Chapter

Introduction and Basic Principles

1 Shad Deering

Introduction 1 Summary 3
General Principles 1

Introduction
Managing patients on a labor and delivery suite can be a daunting task for any provider. It is
an intimidating place to learn, where the clinical situation is constantly changing and more
blood is being lost in a shorter amount of time than nearly anywhere else in the hospital.
The care team is charged with taking care of two patients at the same time and must take
into account how the care of one affects the other. Add to this the fact that you are dealing
with all the expectations that nine months of pregnancy brings to the new parents, and that
decisions must often be made quickly to ensure the best outcome when emergencies arise,
and you have the modern labor and delivery ward.
Too often in obstetric training, the management of laboring patients is learned by
being thrust onto labor and delivery without the benefit of adequate preparation for
what will be encountered. While there is much that can only be learned by actually
doing, such as cervical exams and deliveries, it is imperative to understand certain basic
principles of labor and delivery management up front. This book is intended to provide
a simple, structured overview of how to manage laboring and postpartum patients and
function on a labor and delivery unit. While senior physicians and nurses must
continue to teach and mentor junior staff, residents, and students how to perform
obstetric exams and procedures, this book will provide a solid framework and back-
ground to work from.
The following is a concise set of general principles and information about labor and
delivery that every provider should know.

General Principles
1. Understand the basics. The goal of this text is to help you to know the basic concepts
you will need to manage laboring patients, as well as to recognize when problems occur.
If you don’t understand why a complication occurs, it is difficult to anticipate or correct
it. You also need to know what medications, doses, and instruments to ask for during
emergencies, because there are situations where even a short delay can make the
difference between life and death. This knowledge is critical to responding to urgent
situations in a calm and appropriate manner. While taking care of patients is a team

1
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 2 Chapter 1: Introduction and Basic Principles

effort, junior or inexperienced staff may not know what you need in an emergency, and
you must be very specific in terms of medication doses, instruments needed, and where
to find them.
2. Never be afraid to ask for help. The best providers, when they are unsure of the proper
course of action, will ask for another opinion. When, not if, a situation arises and you do
not know what to do, think through the problem and have an idea of what you would like
to do, and then ask for guidance. It is a sign of maturity, not weakness, to ask for help,
and it will protect your patients.
3. Do not make decisions without examining the patient. When you first start to work
on a labor and delivery ward, it is imperative to look at the patient before making
decisions about management. As you progress and your clinical skills improve, you
will have an idea of exactly what to do before you see the patient. But if there is
ever a question in your mind about what action to take, then go and see the
patient. This especially applies to the interpretation of fetal heart rate (FHR)
tracings, which always look slightly different at the bedside, sometimes more
reassuring, sometimes less.
4. Communicate with your team. Nothing you will learn from this book can help you if
you don’t work well with the rest of the care team. More than half of poor outcomes in
obstetrics are related to breakdowns in communication and teamwork. Make it a point
to know all of their names. At the beginning of every shift, be clear on who is the staff,
charge nurse, anesthesia staff, etc. Keep them informed when you are expecting patients
on labor and delivery, when you decide to admit a patient, and whenever you write an
order or the plan of care changes. Doing these simple things will make your job of
working on and managing a busy labor and delivery unit infinitely easier, and will keep
your patients safe.
5. Know where supplies are located. If you are faced with an emergency, e.g.,
a postpartum hemorrhage, an eclamptic seizure, or fetal bradycardia, and everyone is
busy with other patients, it is imperative that you know where to get the appropriate
medications, instruments, or forceps in a timely manner. Remember that even if it isn’t
your role to go and get the medication, you may have to tell a new person where to
find it.
6. Practice with simulation when possible. In the past, much of what you would do in
labor and delivery was learned by the “see one, do one, teach one” method, but there are
now simulators available for many procedures. You can practice performing a vaginal
delivery, repairing vaginal lacerations, and even managing complications without any
risk to actual patients. There is clear evidence that working with simulators can improve
outcomes in real life. For an example and explanation of this, you can watch the TEDx
talk “Why Doctors Should Play with Dolls,” which can be seen at www.youtube.com/
watch?v=rnuNft5sWUg.
7. Assume the worst and hope for the best. Whenever you evaluate a patient for
a complaint, even one as simple as a headache, think of the worst thing it could be and
work backward to the most benign. This will prevent you from missing the diagnosis of
something uncommon but serious in favor of a more common and minor problem.
An example of this is a headache in pregnancy. While it may be due to lack of sleep,

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 Chapter 1: Introduction and Basic Principles 3

a migraine, or a simple cold, you should think of preeclampsia first and convince
yourself that this is not the cause. It is usually an easy thing to rule out severe problems,
but at least you will have considered them and not missed something that could have
significant consequences for the patient.
An important part of this last basic concept is not to unnecessarily worry the patient.
Do not tell every woman who has a headache, “I just want to make sure you don’t have
a tumor or bleeding in your head.” You must consider everything to be thorough, but
you do not need to mention the very serious but rare possibilities if you can rule
them out.

Summary
By choosing to work on the labor and delivery unit, you assume an awesome responsi-
bility. There is no greater reward or feeling than helping to bring life into the world, and
no greater guilt than when things go poorly and you wonder if you could have done
better. This book is written with the weight of this in mind. It will help you both to
manage the normal, uncomplicated laboring patient, and to respond quickly and
appropriately to common obstetric emergencies. Thank you for taking the time to
prepare and do the best for your patients.

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