Houseman Guide (updated 3/4/14)

LABOUR ROOM

New patient may come from PAC or ward. Read the BHT for diagnosis and underlying
condition, and find out what urgent thing to do.

1) ARM
* VE Before ARM, If Os <4, to informed mo , KIV to send pt back to ward if not
indicated .
2) Make sure head is engaged (not floating, HPA 3/5 or less) before do ARM, this is
to prevent cord prolapse
- make sure Membrane Intact. If the bulging of the membrane is not easily
palpable, you can try (1) push up the baby head slightly with your fingers, be
careful not to cause cord prolapse (2) ask the mother to bear down or cough (3)
empty the bladder (4) apply fundal pressure
- If membrane absent, just performed VE to confirm the findings. You will be able
to feel the hair of the baby. If you accidentally leave scratch mark on baby head,
please be responsible to explain and apologize to the mother and document in
BHT  explain mark will fade off, not to worry
- Proper post ARM documentation. Problem list, VE findings, Liqour clear/ LMSL/
TMSL, no cord, no placenta
- GDM on Diet control
- to do DXT stat and 2 hourly.
- If DXT > 7, to start sliding scale. Also to remember to refer paeds post delivery
for infant of diabetic mother on D/c started on sliding scale.
- GDM on s/c insulin
- start sliding scale immediately. Take RBS and BUSE to look out for diabetic
ketoacidosis
- Analgesic choice
- Im pethidine 50mg /75mg prn + Im Phenergen 25mg prn for primigravida
/pseudoprimid / previous LSCS untested / very thick posterior cervix & small OS
- IM nubain 10mg prn for those who have previously gave birth vaginally

*Controlled ARM is to be performed by MO/ with MO supervision

2) insert green branula and take blood  every patient in labour room
Dr Halimah emphasized that we should set branula before performing ARM. In a
case of amniotic fluid embolism, the circulatory system will collapse very soon and we
will have great difficult in getting a line.
GSH for cases with high risk PPH or high tendency for LSCS :
- LMSL/TMSL
- 1 previous scar
- Rhesus negative mother
- Grandmultigravida
- IE/PE/HTN crisis on iv medications
- GDM on s/c insulin
- SGA/ IUGR babies
3) post ARM
- Interpret CTG post ARM and record/write on the CTG paper (baseline, BTBV,
acceleration and deceleration, number of contraction in 10 min)
- Inform to MO if any abnormalities (type 1, type 2 decelecation, unprovoked
deceleration, variable deceleration, poor variability, delay recovery )
- Do not start pitocin in suspicious/ pathological CTG
- observe CTG post pitocin ( 1 hour after starting pitocin)
- If type 1 deceleration (due to compression on head, parasympathetic response),
ask the mother to apply left lateral position + oxygen. If patient dehydrated,
consider hydration by saline infusion, off pitocin if on
- If poor variability, for left lateral position + oxygen, perform VE to stimulate
baby. Off pitocin if on

4) call paeds to standby if

- ventouse delivery (to inform specialist O&G on call first and if allow then call
paeds)/ forceps
- premature baby (<36 weeks)
- TMSL with os full and going to SVD
- Abruption with OS full and going to SVD

5) Preparation for Caesarean section

- If you are alone, FILL UP THE OT LIST FIRST ,then follow by consent
taking (include husband h/p no), set green branula and take FBC, RP, GSH, then
order OT with patient’s name registered in ward (not from PAC), Call the HO in
charge for OT, and lastly order the lab investigation and GSH
- If patient having bleeding placenta previa and abruption placenta, please prioritize
ordering the GXM, speak to MO blood bank, prepare the ice-box, bring along
transfusion form and run for the blood. You may assign other HO for this
important task. OT will not take start until the Whole blood is ready
-
6) WHITE board management
- When you arrive early in the morning, fill in the HO name in charge for OT and
Labour room
- New patient -> write the name and diagnosis in BLUE/BLACK, risk factor in
RED
- Write the followings in BLUE/BLACK: clear liquor, time for next review
- Write the following in RED: LMSL, Membrane absent, GSH taken
- Once patient has delivered, write “~SVD~” or “~Ventouse~”. Do not rub away
the risk factor that has been written
- If patient planned for EMLSCS, please also write “~EMLSCS~`” so that the JM
will know easily which patient to bring to OT
- Once MO has reviewed that patient, draw a sine wave across that row
- Once patient is transferred out to Post natal ward, clear the name on the board.
This is to facilitate JM to assign bed to new patient
 7) WARD STATUS
- One HO please take the initiative to update the ward status in the morning.
- Information required how the number of patients in each ward, antenatal and post
natal, gyne patient
- Number of cases for IOL. Include the diagnosis (parity, gestation age), indication
for IOL and relevant information
- Number of cases for Caesarean section and its indication

8) Baby update
- Post night HO is responsible to update the newborn. Check the BIG
REGISTRATION BOOK to look for newborn that was admitted to Melor 2 or
NICU.
- Information required for baby admitted to NICU: mode of delivery, complication,
apgar score, reasons for admission into NICU, latest diagnosis by paediatrician,
latest update (CXR findings, duration of antibiotic, surfactant given, intubation,
any desaturation, mode of artificial ventilation, plan for extubation)
- For baby admitted to Melor 2, just do a summary (e.g. 3 baby for presumed
sepsis, 2 for infant of GDM on s/c insulin, 1 for macrosomic baby and 1 for infant
of Rhesus negative
- Daily update for some babies requested by specialist

AFTER PT DELIVERED
1) check baby
- write on baby check list
refer paeds if:
- suction LMSL
- presumed sepsis
- infant of GDM mother on s/c insulin
- SGA/macrosomic baby
- Low apgar score
- any others abnormalities
* please fill in the baby check list even though you refer to paeds

2) order medication for mother :

 Ask any Drug allegry hx before prescribe the medication !
 If Pt has GASTRITIS pls not to give NSAIDs
 If allegry to penicillin pls give ???
- If perineum intact/ skin nick: T. paracetamol 1g TDS for 3 days
- If 1st degree tear and episiotomy: T. voltaren 50mg TDS, T. gelusil II/II TDs, T.
amoxicillin 500mg TDS, T. flagyl 400mg TDS for 5 days
3) When you have no urgent tasks on hand, you may order the neotatal TSH and G6PD
for the baby.
Special notes
*For Mother of rhesus negative, order the following for the cord blood: ABO, coombs,
Reticulocyte, serum bilirubin, neonatal TSH, G6PD
*Order cord blood ABG if baby low apgar score- orders STAT on mothers name and
send ABG yourself STAT . Write in comment ‘ baby ABG’ . If delayed in sending ABG
will not accurate ( because baby registration takes time by PAP)
*New rules: If sending for HPE placenta, for send the whole placenta as sample, with
PERPAT form

Special regulation by dr Tan JW (especially on days he is on call,)

- When you have no urgent task, please do the following:
(1) Counsel the patient for the use of entonox (50% N2) + 50% Oxygen) – to take 6
deep breath (not shallow and not continuous) of entanox when patient beginning
to feel the contraction pain (not during the peak of the pain). No need to take if
not in pain. If side effect occurs (dizziness, headache, nausea), just stop taking
Entanox, close the eyes for some rest. Give assurance to patient that she will fine
(2) Counsel all patients on the indication, risk and complication of LSCS, especially
those with higher tendency for LSCS. Patient can understand better when they are
not in pain and stress.
(3) Allergy history and stamp it on the admission form
(4) Apply the CTG to patient, interpret and show any abnormality to MO( make sure
toco well apllied)
(5) Involve actively in conducting the labour, delivering the placenta and repairing
the perineum
(6) Post delivery monitoring: BP

Special request by dr Sushil

- to perform pelvimetry on all primids/ pseudoprimid/ previous scar maybe for poor
progress, secondary arrest , failed IOL , prolonged second stage not feasible for
instrumentation
- An adequate pelvis would have the following criteria
- Sacral promontory: not palpable
- Sacrosciatic notch: can easily fit 2 fingers
- Ischial spine: not prominent (which means cannot feel both ischial spine at the
same time. Please note that ischial spine is the landmark for the station 0 )
- Lateral wall: parallel or divergent
- Subpubic angle >90 degrees
- Intertuberositas diameter: can easily fit 4 knucles (apply the fist outside the vulva)
Glove size
7 ½ Dr Chandran, Dr Sushil ,Dr Shamsul, Dr Shasi, Dr Farhan,
7 Dr Priyah, Dr Azri, dr seema, Tan CG (not proceudre)
6 ½ Dr Azura, Dr Najah, Dr Maslina, Dr Tan CG ( procedure )
If you have any questions, please do not hesitate to ask Dr Seema. She will be most
happy to clarify your doubts.

***IF You all dun know anything, Please Kindly OPEN YOU GOLDEN MOUTH.
MO ARE KIND!!

** PLEASE PREPARE A BLACK AND RED PEN. Write all the normal
investigation findings with black pen and all the abnormal investigation findings with
red pen.

** Please be more active. You all are allow to do lot’s of things.

Please ask permission before you do any procedure .
You must learn:
1. How to manage O&G Emergency Case
2. Must know how to conduct
3. Must know how to do episiotomy and repairing
4. Must know how to scan ( Love the Probe and love the machine)
5. Must know how to manage the comment O&G case as listed in the log book
6. Must help MO in PAC, like help us in clerking, do the scan if you able to and
prepare for CS if indicated and some blood taking and sample order.
“We feel lonely”
(WARNING: We were not allowed to clerk in PAC, 1patient=extension of 1week!!!
Ordered by Dr.Kuna)
7. Must join all the activity in O&G
e.g. Caeser audit every Tuesday, time will be informed on the day
CME every Thursday morning at 8am
HO teaching

If you have time, please read more and challenge us. We are welcome your
Question. But please dun ask the “brainless” question !

**All highlighted sentences are added/modified by Dr.Tan CG**

Be a safe doctor, stay out of troubles 

<--------By : Dr Chin & Dr Fathee ------ approved by Dr Seema 3/4/2014----