advanced labour ward practice atsm 2018 · web viewthe atsm comprises 5 advanced skills modules...

Colour key: Common competency framework competencies Medical leadership framework competencies Health inequality framework competencies

Advanced Labour Ward Practice (2018) – approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018AimTo underpin the management at Consultant level of high-risk pregnancy both intrapartum and post-partum.

PrerequisitesSuccessful completion of an Obstetric Emergency Course, for example MOET or equivalent.The Basic Obstetric Ultrasound modules must be completed prior to starting the ATSM.Please note that this ATSM is a prerequisite for the Labour Ward Lead ATSM.

Key componentsThe ATSM comprises 5 Advanced Skills Modules (ASM). Completion of all 5 ASM is required to be awarded the ATSM as part of CCT. Outwith CCT, individual ASM may be recognised separately as part of continuing professional development towards your CPD programme.

ASM 10 Key Intrapartum Obstetric Medical Disorders Identical to the ASM of the same name in the Obstetric Medicine ATSM

ASM 14 Key intrapartum scenarios and the technical and non-technical skills necessary for their management. ASM 15 Ultrasound to support intrapartum care. ASM 16 The range of conditions encountered on Labour Ward.ASM 17 Effective communication and governance skills for the Labour Ward.

Educational SupportAttendance at the annual RCOG/BMFMS Advanced Labour Ward Course or an equivalent course prospectively approved by your Regional Preceptor.Attendance at the course must be after registering for the ATSM and no more than three years prior to completing the module.TOG, STRATOG and e-portfolio support is provided by the RCOG.

Clinical SupportThe ATSM should be undertaken under the supervision of an identified Obstetric Consultant supervisor, who must be in a position to directly supervise and assess competence as well as approve appropriate professionals to train for the wider curriculum components.An average of least two sessions per week is required to work towards the targets.Additional, specific, themed sessions relevant to the ATSM are listed in the module.Work intensityFor pre-CCT trainees the ATSM has been allocated a work intensity score of 1.0.

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GMC Good Medical Practice (GMP) Domains: Domain 1: Knowledge, skills and Performance Domain 2: Safety and quality Domain 3: Communication, Partnership and Teamwork. Domain 4: Maintaining Trust


ASM 10 Key Intrapartum Obstetric Medical Disorders

Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence /assessment

(10.01) Severe preeclampsia

(10.02) Eclampsia

(10.03) HELLP syndrome

1,2

1,2

1,2

(10.01-10.3)Understand best practice for the management of severe pre-eclampsia. Including its definition, diagnosis, acute management and associated complications.

Understand the pathophysiology and pharmacology for the condition. Be able to interpret investigations

Understand the acute and long-term maternal and fetal risks associated with the condition.

1,2,3

1,2

1,2

(10.01)Take an appropriate medical history and examination of a woman with symptoms of severe disease.

Be able to interpret and act appropriately upon investigations.

Be able to construct a differential diagnosis and recognise symptom and signs of co-existing maternal disease (HELLP, chronic hypertension, pre-existing renal damage.)

(10.01-10.02)Manage cases of complex severe pre-eclampsia with:(a) HELLP(b) eclampsia(c) pulmonary oedema(d) acute renal failure

(10.01-10.02) Institute / modify drug therapies, plan delivery and postnatal care refer, where appropriate, for further assessment / treatment.

1,2,3,4

1,2,3

1,2

1,2,3

1,2,3

(10.01-10.03)RCOG Green to guideline N0.10a Pre-eclampsia /eclampsia management.

RCOG Patient information (2012) Pre-eclampsia.

(10.01-10.12)Each condition within ASM.10 is core to the understanding of medical problems during labour.

For each of the 12 conditions your supporting evidence must be based upon more than one case in which you have been directly involved.

Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.

In addition to direct exposure,

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Be able to give accurate advice for future pregnancies.

(10.02 -10,3)Be proficient in the acute management of eclampsia and HELLP according to best practice guidelines. Liaise effectively with the wider MDT.

1,2,3,4

1,2,3

CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover the breadth of the condition.

(10.04) Diabetes Mellitus

(10.05) Gestational Diabetes

1,2

1,2

(10.04) Understand how pregnancy influences diabetes and how diabetes can impact upon the pregnancy for both complicated and uncomplicated diabetes.

Pre-existing diabetes: pathogenesis & classification, prevalence, complications (metabolic, retinopathy, nephropathy, neuropathy, vascular disease).

Know how to undertake pre-pregnancy assessment and screening for complications.

Know how to monitor and optimise glucose control in pregnancy and postpartum.

Know how to manage hypoglycaemia and ketoacidosis in pregnancy.

1,2

1,2

1,2

1,2

1,2

(10.04) Perform, under supervision, appropriate assessment and management of women with pre-gestational diabetic complications

Ability to take an appropriate history and conduct an examination to assess a woman with pre-gestational diabetes.

Ability to perform and interpret appropriate investigations formulate, implement and where appropriate modify a multi-disciplinary management plan.

(10.04-10.05)Liaise with diabetologists, diabetic nurse specialists, dieticians, and other specialists where

1,2,3

1,2,3,4

1,2,3

1,2,3,4

(10.04 -10.05)RCOG Scientific impact paper No. 23 Diagnosis and treatment of Gestational diabetes.

NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period. RCOG Patient information (2013). Gestational diabetes.

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Know how to appropriately monitor the fetal condition at all stages of pregnancy.

(10.05)Understand how GDM is identified in pregnancy, its impact and how to mitigate its effects. Understand its short and long term implications.

1,2

1,2

appropriate, counsel, maternal and fetal risks, importance of good glycaemic control (including use of insulin in GDM)

Discuss long-term risks, contraception options and the management future pregnancies.

1,2,3,4

Attendance at Obstetric Medical clinics / adult diabetes clinics.

STRATOG Advanced, Maternal Medicine eLearning: Gestational diabetes mellitus (2016).

STRATOG Advanced, Maternal Medicine eLearning: Pre-existing diabetes without complications (2015).

(10.06) Known haemoglobinopathy 1,2 (10.06)Understand how haemoglobinopathy impacts upon the antenatal and intrapartum care of the woman.Understand the risks to the fetus and how these may be monitored.Understand the genetic basis for the

1,210.06)Manage thalassaemia or other haemoglobinopathy. Counsel on fetal and maternal risks, arrange and interpret appropriate investigations liaise regarding therapy, plan delivery and

1,2,3,4

(10.06)Green top guideline No.66 Thalassemia in pregnancy.

RCOG patient

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common haemoglobinopathies and what prenatal testing is available.

1,2 postnatal care.

Be able to explain the option of prenatal diagnosis. 1,2,3,

4

information (2015). Beta Thalassemia and pregnancy.

(10.07) High risk for venous thromboembolism

(10.08) Prior thromboembolism

1,2

1,2

(10.07-10.08)Understand how to quantify thromboembolism risk and how best to mitigate that risk.

1,2 (10.07-10.08)Manage a case of thrombophilia and / or previous VTE in pregnancy, arrange and interpret appropriate investigations.

Be able to accurately risk score for thromboembolism, and to communicate that risk effectively.

Discuss and plan treatment accordingly. Institute/modify VTE prophylaxis where appropriate.

1,2,3

1,2,3,4

1,2,3,4

(10.07-10.08)RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and after birth.

STRATOG Advanced, Maternal Medicine eLearning: Previous venous thromboembolism (2016).

(10.09) Renal disease in labour 1,2(10.09)Have an understanding of the effects of labour and the immediate postpartum period on chronic renal disease.

1,2 (10.09)Perform, under supervision, appropriate assessment and management of a labouring woman with renal disease.

Arrange and interpret appropriate investigations, formulate, implement and where appropriate modify a multi-disciplinary management plan

1,2,3,4

1,2,3

(10.09)STRATOG Advanced, Maternal Medicine eLearning: Kidney Disease in Pregnancy.

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with appropriate liaison where necessary.

(10.10) HIV including MDT approach to minimising potential sequelae.

1.2(10.10)Understand how HIV impacts upon the antenatal, intrapartum and postpartum care of the woman.Understand the risks to the fetus and how these may be reduced.

Understand the transmission of HIV and how viral load may be monitored and the treatments available.

1,2

1,2

(10.10)Manage a case of HIV in labour: plan mode of delivery and suitable treatment to minimise neonatal transmission.

1,2,3(10.10)RCOG Patient information (2013) HIV in pregnancy.

(10.11) Intrapartum pyrexia 1,2(10.11)

Understand the causes of pyrexia in labour, their investigation and treatment as well the potential impact upon mother and baby.

1,2 (10.11)Manage intrapartum pyrexia, coordinating midwifery, neonatal and microbiology assistance as required.

1,2,3(10.11)RCOG Green top guideline No.64 Sepsis in pregnancy.No.64b Sepsis following pregnancy.

(10.12) Increased risk to new-born from Group B Haemolytic Streptococcus

1,2 (10.12)Understand which groups are at increased risk of GBS and how to mitigate this increased risk. Understand the features of early and late onset neonatal GBS infection.

1,2(10.12)Explain risks and implement local policy to reduce risks of GBS in the new-born.

Liaise appropriately with neonatal team.

1,2,3,4

1,2,3

(10.02)RCOG Patient information (2013). Group B streptococcus infection in new-born babies.

ASM 10: Intrapartum Obstetric Medical Disorders Part of the Maternal Medicine ATSM and the Advanced Labour Ward Practitioner ATSM

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LogbookCompetence level Not required

Level 1 Level 2 Level 3ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature Date Signature Date Signature

Severe preeclampsia

Eclampsia

HELLP syndrome

Diabetes Mellitus

Gestational Diabetes

Known haemoglobinopathy

High risk for venous thromboembolism

Prior thromboembolism

Renal disease in labour

HIV including MDT approach to minimising potential sequelae.

Intrapartum pyrexia

Increased risk to new-born from Group B Haemolytic Streptococcus

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Training Courses or sessions

Title Signature of educational supervisorDate

Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

Completion of ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature

Safe and effective management of these maternal medical conditions has been achieved through direct exposure and decision making for a range of clinical cases including timely liaison with the MDT and tertiary services if appropriate.

ASM 14: Key intrapartum scenarios: non-technical and technical skills

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Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/assessment

Safely manage non-cephalic presentation.(14.01) Non-technical: Recognition and informed counselling for breech presentation.

(14.02) Technical: Competency for the recognition of non-cephalic presentation.

(14.03) Delivery of vaginal breech (may use Other Methodology).

(14.04) Delivery at caesarean section for breech and transverse lie.

1,2,3,4

1,2

1,2

1,2

(14.01- 14.04)

Understand the appropriateness of the different modes of delivery for breech, transverse and oblique lie presentations.

Understand how management might differ for multiple pregnancy.

Understand the manoeuvres to minimise the risks for both assisted breech delivery and breech extraction for singleton and multiple pregnancies during vaginal delivery and also at caesarean section.

Understand when ECV in labour (for breech, transverse lie and second twin) may be considered and the techniques involved.

Understand when and how internal podalic version is appropriate for multiple pregnancy.

1,2

1,2

1,2

1,2

1,2

(14.01-14.04)

Be able to communicate effectively in a manner that can easily be understood the risks accompanying all non-cephalic presentations and the options available.

Be able to construct a safe birth plan and where appropriate modify this according to the clinical findings as they evolve.

Effectively liaise where appropriate, with anaesthetists, midwifery and theatre staff and neonatologists.

1,2,3,4

1,2,3

1,2,3

(14.01-14.04)

RCOG Green top guideline No. 20a (2006) ECV reducing the risk of breech presentation.

No.20b (2006) Management of Breech Presentation.

For this ASM each intrapartum scenario listed is core to the safe practice on the delivery suite.

For each of the scenarios your supporting evidence must be based upon more than one case in which you have been directly involved.

Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.

(14.01-14.02, 14.09) OSATS of External Cephalic version in labour

(14.03) OSATS of

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Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/assessmentVaginal breech delivery and OSATS of Manual Rotation

(14.05-14.06) OSATS of Cervical cerclage

(14.11014.12) OSTAS of Rotational instrumental delivery

In addition to direct exposure, CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover the breadth of the condition.

Safely manage preterm labour.(14.05) Non-technical: Demonstrate expertise when balancing delivery with aiming to prolong pregnancy. Good communication with the family and wider MDT including

1,2

3,4

(14.05-14.07)Understand the pathophysiology, investigations and management of preterm labour and preterm premature rupture of membranes (PPROM).

1,2(14.05-14.07)Ability to liaise effectively with neonatologists / microbiologists; to arrange in-utero transfer if appropriate.

1,2,3(14.05)RCOG Green top guideline No.7 (2010) Antenatal steroids to reduce

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paediatric team.

(14.06) Technical: Proficiency in intrapartum care for preterm vaginal delivery.

(14.07) Technical: Proficiency in preterm (<32 week) caesarean section.

1,2

1,2

Understand the symptoms, signs and range of presentations for acute chorioamnionitis.

Understand when and how to use tocolytics.

Understand the maternal risks associated with preterm delivery and the options that are available to minimise these risks.

Understand the risks of prematurity to the fetus and for the neonate both the short and long-term risks.

1,2

1,2

1,2

1,2

Counsel women and their partners accordingly on the maternal, fetal and neonatal risks in a manner that is easy to understand.

Debrief and formulate a suitable management plan for future pregnancies.

1,2,3,4

1,2,3,4

preterm morbidity.

Green top guideline No. 1b Preterm labour and tocolytic drugs.

Scientific impact paper No.41 (2014) Perinatal management of the pregnant women at the threshold of fetal viability.

Scientific impact paper No.33 Preterm labour, antibiotics and cerebral palsy.

(14.06)No. 60 (2011) Cervical cerclage.

RCOG Scientific impact paper No.29 (2011) Magnesium sulphate to prevent cerebral

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palsy following preterm birth.

(14.07) Green top guideline No.45 (2015) Birth after previous caesarean section.

Safely manage multiple pregnancy.14.08) Non-technical: Formulate clear intrapartum care plans based on clear communication of all issues.

(14.09) Technical: Competency for the delivery of preterm multiple pregnancy.

(14.10) Technical: Competency for delivery by term caesarean section and term vaginal delivery.

1,2

1,2

1,2

(14.08-14.10)Understand the influence of fetal growth restriction, discordant growth, prematurity, chorionicity and malpresentation on the recommendation and successful conduct for all modes of delivery for multiple pregnancies.

Understand the role of intrapartum ultrasound and CTG monitoring for multiple pregnancies.

1,2

1,2

(14.08-14.10)Be able to construct a suitable intrapartum care plan, liaising appropriately.

Be able to explain the delivery options and any associated maternal and fetal risks in a manner that is easy to understand. risks

Be able to run a multiple pregnancy skills drill that could include:

- Malpresentation of twin 1

- Malpresentation of twin 2 after vaginal delivery of twin 1.

- CTG concerns- Preterm labour- ECV in labour- Internal podalic version

1,2,3

1,2,3,4

1,2,3

(14.08-14.10)NICE Clinical Guideline CG 129 Management of twin and triplet pregnancies in the antenatal period.

RCOG Green top guideline N0.51 Monochorionic twin pregnancy.

RCOG Consent Advice No.7 (2009) Caesarean Section

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Safe rotational vaginal delivery.(14.11) Non-technical: Provide appropriate information to support informed choice for all method of delivery options.

(14.12) Technical: Competency in at least 2 of the following 3 methods to rotate to the occipito-anterior position: manual rotation, ventouse rotation, and Kiellands forceps.

1,2

1,2

(14.11-14.12)Understand the indications and contra-indications for each form of instrumental delivery:Neville Barnes forcepsKiellands forcepsKiwi cup ventouse Soft cup ventouseMetal cup ventouse including the posterior cup.

Understand how each of the techniques is used for safe vaginal delivery and the options available if unsuccessful at any stage of their application.

Understand which method is preferable across all of the common intrapartum scenarios.

1,2

1,2

1,2

(14.11-14.12)Be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained.

Understand your own limitations for each method and liaise appropriately including seeking advice at an early stage if necessary.

Debrief after delivery; be able to record your findings and the procedure used accurately.

1,2,3,4

1,2,3

1,2,3,4

(14.11-14.12)RCOG Green top guideline No.26 (2011) Operative vaginal delivery.

STRATOG eLearning and simulation for instrumental delivery (2016).

STRATOG Advanced, Generic Skills Case Studies eLearning: Risk management of rotational forceps delivery (2015).

Safe delivery for the morbidly obese.(14.13) Non-technical: Good communication skills for the issues involved. Demonstrate MDT working and strategies to minimise risk.

(14.14) Technical: Competency in vaginal delivery for the morbidly obese (BMI > 40).

1,2,3,4

1,2

(14.13)Understand what delivery options are most suitable for those who are morbidly obese and how the use of the MDT may minimise the risks involved.

(14.14)Understand how to assess the suitability for assisted vaginal delivery where fetal macrosomia is a potential risk and where maternal obesity presents significant risks.

1,2

1,2

(14.13 -14.14)Be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained.

Liaise effectively with the MDT to minimise intrapartum and postpartum risks.

1,2,3,4

1,2,3

(14.13-14.14) CMACE/RCOG Joint Guideline (2010) Management of women with obesity in pregnancy.

NICE Guideline Intrapartum Care for High Risk

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Be aware of the techniques available to facilitate both vaginal delivery as well as caesarean section.

Understand how caesarean section rand postpartum risks may be minimised and the operative strategies that may be used to overcome the difficulties that are often encountered.

1,2

1,2

Women (in development 2017).

Safely manage PPH.(14.15) Non-technical: Demonstrate good communication skills and the use of MDT.

(14.16) Technical: Acute resuscitation and medication for PPH

(14.17) Technique: Uterine balloon tamponade.

(14.18) Technical: B Lynch suture technique.

1,2,3

1,2

1,2

1,2

(14.15-14.18)Understand the factors that predispose to PPH and how these risks may be minimised.

Understand the consequences of massive acute PPH and how the situation may be investigated and monitored.

Understand the role of the MDT for massive PPH.

Understand the surgical management of PPH: intrauterine balloon, brace suture internal iliac ligation hysterectomy and interventional radiology (vascular balloons and coils).

Understand the medical management of PPH: oxytocin, ergometrine, 15 methyl-prostaglandin F2, misoprostol, and recombinant factor VIIa.

1,2

1,2

1,2

1,2

1,2

(14.15-14.18)Be able to rapidly assess the extent of haemorrhage and institute appropriate resuscitative measures.

Ability to lead the team for all aspects of PPH including the acute maternal resuscitation, investigation and subsequent management.

Be able to run skills drill for primary PPH incorporating:- uterine atony- inverted uterus- adherent placenta- uterine rupture

Be able to debrief all involved and communicate effectively in a manner that can be easily understood.

1,2

1,2,3,4

1,2,3

1,2,3,4

(14.15-14.18)NICE Clinical Guideline CG190 (2014) Intrapartum Care.

RCOG Green top guideline No.52 (2009) Prevention and management PPH.

RCOG Good Practice Guideline No.6 (2007) The role of emergency and elective interventional radiology in PPH.

Observation of and discussion with senior

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medical staff

Appropriate postgraduate courses (Management of the Labour WardMOET or equivalent).

Sessions in Obstetric Anaesthesia, ITU/HDU.

STRATOG

Safely manage maternal sepsis(14.19) Technical: timely recognition, investigation and treatment.

(14.20) Non-technical: Demonstrate good communication skills with patient, relatives and MDT liaison.

1,2

1,2,3,4

(14.19-14.20)Understand the various causations and presentations of sepsis the maternal and fetal risks, how to investigate and manage suspected and confirmed sepsis.

Understand antibiotics pharmacology and which are most suitable for use in pregnancy and postpartum.

1,2

1,2

(14.19-14.20)If delivery is indicated be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained.

Be able to liaise effectively within the MDT to optimise the outcome for mother and baby.

Be aware of your own limitations and know when to seek further advice.

1,2,3,4

1,2,3,4

1,2,3

(14.19-14.20) RCOG Green top guideline No.44 (2010) Preterm prelabour rupture of membranes.

RCOG Green top guideline 64a (2012) Sepsis in Pregnancy and 64b (2012) Bacterial sepsis following pregnancy

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Safely manage antepartum stillbirth(14.21) Technical: Competency in the conduct of all stages of labour for stillbirth.

(14.22) Non-technical: Demonstrate good communication skills; explain diagnosis, management options appropriate investigations and follow up.

1,2

1,2,3,4

(14.21)Understand the options available to effect safe delivery. Be able to explain the risks in terms of both short term and potential long-term complications.

Understand treatments available to reduce associated risks.

Be familiar with the investigations that may determine causation of antepartum stillbirth including the option of post-mortem examination and karyotyping.

1,2,3,4

1,2

1,2

(14.22)Be able to communicate effectively and sensitively with colleagues, patients and relative.

Construct an individualised care pathway for labour and delivery.

Be able to take informed consent for post-mortem based upon a thorough understanding of the process and the value of the procedure.

Be able to liaise effectively and organise suitable support and follow up.

1,2,3,4

1,2,3

1,2,3,4

1,2,3,4

(14.21-14.22)RCOG Green top guideline No.55 (2010) Late intrauterine fetal death and stillbirth.

RCOG Good Practice Guidelines No.4 Registration of stillbirth before 24 weeks and No.5 Disposal following pregnancy loss before 24 weeks.

SANDS Information for Professionals. Guide for post-mortem consent takers.

SANDS (2016) Pregnancy loss and the Death of a Baby: guidelines for professionals.

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Part of the Advanced Labour Ward Practice ATSM

Logbook


Competence level Not required

Level 1 Level 2 Level 3

Date Signature Date Signature Date Signature

Safely manage non-cephalic presentation.

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Logbook





Non-technical: Recognition and informed counselling for breech presentation. Safely manage non-cephalic presentation.Technical: Competency for the recognition of non-cephalic presentation. Delivery of vaginal breech (may use OM).Safely manage non-cephalic presentation.Technical: Competency for the recognition of non-cephalic presentation. Delivery at caesarean section for breech and transverse lie.Safely manage preterm labour.Non-technical: Demonstrate expertise when balancing delivery with aiming to prolong pregnancy. Good communication with the family and wider MDT including paediatric team.Safely manage preterm labour.Technical: Proficiency in intrapartum care for preterm vaginal delivery.Safely manage preterm labour.Technical: Proficiency in preterm (<32 week) caesarean section.Safely manage multiple pregnancy.Non-technical: Formulate clear intrapartum care plans based on clear communication of all issues.Safely manage multiple pregnancy.Technical: Competency for the delivery of preterm multiple pregnancy.Safely manage multiple pregnancy.Technical: Competency for delivery by term caesarean section and term vaginal delivery.Safe rotational vaginal delivery.

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Logbook





Non-technical: Provide appropriate information to support informed choice for all method of delivery options.Safe rotational vaginal delivery.Technical: Competency in at least 2 of the following 3 methods to rotate to occipito-anterior position: manual rotation, ventouse rotation, and Kiellands forceps. Safe delivery for the morbidly obese.Non-technical: Good communication skills for the issues involved. Demonstrate MDT working and strategies to minimise risk.Safe delivery for the morbidly obese.Technical: Competency in vaginal delivery for the morbidly obese (BMI > 40).Safely manage PPH.Non-technical: Demonstrate good communication skills and the use of MDT. Safely manage PPH.Technical: Acute resuscitation and medication for PPH

Safely manage PPHTechnique: Uterine balloon tamponade.

Safely manage PPH.Technical: B Lynch suture technique.

Safely manage maternal sepsisTechnical: timely recognition, investigation and treatment.

Safely manage maternal sepsisNon-technical: Demonstrate good communication skills with patient, relatives and MDT liaison.Safely manage antepartum stillbirthTechnical: Competency in the conduct of all stages of labour

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Logbook





for stillbirthSafely manage antepartum stillbirthNon-technical: Demonstrate good communication skills; explain diagnosis, management options appropriate investigations and follow up.



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Completion of ASM 14: Key intrapartum scenarios: non-technical and technical skills Date Signature

Safe and effective communication and management of intrapartum conditions has been achieved to level 3 through direct exposure to the required range of clinical cases including timely liaison with the MDT and tertiary services if appropriate.

ASM 15: Intrapartum Ultrasound Skills


(15.01) Identify the presenting part prior to induction of labour.

(15.02) Determine each presentation and lie for twin pregnancy at term.

1,2

1,2

(15.01-15.03)Be able to identify the following:-Fetal lie-Presenting part (cephalic, breech flexed, extended and footling as well as shoulder presentation),

1,2(15/01-15.03)Be able to use and set up the ultrasound machine correctly. Be able to clearly record your findings.

1,2These skills build upon those undertaken during the RCOG Basic obstetric ultrasound

(15.01- 15.08)These skills are designed to be used on the delivery suite but may also be

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(15.03) Determine the presenting part in preterm or suspected preterm labour.

1,2- Identify the landmarks of the fetal head- Determine the position of the fetal spine, placental location and amniotic fluid volume.

Be able to advice on the intrapartum care based upon your ultrasound findings.

1,2,3,4

module.

Direct supervision on the delivery suite wherever possible.

(15.01-15.07) These skills may also be acquired through ultrasound assessments in non-labouring women during the third trimester.

acquired in non-labouring women in the third trimester.

OSAT(15.04) Locate fetal heart beat intrapartum

1,2 (15.04)Be able to confirm and appropriately record intrapartum fetal viability.

1,2(15.04)Be able to explain the findings in a manner that is easy to understand.

1,2,3,4

(15.05) Confirmation of intrauterine fetal demise.

1,2 (15.05)Be able to rapidly and accurately determine the activity of the fetal heart within the fetal chest and whether a fetal heartbeat is present. Recognise the ultrasound features of intrauterine demise and record

1,2(15.05) On confirmation of the diagnosis be able to explain the findings in a sympathetic manner and advise on a suitable and safe management plan.

1,2,3,4

(15.06) Intrapartum Identification of occipital-anterior presentation.

(15.07) Intrapartum identification of occipito-posterior presentation.

1,2

1,2

(15.06 -15.07)Understand how ultrasound may be used to augment and confirm the clinical findings of abdominal palpation and vaginal examination.

Recognise the necessary landmarks: intracranial (midline echo, thalami, head shape) and extracranial (position of the ears, eyes, nose and fetal spine) so that the attitude of the fetal head and the position of the occiput may be determined.

1,2

1,2

(15.06-15.07)Be able to correctly orientate the probe so that the intrapartum orientation of the fetal occiput can be correctly determined.

1,2

(15.08) Recognise the normal appearances of the postpartum uterus.

1,2 (15.08)Understand the physiological changes that occur postpartum and the typical

1,2(15.08)Where there is a high index of suspicion for retained products,

1,2,3

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intrauterine appearances.Recognise the ultrasound features that suggest retained products of conception.

be able to construct a suitable management plan.

ASM 15. Ultrasound Skills to support intrapartum care. Part of the Advanced Labour Ward Practice ATSM

LogbookCompetence level


ASM 15: Intrapartum Ultrasound Skills Date Signature Date Signature Date Signature

Identify the presenting part prior to induction of labour.

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LogbookCompetence level


ASM 15: Intrapartum Ultrasound Skills Date Signature Date Signature Date Signature

Determine each presentation and lie for twin pregnancy at term.

Determine the presenting part in preterm or suspected preterm labour.

Locate fetal heart beat intrapartum

Confirmation of intrauterine fetal demise.

Intrapartum Identification of occipito-anterior presentation.

Intrapartum identification of occipito-posterior presentation.

Recognise the normal appearances of the postpartum uterus.



24





Completion of ASM 15: Ultrasound Skills to Support Intrapartum Care Date Signature

Safe and effective use of ultrasound for intrapartum and peripartum scenarios has been achieved through direct exposure and decision making for a range of clinical cases.

ASM 16: The Range of Conditions Encountered on Labour Ward


(16.01) Epilepsy in labour 1,2 (16.01) Recognise the common forms of epilepsy and their distinguishing features. Consider the overlap in presentation with eclampsia and how to investigate and manage each in

1,2(16.01)RCOG Green Top Guidelines:10A (Management of preeclampsia/

(16.01-16.16)These are relatively rare conditions

25




the intra partum setting. eclampsia).

No.68 Epilepsy in pregnancy.

Evidence may include a suitable simulation manikin based obstetric emergency course.

Supplement any clinical exposure with CBD undertaken with an experienced supervisor.

Suitable evidence may include evidence of eLearning, MDT meetings as well as direct clinical exposure.

OSAT

CBD

Reflective Practice.

(16.02) Herpes Simples Virus

(16.03) Hepatitis B, Hepatitis C

1,2

1,2

Note: These competencies are also found in ASM.8 High risk secondary to medical and obstetric factors (8.12-8.16). Here the focus is on their intrapartum management.

(16.02-16.03)Know the transmission risks, neonatal consequences, long term prognosis and management strategies to reduce vertical transmission of: Herpes Simplex (HSV) and Hepatitis B & C.

1,2

(16.02-16.03)Counsel women and their partners on intrapartum and postpartum risk reduction for each viral infection.

Respect confidentiality and liaise appropriately.

1,2,3,4

1,3,4

(16.02)RCOG Green Top Clinical Guidelines:30: Management of genital herpes during pregnancy.

(16.04) Sickle cell crisis 1,2(16.04)Note: These competencies are also found in ASM.11 (11.13) and ASM 12 (12.09). Here the focus is on their intrapartum management.

Review the genetics, presentation and management of sickle cell disease in pregnancy with particular emphasis on treatment options and the potential for sickle cell crises.

Understand how and why sickle cell crises may present during labour or postpartum. Understand its monitoring and the

1,2

1,2

(16.04)With appropriate liaison manage women with sickle cell disease demonstrating an understanding of how risks may be minimised intrapartum.

Be able to explain these risks in a manner that is easy to understand.

1,2,3

1,2,3,4

(16.04)RCOG Patient information (2014) Sickle cell disease in pregnancy.

26




potential for fetal and maternal sequelae.

Understand how the risk of a crisis may be minimised.

Understand the role of the haematologist in managing the conditions.

1,2

1,2

(16.05) Cardiac disease in labour.

(16.06) Respiratory disease in labour

1,2

1,2

(16.05-16.06)Review these conditions with a focus on minimising the intrapartum risks.

Understand the impact of labour on the cardiovascular and respiratory systems and the risks this creates for co-existing disease. Understand how the pregnancy should be monitored and the role of the physician intensivist and anaesthetist in delivery of acute care.

1,2

1,2

(16.05-16.06)Demonstrate the ability to summarise and explain complex medical conditions in a way that is easy to understand.

To be able to balance the risks to the fetus with those to the mother.

With MDT support be able to advise a suitable delivery plan.

To know your limitations and seek further advice when appropriate.

1,2,3,4

1,2

1,2,3

1,2,3

(16.05)RCOG Good practice guideline No.13 (2011) Cardiac disease and pregnancy.

(16.07) Amniotic fluid embolism.

(16.08) Massive pulmonary embolism.

(16.09) Cerebrovascular accident.

(16.10) Cardiac event.

1,2

1,2

1,2

1,2

(16.07)Understand the principles of maternal resuscitation and how these relate to pregnancy collapse and massive postpartum haemorrhage.

For each condition review its aetiology and differential diagnosis. Consider how pregnancy may influence the presentation and lead to specific challenges for effective

1,2

1,2

(16.07)Be able to rapidly assess the urgency of the clinical situation obtain help and provide rapid resuscitative measures.

Liaise appropriately with the MDT.

Be able to debrief all involved and

1,2,3

1,2,3

1,2,3,

(16.08-16.09)RCOG Green top guideline 37 a & b (2015) reducing the risk and acute management of VTE.

STRATOGCore training.

27




treatment. communicate effectively in a manner that can be easily understood.

4 Stroke in pregnancy.Core training Venous thromboembolic disease.

(16.11) Management of the morbidly adherent placenta

1,2 (16.11)Review the knowledge base and skills under ASM14.15-14.16 for the safe management of PPH.

Understand the aetiology of morbidly adherent placenta, its diagnosis on ultrasound and on MRI.

Understand the risks versus the benefits of leaving the placenta in situ. The role of interventional radiology.

1,2

1,2

(16.11)Be able to select the most appropriate place, timing and ultimately the best uterine incision for delivery of the baby.

Have preparations made to activate the local major haemorrhage protocol for massive obstetric haemorrhage.

Rapidly assess the extent of haemorrhage and institute appropriate resuscitative measures.

Ability to lead the team for all aspects of PPH including the acute maternal resuscitation, investigation and subsequent management.

Be able to debrief and plan for future pregnancies.

1,2

1,2

1,2

1,2,3,4

1,2,3,4

(16.11)RCOG Green top guideline No. 27 (2011) Placenta praevia, placenta praevia accreta, vasa praevia: Diagnosis and management.

RCOG Good Practice Guideline No.6 (2007) The role of emergency and elective interventional radiology in PPH.

(16.12) Correction of uterine 1,2 (16.12) (16.11 -16.12)

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inversion Review the hydrostatic technique, the manual and surgical technics for correction of uterine inversion. Understand the pharmacological support available both uterine relaxants and the role of anaesthesia.

1,2 Be able to quickly recognise and assess the clinical situation.

Through effective team-working minimise the risks of maternal collapse, haemorrhage.

1,2

1,2,3,4

(16.13) Management of perineal or abdominal wound breakdown

1,2 (16.13)Understand the principles of wound care, how to minimise breakdown and infection.

Review the basis for choosing late versus early repair of perineal breakdown and healing by secondary intention versus suturing (Cochrane review 2013).

1,2

1,2

(16.13)Communicate effectively all of the options available in order to obtain valid consent.

Construct suitable follow up with the involvement of primary care.

1,2,3,4

1,2,3,4

(16.13)NICE Clinical Guideline No.74 (2008) Prevention and treatment of surgical site infection

STRATOG – technical skills eLearning: Perineal assessment and repair (2015).

Cochrane Database of Systematic Reviews (2013) Secondary suturing compared to non-suturing for broken down perineal wounds

29




following childbirth.

(16.14) Surgical Management of intra-abdominal haemorrhage

(1615) Classical caesarean section

(16.16) Caesarean hysterectomy

1,2

1,2

1,2

(16.14-16.16)Understand how to apply the radiological and pharmacological available to supplement the surgical approaches to minimise bleeding.

Be able to plan effectively if a classical caesarean section is likely or when hysterectomy is necessary.

1,2

1,2

(16.14-16.16)Know your own limitations for these rare conditions. Use the MDT effectively to plan the intervention and support the surgical management to minimise risks.

1,2,3,4

(16.14)RCOG Green top guideline No.63 (2011) Antepartum haemorrhage. No.52 Postpartum haemorrhage.

(16.15-16.16)RCOG Safety alert No.1 (2011) Out of hours cover for consultants who do not perform major gynaecological surgery.

(16.17) Management of non-longitudinal lie in labour, internal podalic version / external cephalic version if appropriate.

1,2 (16.17)(Note: These skills are also found in ASM14: 14.01- 14.04)Understand the appropriateness of the different modes of delivery for breech, transverse and oblique lie presentations.

Understand how management might differ for multiple pregnancy.

1,2

1,2

(16.17)Be able to communicate effectively in a manner that can easily be understood the risks accompanying all non-cephalic presentations and the options available.

Be able to construct a safe birth plan and where appropriate

1,2,3,4

1,2,3

(16.17)RCOG Green top guideline No. 20a (2006) ECV reducing the risk of breech presentation.

No.20b (2006) Management of

(16.17)OSAT

CBD

Log of cases

30




Understand the manoeuvres to minimise the risks for both assisted breech delivery and breech extraction for singleton and multiple pregnancies during vaginal delivery and also at caesarean section.

Understand when ECV in labour (for breech, transverse lie and second twin) may be considered and the techniques involved.

Understand when and how internal podalic version is appropriate for multiple pregnancy.

1,2

1,2

1,2

modify this according to the clinical findings as they evolve.

Effectively liaise where appropriate, with anaesthetists, midwifery and theatre staff and neonatologists.

1,2,3

Breech Presentation.

(16.18) Understand risks and benefits of all anaesthesia options for delivery and intrapartum surgical procedures.

(16.19) Understand risks and benefits of all analgesia options for delivery and intrapartum surgical procedures.

1,2

1,2

(16.18-16.19)Review all forms of analgesia and anaesthesia for use in labour.

Understand the inherent risks and benefits of each and when each is most appropriate depending on the clinical scenario.

1,2

1,2

(16.18-16.19)Be able to explain complex information including all forms of risk in a way that is easy to understand.

Be able to communicate effectively with the MDT.

1,2,3,4

1,2,3

(16.18-16.19)Royal College of Anaesthetists (2013) Pregnancy Guidelines.

(16.18-16.19)Evidence of a short attachment to obstetric anaesthesia, HDU/ITU.

CBD with anaesthetic input.

31



ASM 16. The range of conditions encountered on Labour Ward. Part of the Advanced Labour Ward Practice ATSM.

ASM 16. The range of conditions encountered on Labour Ward

Competence level

Level 1 Level 2

Date Signature Date Signature

Medical

Epilepsy in labour

Herpes Simples Virus

Hepatitis B, Hepatitis C

Sickle cell crisis

Cardiac disease in labour

Respiratory disease in labour

Obstetric

32



ASM 16. The range of conditions encountered on Labour Ward

Competence level

Level 1 Level 2

Date Signature Date Signature

Amniotic fluid embolism

Massive pulmonary embolism

Cerebrovascular accident

Cardiac event

Surgical and technical Procedures

Management of the morbidly adherent placenta

Correction of uterine inversion

Management of perineal or abdominal wound breakdown

Surgical Management of intra-abdominal haemorrhage

Classical caesarean section

Caesarean hysterectomy

Management of non-longitudinal lie in labour Internal podalic version / External cephalic version if appropriate.Understand risks and benefits of all anaesthesia options for delivery and intrapartum surgical proceduresUnderstand risks and benefits of all analgesia options for delivery and intrapartum surgical procedures.

33







34



Completion of ASM 16: The range of conditions encountered on Labour Ward. Date Signature

Thorough knowledge and application where possible of both technical and non-technical skills covering the breadth of conditions that may arise peripartum. When to liaise with allied specialities and refer to the tertiary centre if appropriate. Sessions spent with anaesthetists to acquire an understanding of their role and the full range of analgesia and anaesthetic options available.

ASM 17: Effective Communication for the Labour Ward


(17.01) Explain the risks and benefits of the different forms of analgesia and anaesthesia for labour.

(17.02) Explain the risks and benefits of the different forms of analgesia and anaesthesia for assisted delivery and caesarean section.

1,2,3,4

1,2,3,4

(17.01-17.02)Review all forms of analgesia for use in labour with the focus on how best to explain them. Understand the inherent risks and benefits of each and how best to balance these risks for the common intrapartum clinical situations.

1,2,3,4

1,2

(17.01-17.02)Be able to explain complex information including all forms of risk in a way that is easy to understand.

1,2,3,4

(17.01-17.02)NICE Clinical Guideline CG.190 (2014) Intrapartum care.

Royal College of Anaesthetists (2013) Pregnancy Guidelines.

RCOG Clinical Governance Advice No.7 (2008) Presenting information on risk.

(17.01 -17.07)These are largely non-technical skills and the supporting evidence should reflect this.

Evidence of a short attachment to obstetric anaesthesia, HDU/ITU.

Feedback should be multisource wherever possible and include obstetric anaesthetists.

OSAT

CBD

(17.03) Agree intrapartum care plan for previous traumatic delivery.

1,2 (17.03)Understand shared decision making and best practice for constructing care plans in labour.

1,2,3(17.03)Be able to provide honest, informative and balanced clinical information in a way that is easy to understand.

1,2,3,4

(17.03)STRATOG Non-technical skills eLearning: Communication

35




skills and Communicating with patients. Supporting

evidence in ePortfolio of reflective practice.

(17.08)Relevant Audit or other Quality Improvement Project.

(17.10)Log of risk management cases.

(17.04) Demonstrate good communication skills following stillbirth.

(17.05) Debrief family after adverse intrapartum outcome.

(17.06) Debrief staff after adverse intrapartum outcome.

1,3,4

1,3,4

1,2,4

(17.04-17.06)Understand the bereavement reaction, how people react often to bad news and how best to approach difficult and challenging consultations.

Be familiar with the investigations that may determine causation of antepartum stillbirth including the option of post-mortem examination and karyotyping.

1,3

1

(17.04-17.06)Be able to break bad news appropriately and support distress.

Be able to advise upon the local support available and the options for further discussion.

Know when to ask for assistance and how to offer a second opinion if required.

1,3,4

1,3,4

1,3,4

(17.04-17.06) STRATOGCore training (2016) Communication skills.

RCOG Green top guideline No.55 (2010) Late intrauterine fetal death and stillbirth.

(17.07) Co-ordinate the clinical running of Labour Ward: triage and staffing.

1,2,3,4

(17.07)Understand how to triage clinical cases according to local guidelines.

Understand the labour ward staffing structure and the minimum staffing number safety standards.

1,2

1,2

(17.07)Ability to co-ordinate the LW appropriately and communicate effectively all plans and decisions to team members.

1,2,3,4

(17.07)Direct supervision by senior staff and indirect support as confidence develops.

Feedback from NOTTS.

(17.08) Produce a relevant Audit, 1,2RCOG Clinical Governance

36




Guideline or other Quality Improvement Project (attach supporting evidence).

Advice No.1c Producing a clinical practice guideline.

No.2 Improving patient safety. Risk management for maternity and gynaecology.

No.5 Understanding Audit.

RCOG/RCM RCoA, RCPCH (2007) Safer Childbirth. Minimum standards for organisation and delivery of care in labour.

(17.09) Lead Labour Ward forum.

(17.10) Lead Risk Management case review.

1,2,3,41,2,3,4

(17.09-17.10)Understand the Governance structure within the obstetric department and how serious untoward events are investigated and acted upon within the department and Trust.

1,2,3(17.09-17.10)Demonstrate effective communication with colleagues.

Demonstrate good working relationships with colleagues and the ability to work in clinical teams.

3,4

3,4

(17.10)RCOG Clinical Governance Advice No.1c Producing a clinical practice guideline.

No.2 Improving patient safety. Risk

37




management for maternity and gynaecology.

STRATOG Advanced, Generic Skills Case Studies eLearning: Risk management of rotational forceps delivery (2015).

(17.11) Know when and how to refer to support services (for example intensive and high dependency care, neonatology, haematology, medical and surgical teams).

1,2,3,4

(17.11)Understand the structure and organization of high dependency, intensive care, surgical and medical outreach teams.

1,2(17.11)Be able to rapidly assess the seriousness of the common labour ward clinical situations.

Liaise effectively if concerns are raised.

1,2

3,4

(17.12) Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.

1,2,3,4

(17.12)Be able to reflect constructively upon clinical events. Afterwards ensure that you receive an external perspective, typically from your educational supervisor.

1,2,3,4

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ASM 17. Effective Communication Skills for the Labour Ward




Effective Communication Skills for the Labour Ward Date Signature Date Signature Date Signature

Explain the risks and benefits of the different forms of analgesia and anaesthesia for labour.

Explain the risks and benefits of the different forms of analgesia and anaesthesia for assisted delivery and caesarean section.Agree intrapartum care plan for previous traumatic delivery.

Demonstrate good communication skills following stillbirth.

Debriefing family after adverse intrapartum outcome.

Debriefing staff after adverse intrapartum outcome.

Co-ordinate the clinical running of Labour Ward – triage and staffing.

Governance

Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence).

Lead Labour Ward forum

Lead Risk Management case review.

Know when and how to refer to support services (for example intensive and high dependency care, neonatology, haematology, medical and surgical teams).

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ASM 17. Effective Communication Skills for the Labour Ward




Effective Communication Skills for the Labour Ward Date Signature Date Signature Date Signature

Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.



40





Completion of ASM 17: Effective communication for the labour ward Date Signature

The full range of communication, professionalism and governance skills have been demonstrated within the labour ward setting incorporating adequate liaison with the wider MDT team and tertiary services as required.

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advanced labour ward practice atsm 2018 · web viewthe atsm comprises 5 advanced skills modules...

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