Table 4 Summary of recommended interventions to improve management of foetal distress following baseline audit feedback

I. Interventions to improve pre-operative assessment and management of foetal distress

1. Specialist on call should stay within the hospital compound at all times

2. In case of emergency, midwives should communicate directly with the specialist when residents on call are unavailable

3. Specialist on call should make regular visits in the labour ward, preferably during morning major ward round and afternoon and evening service ward rounds

4. Strengthen documentation during patient review, either by self, over the phone, or during major ward round

5. Provide Fetal Dopplers and vacuum extractors, and re-train doctors and midwives on foetal heart monitoring and vacuum extraction

6. Doctors should register their private mobile phone numbers in the doctors’ free call system provided by Voda Com mobile company to improve communications and consultations within MNH and with external referring points

II. Interventions to reduce decision to delivery interval

1. In cooperation with and appraisal of ‘the Golden hour’ of decision to delivery intervention as part of the “Kaizen” hospital quality improvement system

2. Enforce mandatory prior communication of foetal distress to operating theatre after decision of CS to insist on the level of emergency and facilitate prioritisation in theatre

3. Re-organise midwives’ shifts to cater for increased workload during off hours and public holidays

4. Strengthen leadership and re-organise feedback meetings and clinical rounds to encourage teamwork and constructive routine perinatal audits among doctors and midwives

5. Care providers in theatre including obstetrician/resident on call, theatre nurse and anaesthesiologists/anaesthetists, should triage patients together in the pre-operative ward

6. Provide extra operating space by opening the gynaecology theatre for obstetric patients in the event of being overwhelmed by the workload in the two obstetric theatres

7. Referred patients should be sent to MNH when the decision of referral is made, rather than accumulating several patients to be referred all at once