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Obstetric Aspects of the Early Discharge of Maternity Patients

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Obstetric Aspects of the Early Discharge of Maternity Patients 520 26 August 1967 Discharge of Maternity Patients-Arthurton and Bamford MBJ2RRL early discharge, and long-stay hospital patients is recorded; REFERENCES it has shown that mothers confined in hospital begin to feed Brit. med. ,, 1964, 2, 70. their babies and become established breast-feeders more often College of General Practitioners, Bradford Group (1966). Lancet, 1, Br Med J: first published as 10.1136/bmj.3.5564.520 on 26 August 1967. Downloaded from than do women delivered at home. 536. Craig, G. A., and Muirhead, J. M. B. (1967). Brit. med. 7., 3, 520. Douglas, J., Edgar, W., and Home, K. (1961). Med. Offr, 106, 333. We wish to thank Dr. A. P. Roberts for permission to review Hellman, L. MA, Kohl, S. G., and Palmer, J. (1962). Lancet, 1, 227. cases in his care; Miss G. Clayton, Matron of St. Luke's Maternity Ministry of Health (1958). Repon of the Matertity Services Committee Hospital, and Miss E. R. Entwhistle, Supervisor of Midwives, for (Cranbrook Report). H.M.S.O., London. their invaluable help on numerous occasions; and Dr. G. Hill for Pinker, G. D., and Fraser, A. C. (1964). Brit. med. 7., 2, 99. statistical advice. We wish to pay tribute to a very loyal junior Theobald, G. W. (1959). Ibid., 2, 1364. staff. - (1962). Lancet, 1, 735. Obstetric Aspects of the Early Discharge of Maternity Patients G. A. CRAIG,* M.B.E., F.R.C.S., F.R.C.O.G.; J. M. B. MUIRHEAD,* M.B., B.CH., M.R.C.O.G. Brit. med. J., 1967, 3, 520-522 It is now nine years since planned early discharge of the normal women in each parity group is shown in Table II. The length mother and normal baby on the second day of the puerperium of stay in hospital of the 5,000 patients is given in Table III. was commenced in Bradford. The scheme has since been in con- The original policy was to discharge on the second day those tinuous operation, and to date approximately 13,000 puerperal mothers and babies whose condition did not seem to justify women have been managed in this way. Theobald (1959, 1962) further hospital care. A number of women who had had and Douglas et al. (1961) described the reasons for and the abnormalities during labour or at the time of delivery have initial planning of the scheme, and recorded its early results. participated in the scheme. The incidence of intrapartum In 1966 members of the College of General Practitioners complications in the 5,000 patients whose records were analysed (Bradford group) reported on a survey of 100 early discharge is shown in Table IV. The complications that occurred at the cases. time of delivery in patients discharged early are recorded in Five thousand consecutive case records have been analysed Table V. in order to show the types of patients that have participated in the scheme. Abnormalities that occurred but which were not TABLE IV.-Intrapartum Complications in Patients Discharged Early thought sufficiently important to warrant retaining the patient in hospital for longer than 60 hours have been recorded. The Intrapartum Complication Prinmigravidae Multigravidae purpose of the paper is to present these results, and it also Artificial rupture of membranes 512 (10-2%) 916 (18-3%) http://www.bmj.com/ Oxytocin drip .. 84 (1-7%) 197 (3-9%) includes a discussion of our experience. Pyrexia 99-99 8° P. (37 2-37V7° C.) on two or more occasions .. 17 (0 3%) 38 (0-8%) Pyrexia 10O' F. (37.80 C.) and over 3 (0 06%) 9 (0 2%) Patients Discharged Early TABLE V.-Complications at Time of Delivery in Early Discharge Of the 5,000 patients whose records were analysed 70% Patients were booked for hospital confinement and 30% were emergency during the antenatal period or during labour. Complication Primigravidae Multigravdae admissions either on 1 October 2021 by guest. Protected copyright. The age distribution is recorded in Table I. The number of Ruptured perineum .. 520 (10-4%) 866 (17-3%) Episiotomy . 533 (10 7%) 324 (6-5%) Forcepsdelivery .185 (3-7%) 79 (16%) Distribution Patients Early Breech delivery .27 (0o5%) 69 (1-4%) TABLE I.-Age of Discharged Other vaginal delivery .. 16 (0 3%) 31 (0-6%) Manual removal of placenta 9 (0 2%) 30 (0 6%) Age Group Primigravidae Multigravidae Postpartum haemorrhage without transfusion .. .. 49 (1-0%) 85 (17%) Under 20 years .421 (8-4%) 89 (1 8%/ ) Postpartum haemorrhage with 20-24 years 644 (12-9%) 695 (13-9%) transfusion 2 (0 04%) 9 (0 2%) 25-29 years 320 (6-4%) 1,028 (20-60') 30-34 years 136 (2-7%) 848 (17-0%) 35 years and over .30 (0 6%) 789 (15-8%) TABLE II.-Parity Distribution of Patients Discharged Early Hospital Organization Para .. 1 2 3 4 5 + The early discharge scheme has resulted in a considerable No.(%) 1,551 (31) 1,300 (26) 818 (16-4) 498 (10) 833 (16-7) increase in the work done in the hospital. St. Luke's Maternity Hospital is the only maternity hospital in Bradford. It was TABLE III.-Patients' Duration of Stay in Hospital designed to manage approximately 1,500 confinements a year. Before the introduction of the scheme in 1958 this figure had Primiparae Multiparae Total risen to 2,000 a year and since then it has continued to rise Duration of Stay N. % N 4No. % No. /0No| No. % until in 1964 it almost reached 4,000. Such an increase imposes Patients discharged in a very severe strain on all members of the hospital staff, less than 24 hours . 56 1.1 127 2-5 183 3-7 particularly. those engaged in the labour ward. In such circum- Patients discharged in 24-36 hours.. .. 1,094 21-9 2,450 49 0 ~,544 70 9 stances it is difficult to maintain standards and the continuous Patients discharged in 36-60 hours.. .. 401 8-0 872 17-4 1,273 25-4 * Consultant Obstetrician and Gynaecologist, Bradford. BRIsIS 26 August 1967 Discharge of Maternity Patients-Craig and Muirhead MEDICAL JOURNAL 521 supervision that is necessary. It was therefore necessary to incidence of eclampsia in booked patients has not gone up and review the existing arrangements within the hospital and to has remained consistently below that of non-booked patients. effect any changes that would help a willing and competent Table III shows that it has not been possible to discharge Br Med J: first published as 10.1136/bmj.3.5564.520 on 26 August 1967. Downloaded from nursing staff, whose numbers were inadequate, to meet the all patients on the morning of the second day; in nearly all increased demands made upon them. cases the decision to discharge a patient in less than 24 hours Ward clerks and ward and theatre orderlies have been was taken because beds were urgently required. Patients whose appointed as liberally as our financial resources permit in order that the nursing staff may be relieved, so far as is possible, from 3 all non-nursing duties. The labour ward of 12 beds is at the 2 time of writing staffed with six sisters, six midwives, five pupil 0 P. E.D. I . I midwives, two ward clerks, four theatre orderlies, and five \ DCMICILIARY ward orderlies. Staff rotation between the various wards is 0 . 09 practised. The theatre is now in charge of a sister who is not Z 0-8 a midwife. This particular innovation has been a success. So far as is possible, all operative procedures and abnormal muQ 07 OX 06 deliveries are performed in the operating-theatre. us 0*5* Patients in labour are admitted direct to the labour suite, I< 04 which is situated on the ground floor of the hospital. This I -0'S-1 suite has accommodation for 12 patients in labour, has two 0 3 delivery rooms, an anaesthetic room, and an operating-theatre. 0-2 Continuous with the labour suite is a recovery ward of 12 beds. 0 Patients who are thought to be suitable for early discharge are 58 59 60 6I 62 63 64 65 accommodated in the recovery ward until the decision to dis- YEAR charge or not to discharge them is made. FIG. 1.-Readmission rates, domiciliary and planned If for any reason a patient and her baby are not discharged early discharge patiens early they are immediately transferred to one of the lying-in wards. Those mothers who are to remain in hospital for 10 2 - days are usually transferred from the labour ward to one of the lying-in wards shortly after their delivery has been completed. 10- If, however, it is thought that their condition after delivery z warrants continued close supervision then they are accommo- LU 8 dated in the recovery ward until their condition has improved sufficiently to warrant their transfer to a lying-in ward. As a 6 result of this reorganization the acute work of the hospital is 0 accommodated on one floor and there has been a considerable 4 reduction in the movement of patients within the hospital. It z has also facilitated both medical and nursing arrangements. 2 We have been greatly impressed with the advantages that have resulted from a centralized labour ward, with adjacent 0 .II I . delivery room, operating-theatre, and recovery room. We believe 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 http://www.bmj.com/ that single rooms should be provided for women in labour and YEAR that these should be large enough to allow normal deliveries to FIG.
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