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Canadian Journal of Rural Medicine
CJRM Winter 2000 / hiver 2000

Rural patient stories/rural physician management narratives

James T.B. Rourke, MD (Chair)*; James H. Goertzen, MD; Sharon N. Hatcher, MD; Paul W.H. Humphries, MD; Stuart J. Iglesias, MD; Sarah Mackinnon, MD; Lise Morin, MD; Sarah-Lynn Newbery, MD; Conleth O'Maonaigh, MB BCh; Paul Rainsberry, PhD; Joshua Tepper MD; Carl Whiteside, MD; Mark E. Whittaker, MD

CJRM 2000;5(1):21.


In developing the report, "Postgraduate education for rural family practice: vision and recommendations for the new millennium"1,2 the Working Group† felt it was important to illustrate rural family practice with a series of rural patient stories/physician management narratives.1­3 These demonstrate the broad range of knowledge, skills and attitudes used by rural family physicians in responding to the needs of their patients. They provide examples of rural maternity care, mental health care, long-term pediatric genetic disease care and trauma care. They are based on real-life dramas from diverse rural locations across the country. Certain details of these patient stories/physician management narratives have been altered or based on composite examples to protect the identity of the individuals involved. The first on rural maternity care appears here.

Rural maternity care

Setting

A 20-bed hospital with anesthesia backup, but the GP surgeon is away. The nearest referral centre is 2 hours away by road and 45 minutes by air (total transfer arrangement time is 1.75 hours).

Patient's history

A 33-year-old woman, a one-pack-per-day smoker, gravida 3, para 1, aborta 1, presents at 41 weeks and 5 days' gestation with regular contractions. The contractions are strong and every 4 minutes, lasting 45 to 60 seconds each and have been ongoing for 2 hours.

Obstetrical history

Normal pregnancy to date. Dates are accurate and there have been no complications. There were no complications in her prior delivery (stage 1 was 10 hours, stage 2 was 1.5 hours and stage 3 was normal with no postpartum hemorrhage).

Examination findings

Vertex presentation, 4 cm dilatation, a small bulge in the membranes, station -2. The baseline fetal heart beat was 125 beats/min, with good variability, no accelerations and occasional variables.

Decisions: The following decisions need to be made:
  • Should she be kept in this setting or transferred (no cesarean-section backup)?
  • Should she have an artificial rupture of membranes (ARM)?
  • Should she be sent home?
  • Should she have continuous or intermittent fetal monitoring?
Knowledge: The progress of labour, antenatal risk factors, monitoring fetal well-being in labour can be identified.
Skills: Pelvic examination, interpretation of fetal heart status, management of labour, ability to communicate with the patient.
Attitude: Awareness of surroundings and of limitations of the hospital setting with no cesarean-section backup; awareness of the principles of risk management in rural obstetrics.
Plan: Because of the woman's history of smoking, and because she is past her due date, the doctor recognizes the risks for possible placental post maturity. There are no other risk factors, so a decision is made to intermittently monitor with one-on-one nursing care (an extra nurse has
to be called in). The doctor communicates well with the patient to make her aware that there is no cesarean-section backup and to give her the option of transfer at this time or to stay in the community and continue to labour. The doctor also offers the option of ARM. A decision is made for her to stay in hospital locally and not to do ARM at present, as the stage of labour is early.

Labour progresses slowly. She is at 5-cm dilatation 2.5 hours later. No late decelerations are noted with intermittent monitoring and the fetal heart baseline rate is 120 to 125 beats/min. The membranes are still intact.

Decision: The following decision must be made:
  • Should her labour be augmented? If so, what is the best way to do this?
Knowledge: Active management of labour.
Skills: ARM.
Attitude: Risk management.
Plan: ARM is performed because of ease of manoeuvre, evidence to support is the same as the technique for augmentation, and because the doctor would like the labouring mother to be able to continue to walk.

When ARM is performed, meconium is noted. Continuous fetal monitoring is initiated because of concern about fetal well-being. The fetal heart demonstrates a baseline rate of 120 beats/min with variable decelerations, which are slow to recover.

Decisions: The following decisions are required:
  • Should the patient be allowed to continue to labour in the present setting?
  • Should another doctor be consulted?
Knowledge: Indicators of fetal well-being, and nonreassuring signs.
Skills: The ability to interpret the fetal heart tracing and possibly to do a fetal scalp pH.
Attitude: Clinical courage, knowledge of surroundings and local resources and awareness of transfer options and difficulties.
Plan: Another local doctor is consulted and asked to remain "on standby" for neonatal resuscitation if delivery occurs before transfer is arranged. Transfer to the referral centre is discussed with the ambulance base and consulting obstetrician. Weather conditions preclude air transfer. The decision is made to reassess progress in 30 minutes and if there is no progress, or if fetal well-being appears to be endangered, to transfer by road with a doctor in attendance. Thirty minutes later, the woman is 8 cm dilated, the fetal heart rate is 115 beats/min with variable decelerations with every contraction, with slow onset and slow recovery. The scalp pH is 7.23. A decision is made to keep her in the local hospital because of rapid progress since ARM. A second doctor is notified of the patient's progress thus far and of the pH results.

Fifteen minutes later, she is fully dilated with the urge to push.

Stage 2 is 40 minutes in duration with reasonable progress. Deep variable decelerations with slow recovery to a new baseline fetal heart rate of 90 beats/min.

Decisions: The following decisions are required:
  • When should the second doctor be called in?
  • Should a vacuum extraction be attempted?
Knowledge: A normal pattern of second-stage labour, fetal heart interpretation.
Skills: Operative delivery (vacuum or forceps), pudendal block.
Attitude: Clinical courage, commitment to optimize health of both baby and mother, and willingness to use local resources.
Plan: A second doctor is called to ensure neonatal resuscitation tools are in working order, and appropriate medications are drawn up. The decision to perform vacuum extraction is discussed with the second doctor and the decision is made to expedite delivery because of the observation of meconium, and deep variables of fetal heart beat with slow recovery and new baseline bradycardia. Vacuum extraction is performed with easy delivery and intact perineum. The neonate is suctioned on the perineum but is limp and does not cry upon delivery. The neonate is given to the second family doctor who uses a laryngoscope to view the cords and suction the oropharynx for a small amount of meconium. No meconium is visualized below the cords. With 100% oxygen and stimulation, the neonate breathes spontaneously, and the heart rate remains more than 100 beats/min.
Knowledge: Management of stage 2.
Skills: vacuum extraction, neonatal resuscitation.
Attitude: Cooperation of both doctors with one another, good communication between doctors and registered nurses and with the neonate's parents.

Decisions: Three decisions must be made:
  • How can complications now be prevented for the mother?
  • How can complications be prevented for the neonate?
  • How can the health care team be debriefed after this delivery?
Knowledge: Prevention of complications in mother (i.e., with use of syntocinon at the time of delivery), appropriate management of stage 3, evidence for ophthalmic antibiotics, and vitamin K for the neonate.
Skills: Examination of the newborn, postpartum examination of vagina, perineum, etc.; ability to communicate with the health care team to debrief.
Attitude: The importance of prevention, recognition of the importance of communication with the health care team, dedication to the continuity of care for the new family.


Correspondence to: Dr. James Rourke (Chair), Director, Southwestern Ontario Rural Medicine Education, Research and Development Unit, 53 North St., Goderich ON N7A 2T5

This article has been peer reviewed.

*The Working Group for the report "Postgraduate education for rural family practice: vision and recommendations for the new millennium" prepared for the College of Family Physicians of Canada

†A diverse group, comprising members of the College of Family Physicians of Canada (CFPC), the Society of Rural Physicians of Canada (SRPC), and a representative from the Royal College of Physicians and Surgeons of Canada. The group included practising physicians from rural and remote communities across Canada whose practice profiles included special skills and interests in such areas as anesthesia, obstetrics and emergency work. It includes physicians involved in teaching both students and residents for rural practice, family medicine residents, rural program coordinators, a postgaduate family medicine program director, and an associate dean of postgraduate medical education. The group was directed to review the current state of postgraduate education for rural practice in Canada and to outline an appropriate curriculum to prepare new family physicians for the challenges of rural practice. The report was endorsed by the SRPC in April 1999 and approved by the CFPC Board in May 1999.


References
  1. Working Group on Postgraduate Education for Rural Family Practice. Postgraduate education for rural family practice. Vision and recommendations for the new millennium. Can Fam Physician 1999;45:2698-704.
  2. Postgraduate education for rural family practice: vision and recommendations for the new millennium. Full report. A report of the Working Group on Postgraduate Education for Rural Family Practice. Approved by the College of Family Physicians of Canada Board -- May 12, 1999. www.cfpc.ca/ruralpaperfull.htm. Accessed Nov. 19, 1999.
  3. Rourke JT. What a challenge! [editorial] Can Fam Physician 1999;45:2567-8.

© 2000 Society of Rural Physicians of Canada