procedures, not questioning decision making nor suggesting the use of additional procedures/equipment. The induction process for new medical staff is reviewed and adjusted to ensure there is suitable orientation to the facilities, support services and to the likely impact of these on clinical practice Ensure best evidence guidelines specific to the WCDHB are developed, disseminated and available within the unit on; electronic fetal monitoring - including mention that where continuous fetal monitoring is indicated but unable to be obtained, Fetal Scalp Electrode (FSE) should be used the management of twin labour and delivery – including delivery in theatre for all twins A course specifically to improve management of obstetric emergencies is run at the WCDHB as a way of improving multidisciplinary teamwork between Obstetricians, Midwives, Anaesthetists, Duty Nurse and Midwife Managers etc That consideration is giving to transferring women with multiple pregnancies to a tertiary centre at an appropriate gestational age.
SSE_cases_2010_11_FINALv1.docx