Labour analgesia procedure

Concept ID	Description
231259006	Administration of epidural test dose
231260001	Administration of epidural top-up
231261002	Combined spinal/epidural local anaesthetic block
231263004	Combined spinal/epidural technique – spinal needle through Tuohy needle
231262009	Combined spinal/epidural technique with needles at separate spaces
427060008	Continuous thoracic epidural analgesia
1285642008	Dural puncture epidural
18946005	Epidural anaesthesia
67716003	Epidural injection of anaesthetic substance, therapeutic, caudal, continuous
58611004	Epidural injection of anaesthetic substance, therapeutic, lumbar, continuous
1287360000	Injection of epidural anaesthesia during maternal intrapartum period
16388003	Injection of spinal anaesthetic agent for analgesia
2549821000000101	Intramuscular injection of opioid
2549841000000108	Intravenous injection of opioid
180885006	Local anaesthetic lumbar epidural block
231253007	Local anaesthetic lumbar intrathecal block
398044000	Low dose epidural
427035008	Nitrous oxide and oxygen gas analgesia
426060003	Nitrous oxide and oxygen gas analgesia in labour
397905008	Patient controlled epidural analgesia
2549861000000109	Patient controlled intravenous analgesia of opioid
2549871000000102	Patient controlled intravenous analgesia of remifentanil
2570311000000106	PIEB (programmed intermittent epidural bolus) infusion of therapeutic substance
231254001	Saddle block
231249005	Spinal anaesthesia

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests.
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history.

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning.

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”