Midwifery in the Millenium: the Midwifery in the Millenium: the Role of the Advanced Midwifery Role of the Advanced Midwifery Practitioner in the promotion of Practitioner in the promotion of

normality.normality.

Sue Briggs, Angela Chapman, Michelle Sue Briggs, Angela Chapman, Michelle BarfordBarford

On behalf of the team at Diana, Princess of On behalf of the team at Diana, Princess of Wales Hospital, GrimsbyWales Hospital, Grimsby

Northern Lincolnshire and Goole NHS Northern Lincolnshire and Goole NHS Foundation TrustFoundation Trust

Advanced Midwifery Practitioner

The role was developed in order to continue to provide a comprehensive quality service following :

An acute service review and Trust merger Implementation of WTD reducing junior doctors hours Role reconfiguration for junior doctors Plans at that time to relocate maternity services at Grimsby First cohort commenced training in 2001

Evolvement of the Role

The Political climate continues to influence the scope of midwifery practice and boundaries of care are constantly evolving.

The NHS modernisation programme: NHS Plan (DoH, 2000)

Making a difference (DoH 1999) Ideology that encourages exploration of new midwifery

roles Vision 2000 (RCM 2000) Maternity Matters (DoH 2007) Safe births, everybody’s business (Kings Fund 2007) High quality care for all (Darzi 2008) Standards for maternity care (RCOG 2008)

Evolvement of the Role

It was envisaged that the Advanced Practitioner would: Build on and enhance the service Develop practice according to service needs Have a dynamic and constantly evolving role Strengthen relationships with medical colleagues by

having enhanced clinical, diagnostic and decision making skills

Be empowered to increase their knowledge and expertise in managing birth and focusing on “women centred care”

Who is the Advanced Midwifery Who is the Advanced Midwifery Practitioner (AMP)?Practitioner (AMP)?

The AMP is a midwifery clinician who can advance and develop clinical knowledge and skills to promote excellence in maternity care. She is an experienced Labour Co-ordinator

While being trained to an advanced level and able to

undertake activities and procedures traditionally practiced by Medical staff the AMP still has a large role to play in the promotion of normality within the maternity services.

Training

Academic training through local University

Initially input into A33 now Autonomous practitioner programme at degree level

Clinical training with input from Clinical supervisor – lead Consultant for Labour

Competency booklet developed locally

Support from rest of senior medical team and AMPs

What extra does the role encompass?

Input into medical rota 10 sessions/40 hours per week

Carry 2nd on call bleep instead of SHOResponse to emergencies 1st assistant in theatre Ventouse practitionerOrdering of investigations/initiation of

treatment/care planning

Role Development

The role extended beyond the Labour Ward into antenatal, postnatal and neonatal care e.g. maternal admission and discharge; patients reviews e.g. 1st day following operative/ instrumental delivery, examination of newborn

Seamless service, enhanced continuity of care. Guardian of promotion of normality whilst

acknowledging and responding appropriately when deviations from normal occur

Understanding clinical challenges and supporting all colleagues

Role of AMP in Promoting

Normality

Supporter and enabler of staff

Promotes staff development

Promote ‘midwifery’ values and a ‘women

centred‘ service

Is an advocate for mothers and

midwives

Contributes to EB guidelines that support

practice and promote normality

Refrains from undertaking interventions unless clinically indicated and evidence based.

Encourages the A/N education of women

Acts as a catalyst for change

A ‘Team’ player working in partnership with midwives, nurses & medical colleagues

Challenges the bio-medical care model

Educates and facilitates

Promotes research awareness

Leads developments in professional practice

Promotes midwifery skills “rooted in

normality”

““Personal Considerations”Personal Considerations”The Advance Midwife Practitioners Promote a culture of care viewing pregnancy & birth as normal

physiological processes.

Are “guardians” of normality of childbirth, whilst acknowledging & responding appropriately when deviations from normal occur.

Through professional collaboration challenge an overly medical model of care.

Remember their “midwifery roots”/ be an advocate for mothers & midwives.

Collaborate with Midwives & Medics to develop EB guidelines supporting practice that promotes normality.

““Working with mothers”Working with mothers”The AMPs support midwives to:

Identify low risk women & where appropriate promote home birth & MLC.

Help women to view vaginal birth more positively & have confidence in their ability to give birth, breastfeed & be a happy parent.

Provide informal Antenatal education that promotes normality & realistic expectations. e.g. VBAC

Inform women of alternatives to unnecessary medical interventions / work with them to make evidence based informed decisions about their care.

““Creating a conducive Environment”Creating a conducive Environment”The AMPs:-The AMPs:-

Promote a relaxed atmosphere conducive to

normality.

Encourage a “low tech” approach to reinforce concept of minimal intervention.

Maintain a “culture of normality” even when intervention is required, e.g. promote skin-skin following uncomplicated ventouse delivery.

““Clinical Practice”Clinical Practice”The AMPs promote normality by:

Encouraging & supporting less intervention.

Support 1-1 labour care & continuity of care and carer.

Encouraging non supine positions in labour & mobilisation.

Discouraging inappropriate use of EFM Encouraging & supporting IA via Pinnards / doppler. (NICE, 2001)

Encouraging midwives to “get back to basics” by advocating good pressure area, bladder & perineal care.

Encouraging & supporting use of non-pharmacological methods of pain relief and coping mechanisms - relaxation, Tens, birthing ball, use of water / birthing pool.

Encouraging appropriate hydration / nutrition.

Supporting physiological management of 3rd stage of labour for low risk women.

Encouraging early skin - skin contact & breastfeeding support

Encouraging midwives to get mothers not in established labour / pre- lab ROM home

Encourage planned early discharge for low risk mothers (possibly facilitated by AMP/midwife discharge exam of newborn).

EducationalistsEducationalistsThe AMPsThe AMPs

Utilise opportunities for informal teaching.

Are proactive towards multidisciplinary education.

Educate staff about the AMP role (not just for the “abnormal”)

Promote mothers/ midwives educational resources that focus on normality

Facilitate the acquisition of skills/ knowledge in the care of normal low risk mothers.

Remind midwives that “1 intervention leads to another!”

Educationalists cont

The AMPs are actively involved in the in-house training programme which is multidisciplinary

CTGNeonatal resusObstetric emergencies including drillsHCA training

Staff DevelopmentStaff DevelopmentThe AMPs:-The AMPs:-

Lead & support the developing role of midwives in line with unit philosophy e.g. LDRP & Midwifery led care.

Empower Midwives to have confidence in their ability to manage normal birth using a “ low tech” approach.

Promote discussion around low intervention for low risk women.

Encourage Midwives to think critically & reflect on practice.

Support staff to question & change practice.

Research and AuditResearch and AuditThe AMPs promote normality by:-The AMPs promote normality by:-

Keeping up to date with contemporary issues that focus on normality.

Critically appraising the evidence base for midwifery knowledge & practice.

Considering other National / International

perspectives of care / practice.

Encouraging research awareness

Auditing , reviewing & reflecting on practice.

On going Training for AMPs

Regular update in ventouse delivery

ALSO refresher

NLS training

Perineal repair training

An overview of the AMP role in promoting normality An overview of the AMP role in promoting normality

Clinical &ProfessionalBe a visible, credible, role model

Support practice that promotes normality

Lead new initiatives to support normality.

Promote birth as “normal” life event.

CommunicationMaintain a good relationship with multidisciplinary team & network.Be an advocate for mothers and midwives.

Help develop supportive EB guidelines.

Facilitate mothers to make informed choice.

EducationUndertake formal/ informal teaching.

Act as a resource for staff

Facilitate the acquisition of skills/ knowledge in care of low risk mothers.

Remind midwives “One intervention leads to another”

Research & AuditCritically appraise research evidence

Encourage research awareness.

Keep up to date with contemporary issues.

Audit practice & review & reflect.

The effects are clear to see

Reduced CS rates 17.1% 2009 (16.3% 2008) SVD rate 71.2% 2009 (70% 2008) Birthrate plus in 2009 - 45.9% of all births in the

unit within the I and II category which is stated in the report as being “significantly higher than found in many units in England.”

Excellent working relationships with senior medical staff . True Team approach

The Effects cont

Support for junior doctors

Seamless approach to doctors rotation

Challenge practice e.g. induction of labour

Only undertake necessary investigations

Keep a record of cases

Acknowledgements

Special thanks to Sara Butcher for giving us the presentation and allowing us to adapt and add to it

The rest of the AMP team at DPOW Sara Butcher, Jeanette Rowe and Brenda Waite

The other Co-ordinators Tracy Martin and Carol Horsley The Consultants; Werner Mueller, Ian Stuart, Arabinda Saha, Ibrahim

Bolaji, Silas Gimba and Mahadeeva Manohar Staff Grades; Shanka Gangophady and Nasser Mohammed Sheila Youssef Acting HoM, PSM Obs, Gynae & Sexual Health The Midwives at DPOW, NLAG