Implementing A Framework for Maternity ... - Scottish Government
Implementing A Framework for Maternity ... - Scottish Government
Implementing A Framework for Maternity ... - Scottish Government
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<strong>Implementing</strong> A <strong>Framework</strong> <strong>for</strong><br />
<strong>Maternity</strong> Services in Scotland<br />
Overview Report of the<br />
Expert Group on Acute <strong>Maternity</strong> Services<br />
Working together <strong>for</strong> a healthy, caring Scotland
<strong>Implementing</strong> A <strong>Framework</strong> <strong>for</strong><br />
<strong>Maternity</strong> Services in Scotland<br />
Overview Report of the<br />
Expert Group on Acute <strong>Maternity</strong> Services
Foreword<br />
Our National Health Service is changing fast and rising to the challenge of providing modern<br />
health care in the 21st Century. It is responding to a rapidly changing environment in which<br />
new learning, new technology, and new skills can revolutionise how we care <strong>for</strong> Scotland’s<br />
people. Giving every child in Scotland the best possible start in life is a top priority <strong>for</strong> the<br />
<strong>Scottish</strong> Executive. And that starts with our maternity services, be<strong>for</strong>e, during and after childbirth.<br />
The care and welfare of women during pregnancy, childbirth and post-natally has a profound<br />
impact on the wellbeing of our nation, not just in terms of delivering healthy, happy babies,<br />
but also in determining the profile of our national health <strong>for</strong> a very long time thereafter.<br />
As in the rest of the developed world, the <strong>Scottish</strong> birth rate is falling. The age at which our<br />
women become pregnant <strong>for</strong> the first time is increasing. Increasing medical specialisation,<br />
necessary restrictions on the number of hours doctors and nurses work during shifts, and<br />
improvements to training <strong>for</strong> doctors all impact on the shape and size of our work<strong>for</strong>ce. Fewer<br />
births, shifting patterns of need and a changing work<strong>for</strong>ce - all these factors have significant<br />
implications <strong>for</strong> the shape of our maternity services in future.<br />
In February 2001 the Executive launched A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland.<br />
That was based on consultation with maternity services’ professionals and users. It set out<br />
principles and practice <strong>for</strong> a modern, responsive and effective service and reflected the views<br />
and wishes of the women and their families who use that service. We have made much<br />
progress in taking <strong>for</strong>ward implementation of the <strong>Framework</strong>. But we still have more to do.<br />
I set up this short-life Expert Working Group on Acute <strong>Maternity</strong> Services (EGAMS) to examine<br />
how we should apply the principles set out in A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland<br />
to maternity services during childbirth. The Group comprised representatives from the Royal<br />
College of Midwives and the Royal College of Obstetricians and Gynaecologists, other medical<br />
and nursing professionals, NHS Board and Trust management, the <strong>Scottish</strong> Ambulance Service<br />
and the <strong>Scottish</strong> Executive Health Department. I attach great importance to our maternity care<br />
and chaired the Group myself.<br />
page ii
The EGAMS’ report concludes that the current configuration of acute maternity services is no<br />
longer sustainable. This is not about saving money. It is about making the best use of the<br />
skills we have available in the face of the falling birth rate and work<strong>for</strong>ce pressures in<br />
obstetrics and paediatrics. We need to realise the full potential of our midwives. We need to<br />
think across professional and organisational boundaries when planning and shaping our<br />
maternity services. And we need strong leadership and commitment from both managers and<br />
clinicians to carry <strong>for</strong>ward continuous improvement.<br />
The EGAMS’ conclusions and recommendations are based on the best available evidence.<br />
After much hard work, this group of clinical leaders in the field arrived at a strong professional<br />
consensus about the direction <strong>for</strong> our maternity services. The Executive is guided by that<br />
consensus. We accept that the Group’s conclusions are right <strong>for</strong> Scotland. We must now begin<br />
the important debate with all our stakeholders in the NHS and beyond about how this vision<br />
can be taken <strong>for</strong>ward.<br />
Mary Mulligan, MSP<br />
Deputy Minister <strong>for</strong> Health and Community Care<br />
page iii
Contents<br />
Key Messages from the Expert Group 2<br />
Introduction 5<br />
The Expert Group on Acute <strong>Maternity</strong> Services (EGAMS) 5<br />
The EGAMS’ findings 6<br />
Provision of Acute <strong>Maternity</strong> Services 8<br />
Regional services 8<br />
Core principles of delivery in maternity services 8<br />
Care networks 9<br />
Assessing and Managing Risk 11<br />
Risk assessment and management 13<br />
Helping women to assess risk, weigh evidence and take decisions 14<br />
Risks associated with levels of care 14<br />
Education, Training and Work<strong>for</strong>ce Issues 17<br />
The competency approach 17<br />
Continuing professional education and training 17<br />
Work<strong>for</strong>ce issues 19<br />
Midwifery 20<br />
Hospital doctors 20<br />
General practitioners 20<br />
Developing the maternity work<strong>for</strong>ce – investing in skills 21<br />
Principles 21<br />
Remote and rural issues 22<br />
Stakeholder Engagement 23<br />
In<strong>for</strong>mation Management and Technology 25<br />
Transport in Acute <strong>Maternity</strong> Services 27<br />
Appendices:<br />
1. Membership of Short Life Expert Group on Acute <strong>Maternity</strong> Services 29<br />
2. Risk Assessment 32<br />
3. Core Competencies <strong>for</strong> Health Professionals in Acute <strong>Maternity</strong> Services 44<br />
Glossary 49<br />
page 1
Key Messages from the<br />
Expert Group<br />
1. Women must receive high quality care during childbirth. The care should be based on<br />
the available evidence about effective practice and should be woman and babycentred.<br />
A strong multi-professional team approach is vital <strong>for</strong> the delivery of a<br />
clinically effective and seamless service.<br />
2. The principles in A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland are robust and are<br />
based on best professional practice. All of the principles, including the tiered<br />
framework of levels of care provision at the time of childbirth (intrapartum) and <strong>for</strong><br />
the new-born baby (neonate), should be fully implemented.<br />
3. <strong>Maternity</strong> care professionals must work to promote the notion of pregnancy and<br />
childbirth as being normal life events, but must also have the skills to recognise when<br />
either the mother or baby is having problems.<br />
4. One-to-one midwifery care should be the norm <strong>for</strong> all women during labour and<br />
childbirth.<br />
5. The present provision and shape of acute maternity services is no longer sustainable<br />
in the light of changes in the number and locations of births in Scotland (demographic<br />
changes), training and work<strong>for</strong>ce pressures, and the need to ensure clinically safe and<br />
cost-effective practice.<br />
6. NHSScotland should provide services <strong>for</strong> childbirth as close to women’s homes as is<br />
consistent with safe clinical care and in<strong>for</strong>med maternal choice.<br />
7. Local planning and commissioning of maternity services, in particular childbirth<br />
(intrapartum) services, should take place within a regional context. This will help to<br />
ensure that local services reflect regional and national priorities.<br />
page 2
8. There is no such thing as ‘zero risk’ <strong>for</strong> women who are pregnant or giving birth;<br />
an element of risk applies to all pregnancies and childbirth.<br />
9. Women must be in<strong>for</strong>med about risk with unbiased, evidence-based in<strong>for</strong>mation to<br />
help them decide where to give birth. Professionals should balance maternal choice,<br />
demand and need against assessment of risks and available services.<br />
10. <strong>Maternity</strong> care professionals should adopt risk-assessment and management skills as<br />
core responsibilities.<br />
11. Professionals at all levels of maternity care must have appropriate training and should<br />
have access to regular continuing professional development (CPD) opportunities to<br />
equip them with the competencies and skills they need to provide high quality, safe<br />
care <strong>for</strong> women in childbirth (intrapartum care).<br />
12. Networks of services <strong>for</strong> intrapartum care should be developed on a consistent local,<br />
regional and national basis across Scotland, identifying entry points, referral pathways,<br />
levels of care, transport services and communication pathways.<br />
13. In<strong>for</strong>mation management and communication should be developed to aid the planning,<br />
provision and monitoring of intrapartum care throughout Scotland.<br />
14. All maternity units must describe the level of service they offer within the tiered<br />
framework of intrapartum care set out in A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland.<br />
This description should include the maternity unit’s role and remit within the wider<br />
local and regional network of maternity services <strong>for</strong> childbirth, neonatal and maternal<br />
postnatal care.<br />
page 3
page 4
Introduction<br />
1. Scotland’s mix of urban and very remote communities, with some areas of concentrated<br />
poverty and disadvantage in our cities and a very dispersed population in some rural areas,<br />
presents real challenges to the delivery of maternity services. Women across Scotland have<br />
a wide range of needs in pregnancy and childbirth which services must strive to meet.<br />
2. And those needs are changing. Like many other nations in the developed world, Scotland’s<br />
birth rate is falling. Many women are now waiting longer to have their first baby, and medical<br />
and technological advances mean that women with health problems can now be helped to<br />
become pregnant and give birth. Over the last 25 years, the length of women’s stay in hospital<br />
to have their babies has more than halved. Alongside this, infant deaths in childbirth have<br />
now become very rare. 1<br />
3. These trends seem set to continue. Our maternity services are likely to be dealing with fewer<br />
pregnancies and births, but a higher proportion will be more complex, heightening the risk<br />
to the mother and/or baby and the potential need <strong>for</strong> medical intervention. While many<br />
women and obstetric professionals believe that the natural process of pregnancy and<br />
childbirth has become too ‘medicalised’, the percentage of women requiring or opting <strong>for</strong><br />
caesarean section has increased dramatically across the UK, and it is now the chosen<br />
method in almost one in five deliveries. These factors all have significant implications <strong>for</strong><br />
the pattern and nature of acute maternity services across the country.<br />
The Expert Group on Acute <strong>Maternity</strong> Services (EGAMS)<br />
4. The <strong>Scottish</strong> Executive Health Department published A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in<br />
Scotland in February 2001. The document sets out a vision <strong>for</strong> maternity services in Scotland,<br />
and provides a ‘template’ <strong>for</strong> best practice in maternity care <strong>for</strong> use by NHS service planners<br />
and the clinical professionals who are responsible <strong>for</strong> delivering these services. It aims to<br />
ensure that pregnant women receive care that is not only comprehensive and clinically<br />
effective, but is also family-centred, locally accessible, midwife-managed, and based on<br />
joint working between primary, secondary and tertiary services. 2<br />
5. Following representation from the Royal Colleges of Midwives and of Obstetrics and<br />
Gynaecology, the Minister <strong>for</strong> Health and Community Care set up the Expert Group on<br />
Acute <strong>Maternity</strong> Services (EGAMS), a short-life working group of professionals and other<br />
stakeholders in maternity services in February 2002 (see Appendix 1). This Group was<br />
asked to consider how the principles in the <strong>Framework</strong> should be applied to care during<br />
childbirth, and the services in the acute health care sector which deliver that care.<br />
1 Mean stay in maternity units: 1976 – 9.4 days; 1998 – 3.9 days<br />
Caesarean Section rate increase: 1976 – 9%; 1999 – 19.7%<br />
Neonatal Mortality Rate: 1971 – 19.1 per 1000; 1998 – 5.6 per 1000<br />
2 A <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland – Principle 4<br />
page 5
6. The big question <strong>for</strong> the EGAMS was how NHS resources, including the obstetric work<strong>for</strong>ce,<br />
with all its skills, knowledge and experience, should be deployed to achieve the best<br />
balance between:<br />
• ensuring choice <strong>for</strong> women on where, how and by whom their care is provided<br />
• reducing risk, as far as possible, to the pregnant woman and her baby<br />
• ensuring high quality services that offer value <strong>for</strong> money.<br />
7. It is not always possible to meet women’s first choice in relation to their care at childbirth,<br />
particularly in some of Scotland’s very remote areas. This may also present challenges <strong>for</strong><br />
services in more populous areas where the pattern of maternity services sometimes reflects<br />
past practices, rather than current clinical priorities. EGAMS nevertheless wanted to find<br />
means of ensuring that, as far as possible, care delivered to women meets their needs and<br />
is close to their home and family, without compromising safety.<br />
The EGAMS’ findings<br />
8. The EGAMS prepared a comprehensive reference report which describes the shape of<br />
current acute maternity services in Scotland. This reference report describes the challenges<br />
and constraints facing NHSScotland in re<strong>for</strong>ming and further developing the service, and<br />
sets out a service model to meet current and future needs. The reference report includes:<br />
• risk assessment criteria to support clinicians in identifying the appropriate level and<br />
location <strong>for</strong> childbirth according to best evidence about outcomes<br />
• advice on the development of midwife-managed care<br />
• analysis of the work<strong>for</strong>ce skills and competencies needed to provide acute maternity<br />
services in future within the context of a changing environment<br />
• staff training needs<br />
• a detailed list of existing maternity facilities providing care in childbirth.<br />
9. This overview report summarises the content of the reference report and sets out the<br />
strategic vision <strong>for</strong> developing acute maternity services in Scotland <strong>for</strong> all relevant<br />
stakeholders, including the public, health professionals, health service planners, and<br />
political decision makers.<br />
page 6
10. The report shows that in 2002, there were 45 healthcare facilities across the country that<br />
include maternity units offering intrapartum care. At present, most of Scotland’s children<br />
are born in consultant-led maternity units. Four regional specialist maternal-fetal units, two<br />
in Glasgow and one each in Edinburgh and Aberdeen, deal with the most complex and high<br />
risk cases. They also provide general maternity services to their local populations. Over 35%<br />
of all babies in Scotland are born in these four units. Of the other units, approximately 20<br />
provide consultant-led services in district general hospitals, some of them quite small, and<br />
the remainder are community facilities – Community <strong>Maternity</strong> Units (CMUs) – providing<br />
midwifery-managed care, particularly in remote and rural areas.<br />
11. The report considers the sustainability of some consultant-led acute maternity services in<br />
small hospitals. <strong>Maternity</strong> units with low numbers of deliveries are finding they cannot sustain<br />
children’s (paediatric and neonatal) services <strong>for</strong> the few babies who might need them. In some<br />
cases, change in the local configuration of other services or shortages in professional staff<br />
have already made it necessary <strong>for</strong> NHS Boards to reshape their local acute maternity services.<br />
12. Changes in the medical and midwifery work<strong>for</strong>ces are already impacting on maternity<br />
services. A review of the <strong>Scottish</strong> medical work<strong>for</strong>ce 3 concluded that increasing<br />
specialisation, necessary restrictions on working time and demands to maintain clinical<br />
competence through appropriate training and education <strong>for</strong> medical trainees, make<br />
traditional patterns of medical staffing <strong>for</strong> all acute services difficult to sustain.<br />
13. The EGAMS report concludes that the current configuration of acute maternity services is<br />
no longer sustainable. The falling birth rate means that some facilities will not be able to<br />
continue in their present <strong>for</strong>m, as small numbers of births do not allow staff to maintain the<br />
range and level of skills needed to deal with complex cases or emergencies. Acute maternity<br />
services will have to change to reflect sustainable ways of working.<br />
14. To continue to provide childbirth services locally <strong>for</strong> many women in rural areas and to ensure<br />
continuity of individually-tailored care and support, we need to realise the full potential of<br />
midwives. One-to-one midwifery care should be the norm <strong>for</strong> all women in Scotland. The<br />
midwife’s role should be extended to lead management of childbirth in maternity facilities<br />
to provide a local service <strong>for</strong> low-risk births where women are unlikely to need specialist<br />
medical intervention. Such facilities can also provide care <strong>for</strong> women alongside consultantled<br />
units in hospitals.<br />
15. The complete reference report is readily available to clinicians, NHS strategic and<br />
operational managers and other interested people on the Scotland’s Health on the Web<br />
(SHOW) website – www.show.scot.nhs.uk.<br />
3 Future Practice: a Review of the <strong>Scottish</strong> Medical Work<strong>for</strong>ce p. 25, para 43<br />
page 7
Provision of Acute <strong>Maternity</strong><br />
Services<br />
Regional services<br />
1. The <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland set out that maternity care should be<br />
organised to provide a comprehensive, clinically effective, safe, flexible, integrated, multidisciplinary,<br />
seamless and accessible service tailored to meet the needs of women and their<br />
families within a safe and secure environment. The <strong>Framework</strong> asks NHS Boards to develop<br />
<strong>Maternity</strong> Services Strategies and Local Implementation Schemes within a local and<br />
regional context, taking account of the <strong>Framework</strong> guidance.<br />
2. The EGAMS concluded that a regional approach to managing and delivering maternity<br />
services offers the best opportunity to provide high-quality women and baby-centred<br />
services that are clinically effective and make best use of skilled staff resources. Regional<br />
Service Planning Groups (RSPGs) – existing groupings of NHS Boards which develop plans<br />
<strong>for</strong> health services across Board boundaries – should plan and commission services which<br />
provide local access to appropriate levels of maternity care, and ensure that care complies<br />
with core principles of service delivery (Box 1).<br />
Core principles of delivery in maternity services<br />
Box 1<br />
• Care should be high quality and based on the best available evidence.<br />
• Care should be offered as close to the woman’s locality as possible.<br />
• Continuity of care is a key goal.<br />
• Services should be planned to strike a balance between women’s choices, risk and<br />
quality of care.<br />
• All women should be ‘booked’ by a midwife and assigned to the appropriate level of<br />
care, as defined by risk assessment and management principles.<br />
• A ‘lead professional’ <strong>for</strong> the woman’s care should be identified. This can be any<br />
professional. Midwives are likely to be the lead professionals <strong>for</strong> ‘normal’ pregnancies<br />
and births.<br />
• Women should receive one-to-one care when in labour.<br />
• Services should be based on a multi-disciplinary approach to care.<br />
• Women and their partners should be well-in<strong>for</strong>med about arrangements <strong>for</strong> their care<br />
and support throughout the pregnancy and beyond.<br />
page 8
Principles<br />
1.1 Acute maternity services in Scotland should be planned and commissioned on a<br />
regional basis by Regional Service Planning Groups, taking account of NHS Boards’<br />
local plans. The RSPGs should monitor implementation of regional plans by NHS<br />
Boards and Trusts. They should also work in alliance with other regions.<br />
1.2 Regional Service Planning Groups should set up appropriate mechanisms to involve<br />
stakeholders in planning and commissioning maternity services within regions, led by<br />
dedicated Regional <strong>Maternity</strong> Services Co-ordinators.<br />
3. Regional networks of acute maternity services should be underpinned by robust and effective<br />
multi-disciplinary and cross team working. They should become key centres <strong>for</strong> innovation,<br />
change and practice development, pursuing clinical excellence in all aspects of care and<br />
driving <strong>for</strong>ward policy and research agendas. They should be exploring new ways of delivering<br />
services to meet their population’s needs, and should be in the vanguard of new and extended<br />
roles <strong>for</strong> clinical practitioners. Ultimately, they will set the standard <strong>for</strong> maternity services<br />
in Scotland.<br />
4. But it is vital that they do not operate in isolation. Alliances, partnerships and networks<br />
with other regions will be necessary to ensure consistency in the standard of care delivered<br />
throughout Scotland. The EGAMS concluded that regional service networks should consider<br />
how best to ensure co-ordination and co-operation across regional services. Arrangements<br />
should be made to ensure that Regional <strong>Maternity</strong> Co-ordinators throughout Scotland meet<br />
on a regular basis.<br />
Care networks<br />
5. Good communication and the integration of services are central to the provision of quality<br />
maternity care throughout Scotland. Local, regional and national networks provide a vehicle<br />
through which this can be achieved.<br />
6. Networks allow maternity care professionals from different levels of service to work together<br />
to ensure the provision of high-quality, clinically effective services throughout Scotland.<br />
They enable professionals to look beyond the constraints of professional, organisational<br />
and geographical boundaries to develop services which are of a consistently high quality<br />
across the country, and foster a genuine multi-disciplinary approach. They also provide an<br />
infrastructure on which to base a framework of tiered care in maternity services with clear<br />
and explicit communication and referral pathways.<br />
page 9
Principles<br />
1.3 Networks of maternity services should be developed throughout Scotland at local,<br />
regional and national level.<br />
1.4 Networks should devise a framework of tiered care <strong>for</strong> maternity services in Scotland<br />
through mechanisms <strong>for</strong> regional planning.<br />
7. An effective maternity network, operating at local, regional or national level, will develop<br />
systems to provide:<br />
• ongoing professional advice to maternity care professionals<br />
• vehicles <strong>for</strong> good communication between professionals<br />
• clear and consistent advice on key clinical topics, such as resuscitation and stabilisation<br />
procedures (appropriate <strong>for</strong> different kinds of maternity unit)<br />
• criteria <strong>for</strong> care and <strong>for</strong> transfer of care<br />
• criteria <strong>for</strong> escalation to high levels of intrapartum or postnatal care<br />
• criteria <strong>for</strong> access to specialist neonatal services<br />
• criteria <strong>for</strong> access to adult intensive care and high dependency settings<br />
• support <strong>for</strong> transport and transfer systems<br />
• comprehensive specialist outreach antenatal and postnatal care services.<br />
page 10
Assessing and Managing Risk<br />
1. Risk is not easy to assess in maternity care. Nevertheless, maternity care professionals<br />
must take all possible steps to identify and effectively manage risk, with a view to<br />
minimising potential harm. Risk assessment and management should there<strong>for</strong>e become<br />
core functions of care in pregnancy and childbirth.<br />
2. Assessing and managing risk within maternity services is a complex and dynamic process.<br />
There is no such thing as ‘zero risk’ <strong>for</strong> women who are pregnant or giving birth – an element<br />
of risk applies to all pregnancies and childbirth. This must be explicit in developing local<br />
strategies and practice.<br />
Principles<br />
2.1 Each maternity network should develop risk management and assessment as core<br />
elements of practice. They should:<br />
• develop a risk management strategy<br />
• develop and implement protocols and guidance related to risk assessment and<br />
management<br />
• set up multi-professional labour ward <strong>for</strong>ums to explore risk issues<br />
• develop critical incident reporting procedures<br />
• establish ‘emergency-drill’ procedures through which maternity care professionals<br />
are able to explore and rehearse responses to critical incidents<br />
• instigate processes of audit to monitor, assess and evaluate practice.<br />
3. Skills of risk assessment and risk management need to be held not only by professionals in<br />
specialist centres or consultant-led maternity units, but also by all those involved in delivering<br />
maternity services across a wide variety of locations. Particular emphasis on training<br />
practitioners in community maternity units (CMUs) and those in remote and rural locations<br />
will be necessary.<br />
page 11
Principles<br />
2.2 Services should ensure that practitioners in CMUs and remote and rural locations<br />
gain access to training on skills related to risk assessment and management.<br />
2.3 Midwife-led settings <strong>for</strong> childbirth, including home births, CMUs attached to nonobstetric<br />
general hospitals and standalone CMUs, should have the same riskmanagement<br />
strategies. These should ensure that women who experience<br />
complications during labour or postnatally, including those who need epidural<br />
analgesia, are transferred to consultant-led units.<br />
4. CMUs need an adequate safety net to manage risk and deal with emergencies. Midwives<br />
and, where appropriate, general practitioners (GPs) require appropriate arrangements <strong>for</strong><br />
consultation, referral and on-site resuscitation and stabilisation to be in place to manage<br />
complications in pregnancy prior to transfer. Island hospitals should offer emergency<br />
interventions when necessary and in exceptional circumstances.<br />
Principles<br />
2.4 CMUs should have appropriate risk assessment and management procedures in<br />
place to manage acute emergencies effectively.<br />
2.5 In exceptional circumstances, remote and rural island hospitals may offer caesarean<br />
section if appropriate facilities and trained personnel are available.<br />
5. A review of research into midwife-managed care in childbirth indicated that there is no<br />
evidence this is less safe or effective than consultant-led care, and with the right infrastructure<br />
in place, midwife-led care ensures good outcomes <strong>for</strong> women with low-risk pregnancies. It is<br />
the preferred choice <strong>for</strong> many. This research is summarised in the reference report.<br />
page 12
Risk assessment and management<br />
6. The mother and baby are the focus of risk assessment and management. Risk assessment<br />
should be based on the understanding that certain risk factors may rule out a particular<br />
option <strong>for</strong> childbirth rather than determine where the mother should deliver, and should be<br />
reviewed regularly throughout the pregnancy.<br />
Principles<br />
2.6 Risk assessment should be based on exclusion rather than inclusion criteria.<br />
7. Risk assessments carried out in clinical areas have tended to concentrate on clinical issues<br />
such as general medical and surgical health and obstetric history. These are unquestionably<br />
important, but consideration must also be given to non-clinical factors, such as:<br />
• geography and predicted weather conditions<br />
• nature, condition and use of available emergency equipment<br />
• nature of emergency back-up and support<br />
• transfer arrangements.<br />
Principles<br />
2.7 In addition to clinical factors, services should also consider non-clinical factors in risk<br />
assessment.<br />
8. Attention must also be paid to the existing evidence from research and audit which<br />
demonstrates that avoiding medical interventions in women with low-risk pregnancies has<br />
positive outcomes. Problems may arise in any pregnancy, however. Some of them will be<br />
serious or life-threatening, with one in 1,000 mothers per year requiring admission to<br />
intensive care units in Scotland. Services must ensure they have assessed risks in each<br />
case and planned responses appropriately.<br />
page 13
Helping women to assess risk, weigh evidence and take decisions<br />
9. Women have to make difficult decisions about their maternity care, taking into account a<br />
complex range of factors. They may have to consider issues such as demographics and<br />
available evidence, weighing them against their previous experience, personal circumstances,<br />
expectations and needs. They will also weigh the risks and benefits of pursuing a particular<br />
type of care against the other options available.<br />
10. Women must have the right in<strong>for</strong>mation on which to base decisions. They should have<br />
access to the best available evidence presented in non-technical terms related to their care<br />
at appropriate times during their care episode. This will give them the opportunity to make<br />
truly in<strong>for</strong>med choices about their care, based on advice and support from maternity care<br />
and other professionals.<br />
Principles<br />
2.8 Women should have access to the best available evidence relative to their care<br />
throughout their care episodes, delivered by experienced and knowledgeable maternity<br />
care and other professionals.<br />
2.9 All services should ensure they have appropriate treatment and referral pathways in<br />
place to meet the needs of women and babies who become ill at any time during the<br />
pregnancy and after the birth.<br />
2.10 Acute maternity services should ensure they have clear arrangements <strong>for</strong> access to<br />
adult intensive care facilities in a general hospital. Hospitals with consultant-led units<br />
should have ready access to adult intensive care, high-dependency and neonatal<br />
intensive care facilities.<br />
2.11 Consultant-led units should have in place a maternal and neonatal resuscitation service,<br />
a full obstetric and anaesthetic service and access to epidural analgesia in labour.<br />
Risks associated with levels of care<br />
11. The <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland identified the different levels of maternity<br />
and neonatal care that exist to meet the needs of Scotland’s different communities (Table 1).<br />
page 14
Table 1 Levels of intrapartum care in Scotland<br />
Ia<br />
Ib<br />
Ic<br />
Id<br />
IIa<br />
IIb<br />
IIc<br />
III<br />
Location of<br />
delivery<br />
Home (planned)<br />
Stand-alone<br />
community<br />
maternity unit<br />
Community<br />
maternity unit<br />
adjacent to nonobstetric<br />
hospital<br />
Community<br />
maternity unit<br />
adjacent to<br />
maternity unit<br />
Consultant-led<br />
maternity unit<br />
with no neonatal<br />
facility<br />
Consultant-led<br />
maternity unit<br />
with on-site<br />
neonatal facility<br />
Consultant-led<br />
maternity unit<br />
Consultant-led<br />
specialist<br />
maternity unit<br />
Lead carer<br />
Midwife (GP)<br />
Midwife (GP)<br />
Midwife (GP)<br />
Midwife (GP)<br />
Consultant<br />
Obstetrician<br />
(plus midwife)<br />
Consultant<br />
Obstetrician<br />
(plus Midwife)<br />
Consultant<br />
Obstetrician<br />
(plus Midwife)<br />
Consultant<br />
Specialist in<br />
Maternal Fetal<br />
Medicine<br />
(Midwives/others)<br />
Clinical<br />
situation<br />
Normal pregnancy<br />
and labour<br />
Normal pregnancy<br />
and labour<br />
Normal pregnancy<br />
and labour<br />
Normal pregnancy<br />
and labour<br />
Low-risk<br />
pregnancy and<br />
labour<br />
Low- to mediumrisk<br />
pregnancy<br />
and labour<br />
Low- and mosthigh<br />
risk<br />
pregnancies and<br />
labour<br />
Complex and highrisk<br />
pregnancies<br />
and labour<br />
Care need and delivery<br />
Suitable home facility with backup<br />
from the <strong>Scottish</strong> Ambulance<br />
Service (paramedics) and<br />
supporting advice from a linked<br />
maternity unit<br />
Appropriately equipped<br />
midwifery unit <strong>for</strong> normal care<br />
and agreed transfer guidelines to<br />
a linked maternity unit<br />
As Ib above. Medical staff<br />
(surgeon/GP) appropriately<br />
trained to per<strong>for</strong>m emergency<br />
caesarean section<br />
As Ib above<br />
<strong>Maternity</strong> unit care with<br />
monitoring facilities and<br />
anaesthetic cover with no access<br />
to paediatric facilities on site<br />
<strong>Maternity</strong> unit care with<br />
monitoring facilities, access to<br />
anaesthetic and paediatric cover,<br />
but transferring out as required<br />
to special care baby unit or<br />
neonatal intensive care in a larger<br />
maternity unit<br />
Full maternity unit and support<br />
services with easy access to<br />
special care baby unit/neonatal<br />
intensive care and access to adult<br />
high dependency care and adult<br />
intensive care<br />
As <strong>for</strong> level IIc, but with on-site<br />
neonatal intensive care and<br />
access to neonatal surgery and<br />
adult intensive care<br />
Suggested<br />
Number of<br />
deliveries<br />
12. Risk assessment and management mechanisms, based on the principle that all women<br />
should receive individualised, holistic care, should be in place to guide service provision in<br />
all settings. A comprehensive list of inclusion and exclusion criteria <strong>for</strong> each kind of unit,<br />
based on risk assessment and management principles, can be found in Appendix 2.<br />
Principles<br />
2.12 All maternity units should ensure that their level of service is consistent with the risk<br />
assessment exclusion examples shown in Appendix 2.<br />
13. Principle 22 of the <strong>Framework</strong> states that all maternity care professionals must have a clear<br />
understanding of the concept of risk assessment and management. Women also need this<br />
understanding. They need to be involved in risk assessment and given unbiased in<strong>for</strong>mation,<br />
based on the very best available evidence. A consensus about the right level of maternity<br />
care can then be <strong>for</strong>ged between the woman and the professionals caring <strong>for</strong> her, which<br />
balances risks against maternal choice and needs.<br />
Principles<br />
2.13 <strong>Maternity</strong> care professionals should assist the pregnant woman to understand the<br />
concept and nature of risk management to help her make a decision about where and<br />
how she should give birth.<br />
page 16
Education, Training and<br />
Work<strong>for</strong>ce Issues<br />
1. The report of the Education, Training and Work<strong>for</strong>ce Issues Subgroup of A <strong>Framework</strong> <strong>for</strong><br />
<strong>Maternity</strong> Services in Scotland described the challenges in developing a well-equipped and<br />
well-resources obstetric work<strong>for</strong>ce. The report concluded that local solutions, combined with<br />
significant resources, are required to ensure a high-quality maternity service <strong>for</strong> all women<br />
in Scotland, irrespective of geographical location.<br />
The competency approach<br />
2. The EGAMS has defined and described the competencies maternity care professionals need<br />
to provide effective and safe care <strong>for</strong> low-risk women and to manage obstetric emergencies<br />
within remote and non-specialist units. Competencies have subsequently been developed<br />
to cover all types of maternity care facilities in Scotland; all staff must achieve the range of<br />
competencies set <strong>for</strong> low-risk care (Level I), and specialist staff will need to achieve those at<br />
Levels II and III.<br />
3. All the competencies correlate to established good practice. They are designed to ensure<br />
that all professionals working in maternity units have the confidence, skills and attitudes to<br />
deliver a consistently high standard of care, to ensure patient safety and comply with the<br />
requirements of good clinical governance. The full description of the competencies can be<br />
found in Appendix 3.<br />
Principles<br />
3.1 <strong>Maternity</strong> care professionals working in units throughout Scotland should achieve the<br />
competencies appropriate <strong>for</strong> the level of care their Unit provides.<br />
3.2 <strong>Maternity</strong> care professionals should identify present and required competencies<br />
within their individual job descriptions, personal development plans (PDPs) and<br />
continuing professional development (CPD) portfolios.<br />
Continuing professional education and training<br />
4. Once achieved, it is vital that competency-based practice is maintained. This may be relatively<br />
easy to achieve in larger units caring <strong>for</strong> large numbers of women. In smaller units, and in<br />
units in remote and rural areas there are likely to be fewer opportunities. These units will<br />
need to collaborate with other larger Units to ensure that professionals have the chance to<br />
update their skills, knowledge and competencies on a regular basis. They should consider<br />
innovative approaches to training and CPD, <strong>for</strong> example using video-conferencing to enable<br />
staff to participate in educational events.<br />
page 17
Principles<br />
3.3 Small units and those in remote and rural areas should consider using computer<br />
technology to enable staff to update their skills, knowledge and competencies on a<br />
regular basis.<br />
3.4 Staff in small and remote and rural units should be offered opportunities to take<br />
clinical placements/secondments in larger units as a means of updating skills,<br />
knowledge and competencies.<br />
5. Even in the larger Level III units it is important not to be complacent about maintaining skills.<br />
Larger numbers of professionals may be vying <strong>for</strong> opportunities to develop their skills and<br />
competencies, reducing the potential ‘bank’ of developmental opportunities.<br />
6. It is there<strong>for</strong>e crucial that, in addition to CPD opportunities offered by employing organisations,<br />
maternity care professionals take some responsibility <strong>for</strong> the maintenance and development<br />
of their own skills, knowledge base and required competencies. This might include <strong>for</strong>mal or<br />
in<strong>for</strong>mal education through study at a university or other education institution; private study,<br />
conferences and study days, meetings with colleagues, clinical placements, clinical rotations<br />
and visits, all of which can serve to maintain and develop competencies. Wherever possible,<br />
new learning opportunities should be designed to meet the needs of a multi-disciplinary<br />
audience.<br />
Principles<br />
3.5 <strong>Maternity</strong> care professionals should share responsibility <strong>for</strong> their educational<br />
development, in partnership with their employing organisations. They should explore<br />
and undertake a variety of uni- and multi-disciplinary CPD opportunities.<br />
3.6 <strong>Maternity</strong> units and Regional Services should explore options <strong>for</strong> delivery of CPD<br />
activities within multi-disciplinary settings.<br />
7. At higher education level, a co-ordinated programme of learning opportunities leading to<br />
the award of academic and/or professional credits should be developed to reflect the<br />
competencies set <strong>for</strong> each level of maternity service. They should also, whenever possible,<br />
have a multi-disciplinary focus.<br />
page 18
Principles<br />
3.7 A national, post-registration, multi-disciplinary curriculum <strong>for</strong> maternity services in<br />
Scotland should be established. NHS Boards and Trusts, NHS Education <strong>for</strong> Scotland,<br />
professional bodies and education providers should <strong>for</strong>m an alliance to plan and<br />
deliver the programme.<br />
3.8 A Lead Co-0rdinator <strong>for</strong> maternity services education should be identified within NHS<br />
Education <strong>for</strong> Scotland to oversee the development, delivery and evaluation of the<br />
education programme.<br />
3.9 Education curricula at post-registration level should reflect the competencies set <strong>for</strong><br />
different types of maternity services delivery.<br />
Work<strong>for</strong>ce issues<br />
8. <strong>Maternity</strong> services in Scotland are facing challenging work<strong>for</strong>ce pressures. Solutions will<br />
require NHS Boards and Trusts, individually and collectively, to identify and plan work<strong>for</strong>ce<br />
requirements <strong>for</strong> the full range of maternity services in their areas. They will need to work<br />
closely with the regional and national mechanisms introduced in the national action plan on<br />
work<strong>for</strong>ce development, Working <strong>for</strong> Health, to align work<strong>for</strong>ce and service planning in<br />
NHSScotland.<br />
9. Traditional work<strong>for</strong>ce planning approaches are no longer sustainable. Meeting the needs of<br />
the future will require creative thinking about how to make sure that multi-disciplinary teams<br />
have the skills and competencies necessary to provide the highest standards of care.<br />
Options <strong>for</strong> action will need to include alternative working patterns and changes in the<br />
composition and deployment of staff from different professions and disciplines.<br />
10. Some of the key work<strong>for</strong>ce drivers (such as the New Deal <strong>for</strong> Junior Doctors and the<br />
European Working Time Directive) are primarily concerned with achieving safer working<br />
conditions <strong>for</strong> employees and, as a result, enhancing the quality of care <strong>for</strong> NHS service<br />
users. The en<strong>for</strong>cement of limits on the extent to which care can be provided by trainees<br />
and constraints on medical and midwifery hours of work are undoubtedly welcome, but<br />
nevertheless increase pressure on services.<br />
page 19
Midwifery<br />
11. Midwives face significant challenges to their traditional patterns of working. They need to<br />
adopt innovative approaches to care and build on, enhance and refresh their skills and<br />
competencies to provide a modern maternity service. Alongside enhanced responsibilities,<br />
this will bring more autonomy, confidence, and different working relationships within<br />
maternity service delivery teams. These changes will require investment of resources and<br />
time to enhance all maternity professionals’ existing skills and competencies. Nevertheless,<br />
services should not suffer.<br />
Hospital doctors<br />
12. Doctors in training have traditionally provided a large proportion of direct medical care.<br />
Continuing tensions between training and service imperatives can be anticipated, particularly<br />
at Senior House Officer (SHO) grade.<br />
13. The <strong>Scottish</strong> Executive is currently consulting on the proposals contained in the Unfinished<br />
Business report on re<strong>for</strong>m of the SHO grade. The report argues that after graduation, doctors<br />
should enter a two-year foundation programme. Any such re<strong>for</strong>m of training at SHO level will<br />
impact on the hours of service delivery by SHOs, and there<strong>for</strong>e on the working patterns of<br />
doctors at other grades and other members of the clinical team.<br />
14. The new consultant contract sets the expectation that consultants will provide an increasing<br />
proportion of direct care, and will also revise remuneration <strong>for</strong> out-of-hours work. The contract<br />
offers an opportunity to recruit and retain consultants <strong>for</strong> all aspects <strong>for</strong> intrapartum care.<br />
General practitioners<br />
15. GPs are important in helping provide intrapartum care, particularly in remote and rural<br />
areas. But fewer GPs are willing to take training in obstetrics and be involved in intrapartum<br />
care. The moves to a new contract <strong>for</strong> GPs, with maternity care being designated as an<br />
‘additional’ or ‘enhanced’ service, may also have an impact on the way GPs contribute to<br />
the care models of the future.<br />
16. These developments make it imperative that planners of maternity services take a strategic<br />
look at work<strong>for</strong>ce issues.<br />
page 20
Developing the maternity work<strong>for</strong>ce – investing in skills<br />
17. Developing the maternity services of the future relies on developing a work<strong>for</strong>ce that has<br />
the appropriate skills, attitudes and competencies to deliver safe, clinically effective care<br />
across all types of service. Education and training are key to work<strong>for</strong>ce development.<br />
Principles<br />
3.10 Integrated work<strong>for</strong>ce plans <strong>for</strong> maternity services should be driven by the core<br />
competencies necessary <strong>for</strong> the safe and clinically effective delivery of services.<br />
The involvement of the full range of education providers in this process is crucial.<br />
3.11 Opportunities <strong>for</strong> multi-disciplinary education and training should be maximised.<br />
18. The maternity services work<strong>for</strong>ce faces similar pressures to the rest of the health work<strong>for</strong>ce<br />
and the solutions, <strong>for</strong> the various professional groups involved, will follow the same pattern.<br />
The need to plan and organise maternity services at regional level has been emphasised in<br />
this summary overview report. This is consistent with the general thrust of the new<br />
work<strong>for</strong>ce arrangements, which aim to integrate work<strong>for</strong>ce planning with service planning<br />
at regional level. Already, with Level III maternity specialist sites in the North, East and West<br />
of Scotland, there is a sound basis <strong>for</strong> consolidating models of service provision – and with<br />
them the work<strong>for</strong>ce arrangements – that are necessary to meet the various requirements of<br />
the service.<br />
19. Each of the three regions will have work<strong>for</strong>ce planning co-ordinators in place to assist<br />
integrated work<strong>for</strong>ce and service planning. The Regional Work<strong>for</strong>ce Planning Co-ordinators<br />
will work closely with the National Work<strong>for</strong>ce Committee, developing national strategies <strong>for</strong><br />
work<strong>for</strong>ce issues <strong>for</strong> all staff groups and specialities.<br />
Principles<br />
3.12 NHS Boards and Regional Service Planning Groups should work closely with Regional<br />
Work<strong>for</strong>ce Co-ordinators on work<strong>for</strong>ce development issues.<br />
3.13 Specialist staff should be available to undertake some duties on a regional basis.<br />
page 21
Remote and rural issues<br />
20. Remote and rural areas of Scotland present particular challenges <strong>for</strong> the provision of<br />
maternity care and need innovative ways of accommodating and supporting pregnant<br />
women in remote and rural parts of the country be<strong>for</strong>e, during and after childbirth.<br />
Innovative solutions to local problems may require professionals to develop a different<br />
range of skills and devise different arrangements and patterns of provision.<br />
Principles<br />
3.14 <strong>Maternity</strong> courses should be set up <strong>for</strong> midwives, obstetricians, GPs, paramedics and<br />
other health professionals working in remote and rural areas. This will help to ensure<br />
that these professionals receive the appropriate education and support to equip<br />
them to make decisions about care and know when to refer to specialist maternity<br />
care professionals.<br />
3.15 GPs in rural and remote areas must be trained and competent to care effectively <strong>for</strong><br />
pregnant women and their babies. Most GPs in remote settings will be involved<br />
(directly or indirectly) in the delivery of maternity care, especially in cases where the<br />
mother has an illness which may require GP input.<br />
3.16 Other health professionals’ role and competencies should be reviewed in relation to<br />
delivering a safe and effective maternity service in remote and rural areas.<br />
21. New arrangements <strong>for</strong> considering work<strong>for</strong>ce development alongside service planning will be<br />
overseen by a national <strong>Maternity</strong> Services Work<strong>for</strong>ce Group, which will promote a skills and<br />
competency driven team-based approach. Multi-disciplinary training and development will<br />
be a feature and special consideration will be given to the issues in remote and rural areas.<br />
page 22
Stakeholder Engagement<br />
1. The <strong>Scottish</strong> Executive has emphasised the importance of involving stakeholders –<br />
commissioners, providers and users of services and the general public – in the planning,<br />
delivery and evaluation of services. 4 The <strong>Framework</strong> <strong>for</strong> <strong>Maternity</strong> Services in Scotland, <strong>for</strong><br />
instance, was based on wide consultation with professionals and users of services.<br />
2. The consistent message from all stakeholders is the need to ensure maximum safety <strong>for</strong><br />
women and their babies. But different stakeholders hold different perspectives and thresholds<br />
on safety, and this has dogged NHS Boards’ attempts to achieve local consensus about the<br />
shape of local provision. The <strong>Framework</strong> recommends a woman and baby-centred service<br />
with local access. Yet some NHS Boards have centralised provision in larger units, lowering<br />
risk thresholds at the cost of reducing local access.<br />
3. The public must be in<strong>for</strong>med and involved in discussions about reshaping services locally<br />
and nationally. Consensus must be achieved about the range of provision required to support<br />
choice, while not compromising on risk and quality. NHS Boards and Trusts should give high<br />
priority to involving stakeholders in every aspect of planning and developing maternity<br />
services in Scotland. Ways of doing this should be developed at local, regional and national<br />
level to facilitate this, building on current mechanisms and experience and developing new<br />
and creative ways <strong>for</strong> gathering and taking account of the views and experiences of women,<br />
their families and the wider public.<br />
Principles<br />
4.1 The consultation processes on planning, delivery and evaluation of maternity services<br />
at local, regional and national levels should involve all key stakeholders –<br />
commissioners, providers and users of services, and the general public.<br />
4<br />
Our National Health – a plan <strong>for</strong> action, a plan <strong>for</strong> change <strong>Scottish</strong> Executive 2000; Patient Focus, Public<br />
Involvement <strong>Scottish</strong> Executive 2001<br />
page 23
4. All NHS Board areas should now have in place a <strong>Maternity</strong> Services Liaison Committee.<br />
These committees bring together maternity professionals with service users, members of<br />
the public and representatives of health councils to discuss local maternity issues.<br />
They serve to:<br />
• maintain links with current and recent users of maternity services, allowing women from<br />
all parts of the community to have an opportunity to comment on services<br />
• encourage and facilitate user involvement in maternity services<br />
• offer a vehicle <strong>for</strong> change and improvement, driven by suggestions coming directly from<br />
service-users.<br />
Principles<br />
4.2 The role of <strong>Maternity</strong> Services Liaison Committees should be strengthened.<br />
4.3 The National Health Council should consider bringing together representatives of<br />
local <strong>Maternity</strong> Services Liaison Committees to <strong>for</strong>m a body with a strong voice <strong>for</strong><br />
maternity care at national level.<br />
page 24
In<strong>for</strong>mation Management<br />
and Technology<br />
1. The use of in<strong>for</strong>mation technology in health care has grown very quickly in recent years. Its<br />
value in improving in<strong>for</strong>mation management, communication and education within maternity<br />
services in Scotland is yet to be realised, but some innovative projects and initiatives are<br />
underway elsewhere in the NHS, <strong>for</strong> example, assisting diagnosis, treatment and patient<br />
care in remote and rural areas.<br />
2. The potential IT offers in developing professionals’ competencies and knowledge, reviewing<br />
and auditing practice and facilitating access to important in<strong>for</strong>mation <strong>for</strong> women cannot<br />
be ignored.<br />
3. A priority <strong>for</strong> services must be access to accurate and up-to-date in<strong>for</strong>mation in health care.<br />
In<strong>for</strong>mation management processes need to be reviewed within maternity services. Audit of<br />
practice, in particular, should be based on new and innovative approaches involving<br />
in<strong>for</strong>mation technology.<br />
Principles<br />
5.1 <strong>Maternity</strong> services should initiate or further develop ongoing audit in relation to:<br />
• modes of delivery of maternity services by location<br />
• clinical outcomes <strong>for</strong> mothers and babies<br />
• comprehensive transfer data<br />
• critical incidence reporting<br />
• complaints procedure<br />
• litigation costs.<br />
5.2 The <strong>Scottish</strong> Executive should facilitate the development of a national core dataset<br />
<strong>for</strong> feto-maternal medicine.<br />
page 25
4. In<strong>for</strong>mation technology and telemedicine (a system <strong>for</strong> allowing the public and health<br />
professionals access to medical in<strong>for</strong>mation and care via electronic means) also offer<br />
exciting opportunities in the field of education, particularly in remote and rural areas.<br />
<strong>Maternity</strong> services should explore their potential in helping professionals to communicate<br />
with, and learn from, each other, and <strong>for</strong> accessing important educational material and<br />
in<strong>for</strong>mation to develop practice.<br />
Principles<br />
5.3 <strong>Maternity</strong> services should explore the role of in<strong>for</strong>mation technology and<br />
telemedicine in relation to:<br />
• training and education<br />
• developing professional support networks<br />
• developing clinical skills through, <strong>for</strong> instance, workshops, simulation laboratories<br />
and mannequins, computer-aided programmes <strong>for</strong> rehearsal of emergency<br />
responses and procedures<br />
• using video conferencing in direct patient care<br />
• communicating within regional and clinical networks regarding advice, referral,<br />
transfer and network in<strong>for</strong>mation<br />
• transmitting medical diagnostic images, such as cardiotocograph (CTG) recordings,<br />
ultrasound scans and other test results.<br />
5.4 The use of in<strong>for</strong>mation technology and telemedicine should be developed, especially<br />
in remote and rural and isolated communities, to enhance communication, service<br />
provision and education.<br />
page 26
Transport in Acute <strong>Maternity</strong><br />
Services<br />
1. Ambulance transport in Scotland is currently provided by eight Operational Control Centres<br />
serving the relevant NHS Board Areas, although the number will reduce to three Regional<br />
Centres over the next two years. There is also a national Air Ambulance desk, located in<br />
Aberdeen.<br />
2. Ambulances can be accessed in three main ways: the 999 emergency system, direct telephone<br />
numbers used by GPs and hospital-based clinicians, and by pre-book <strong>for</strong>ms sent by mail or<br />
fax to the appropriate control centre.<br />
3. Although maternity-related calls account <strong>for</strong> only a small amount of total ambulance service<br />
workload, any change to the organisation and delivery of maternity services will impact on<br />
ambulance provision and paramedical support. The implications of providing different levels<br />
of maternity care on a regional basis must be fully explored with the ambulance service, and<br />
staff should be equipped with the necessary confidence, education, skills and competencies<br />
to participate effectively to services <strong>for</strong> pregnant women and their babies.<br />
Principles<br />
6.1 Paramedic staff must be trained and skilled to provide effective emergency care to<br />
women be<strong>for</strong>e, during and after childbirth. Training should include early recognition,<br />
and management, of obstetric and neonatal emergencies.<br />
6.2 Paramedic staff should have access to multi-professional maternity care training.<br />
6.3 Training should be practical in focus, and should include ‘hands-on’ experience under<br />
the supervision of an experienced clinician in the hospital setting, such as a midwife<br />
or obstetrician.<br />
6.4 Paramedical staff should receive ongoing training and refresher courses to maintain<br />
and enhance skills and competencies. Whenever possible, these activities should be<br />
multi-professional.<br />
page 27
Neonatal transport<br />
4. Approximately 1,000 babies are transferred across hospitals in Scotland each year. A report<br />
of a working group on neonatal transfer in 2002 concluded that current neonatal transport<br />
services were not sustainable. The <strong>Scottish</strong> Executive Health Department has accepted the<br />
conclusions in the report and has instructed Regional Services Planning Groups to<br />
implement the recommendations and, in particular, that by April 2003:<br />
• a 24-hour neonatal transport system should be set up in three regions of Scotland –<br />
North, South-East and West<br />
• newborn babies should only have to undergo one episode of transport<br />
• adequate staffing and equipment levels should be secured.<br />
page 28
Appendix 1<br />
Membership of Short Life Expert Group on Acute <strong>Maternity</strong> Services<br />
Chair: Mary Mulligan Deputy Minister <strong>for</strong> Health and Community Care<br />
Ms Ann Bethune Implementation Group <strong>for</strong> <strong>Maternity</strong> Services, Highland NHS Board<br />
Ms Yvonne Bronsky Midwife & Service Manager, Women and Children’s Directorate,<br />
Wishaw General Hospital<br />
Professor Andrew Calder Chair of <strong>Scottish</strong> Executive Committee of RCOG & Professor of<br />
Obstetrics and Gynaecology, University of Edinburgh<br />
Dr Alan Cameron Consultant Obstetrician and Feto-maternal Specialist, Queen<br />
Mother’s Hospital, Yorkhill NHS Trust, Glasgow<br />
Dr Jim Chalmers Consultant in Public Health Medicine, Common Services Agency,<br />
In<strong>for</strong>mation & Statistics Division<br />
Mrs Fiona Dagge-Bell Senior Midwife, The Nursing & Midwifery Practice Development<br />
Unit, Clinical Standards Board <strong>for</strong> Scotland<br />
Mrs Mareth Irving <strong>Maternity</strong> Services Liaison Committee, Dumfries & Galloway NHS<br />
Board<br />
Dr John H McClure Consultant Anaesthetist, New Royal Infirmary of Edinburgh<br />
Dr Sheena MacDonald General Practitioner, Earlston, Berwickshire<br />
Dr Margaret McGuire Midwifery Development Officer, NHSScotland/Royal College of<br />
Midwives<br />
Professor Stuart Postgraduate Dean, NHS Education <strong>for</strong> Scotland –<br />
Macpherson South East Region<br />
Mr Gerry Marr Chief Executive, Tayside University Hospitals NHS Trust<br />
Dr Andrew Marsden Consultant Medical Director, <strong>Scottish</strong> Ambulance Service<br />
Ms Anne Mitchell Advanced Neonatal Nurse Practitioner, Simpson’s Centre <strong>for</strong><br />
Reproductive Health, Edinburgh<br />
Dr Catriona Morton General Practitioner Principal, Craigmillar, Edinburgh<br />
Mr John Mullin Chairman, Argyll & Clyde NHS Board<br />
Ms Patricia Purton Director, Royal College of Midwives UK Board <strong>for</strong> Scotland<br />
Dr Judith Steel Associate Specialist in Diabetes, Victoria Hospital, Kirkcaldy<br />
Dr Graham Stewart Clinical Director and Consultant Paediatrician, Royal Alexandra<br />
Hospital, Paisley<br />
Dr Tom Turner Consultant Paediatrician, Queen Mother Hospital, Yorkhill NHS<br />
Trust, Glasgow<br />
Dr Ewen Walker Consultant Obstetrician/Gynaecologist, Ayrshire & Arran Acute<br />
Hospitals NHS Trust<br />
page 29
<strong>Scottish</strong> Executive<br />
Dr Mac Armstrong Chief Medical Officer<br />
Marilyn Barrett Directorate of Human Resources<br />
Dr Ian Bash<strong>for</strong>d Senior Medical Officer<br />
Miss Anne Jarvie Chief Nursing Officer<br />
Ms Jackie McRae Head of Women and Children’s Unit<br />
David Robb Head of Work<strong>for</strong>ce Planning Unit<br />
Iain Ross Women and Children’s Unit (to October 2002)<br />
Mrs Jean Swaffield Nursing Officer<br />
Alexandra Simpson Women and Children’s Unit (to October 2002)<br />
Working Group membership<br />
Dr Margaret McGuire Midwifery Development Officer, NHSScotland/Royal College of<br />
Midwives<br />
Dr Ian Bash<strong>for</strong>d Senior Medical Officer, <strong>Scottish</strong> Executive Health Department<br />
Mrs Jean Swaffield Nursing Officer, <strong>Scottish</strong> Executive Health Department<br />
Dr Alan Mathers Consultant Obstetrician & Gynaecologist, North Glasgow University<br />
Hospital NHS Trust<br />
Dr Ian Laing Consultant Neonatalologist, Lothian University Hospital NHS Trust<br />
Dr Mike Taylor Director of Postgraduate General Practice Education, Aberdeen<br />
Postgraduate Centre<br />
Dr Catriona Morton General Practitioner Principal, Craigmillar, Edinburgh<br />
Dr Ewen Walker Consultant Obstetrician/Gynaecologist, Ayrshire & Arran Acute<br />
Hospitals NHS Trust<br />
Ms Gill Allan Clinical Midwife, Ninewells, Tayside University Hospital NHS Trust<br />
Mrs Yvonne Bronsky Midwife & Service Manager, Women & Children’s Directorate,<br />
Wishaw General Hospital<br />
Mrs Fiona Dagge-Bell Senior Midwife, The Nursing & Midwifery Practice Development<br />
Unit, Clinical Standards Board <strong>for</strong> Scotland<br />
Dr Graeme McLeod Consultant Anaesthetist, Ninewells Hospital, Tayside University<br />
Hospitals NHS Trust<br />
Mrs Monica Thompson Professional Officer <strong>for</strong> Midwifery, NHS Education Scotland<br />
Dr Alan Cameron Consultant Obstetrician/Gynaecologist, Queen Mother’s Hospital,<br />
Yorkhill NHS Trust, Glasgow<br />
Dr Sheena McDonald General Practitioner, The Health Centre, Berwickshire<br />
page 30
Miss Eleanor Stenhouse Senior Midwife, Queen Mother’s Hospital, Yorkhill NHS Trust,<br />
Glasgow<br />
Dr Graham Stewart Clinical Director and Consultant Paediatrician, Royal Alexandria<br />
Hospital, Paisley<br />
Dr Tom Turner Consultant Paediatrician, Queen Mother Hospital, Yorkhill NHS<br />
Trust, Glasgow<br />
Dr Ian Lowles Consultant Obstetrician/Gynaecologist, Borders General Hospital<br />
Dr John H McClure Consultant Anaesthetist, New Royal Infirmary of Edinburgh<br />
Robert Colburn Head of Accident and Emergency Services, <strong>Scottish</strong> Ambulance<br />
Service<br />
page 31
Appendix 2<br />
Risk Assessment<br />
Exit and entry examples to levels of maternity care<br />
Section V explained the rationale <strong>for</strong> the identified entry and exclusion criteria to the different<br />
levels of maternity care. The attached tables provide examples of morbidities and co-morbidities<br />
which would not be suitable <strong>for</strong> delivery in the specified units, but this requires local and<br />
regional agreement and the development of guidelines and explicit networks. This list is not<br />
all-inclusive, and examples are given <strong>for</strong> clarity. The identification criteria may be <strong>for</strong> referral at<br />
any level of care, <strong>for</strong> advice regarding management, or transfer to a higher level of care,<br />
depending on local agreements. It must be stressed that any woman with significant morbidity<br />
is not suitable <strong>for</strong> delivery in Level Ia-d. It is crucial that appropriate referral pathways are used<br />
<strong>for</strong> any mother and baby who give cause <strong>for</strong> concern.<br />
Level IIa exit criteria, especially <strong>for</strong> maternal reasons, will require consultant obstetrician<br />
involvement and care will depend on the available level of service, local facilities and<br />
emergency support. Level IIc units should be able to care <strong>for</strong> the majority of pregnancies.<br />
Though the document has concentrated on exclusion criteria, the following table identifies the<br />
women who are suitable to Level Ia-d of maternity care.<br />
Exit examples <strong>for</strong> Level Ia-d care<br />
Age<br />
Primigravida of >16<br />
Primigravida of
Exit examples <strong>for</strong> Level Ia-d: maternal medical/surgical history (continued)<br />
Haematological Disorders<br />
Haematological disease – e.g.<br />
thrombocytopenia, aplastic anaemia<br />
Coagulation abnormality –<br />
thrombophilia, disseminated<br />
intravascular coagulation (DIC),<br />
DVT, pulmonary embolus (any history)<br />
Rhesus iso-immunisation including<br />
KELL<br />
Haemoglobinopathies<br />
Reproductive/Genital Tract<br />
Mal<strong>for</strong>mations of reproductive/<br />
genital tract<br />
Uterine surgery<br />
Significant pelvic or cervical surgery<br />
Infection<br />
Significant infection e.g. Group B<br />
haemolytic streptococci<br />
Any blood borne virus (HIV, Hep B,<br />
Hep C)<br />
Sepsis<br />
Drug or Alcohol Intake<br />
History of drug or alcohol abuse<br />
There should be a review if the woman<br />
uses therapeutic medication<br />
Genetic Disorders<br />
Marfan’s syndrome<br />
Ehlers Danlos syndrome<br />
Endocrine Disorders<br />
Any endocrine disease<br />
Diabetes (Type I and II) or gestational<br />
diabetes<br />
Thyroid disease – (hypo and hyper)<br />
Adrenal disease e.g. Addisons<br />
Musculo-Skeletal Disorders<br />
Trauma to pelvis, CDH, Kyphosis<br />
Significant connective tissue disorder<br />
Malignant Disease<br />
Previous malignancy<br />
Surgery & Anaesthesia<br />
Any history of significant surgery or<br />
anaesthetic complication must be<br />
considered<br />
Special Needs in Pregnancy<br />
Will need to be independently<br />
considered, e.g.<br />
Learning disability<br />
Social exclusion<br />
Refugee mother<br />
Significant Gastro-intestinal<br />
Disorders<br />
Cholelithiasis<br />
Fatty liver of pregnancy<br />
Hepatobilary disease<br />
Crohn’s disease<br />
Ulcerative colitis<br />
Renal disease<br />
Renal failure, impairment or dialysis<br />
Significant Mental Illness<br />
Diagnosed schizophrenia<br />
Manic depressive psychosis<br />
Postnatal depression<br />
Transplant Surgery<br />
Heart<br />
Lung<br />
Liver<br />
Kidney<br />
page 33
Exit examples Level Ia-d: past obstetric and neonatal history<br />
Antenatal<br />
Antepartum Haemorrhage (including<br />
recurrent placental abruption)<br />
Preterm labour (500 mls primary or<br />
secondary)<br />
Retained placenta<br />
Perineal tear involving the<br />
anal sphincter (3rd or 4th<br />
degree tear)<br />
Pelvic floor repair or<br />
cervical surgery<br />
Stillbirth or<br />
neonatal death –<br />
case review<br />
required<br />
Previous neonatal<br />
birth injury<br />
Previous baby with<br />
haemorrhagic<br />
disease of the<br />
newborn<br />
Risk of, or known,<br />
inherited disease<br />
Previous isoimmunisation<br />
or ABO<br />
incompatibility
Exit examples Level Ia-d: present pregnancy<br />
Maternal<br />
Maternal choice<br />
Hyperemesis gravidarum<br />
Suspected PIH, raised BP<br />
Cholestasis (including fatty liver of<br />
pregnancy and HELPP)<br />
Raised AFP with abnormal growth scan<br />
at 34-36 weeks<br />
Anaemia (Hb 40/52+10 days<br />
Suspected or proven fetal<br />
abnormality<br />
Intrauterine death<br />
Combined<br />
Multiple pregnancy<br />
Preterm labour 12<br />
hours<br />
Oligohydramnios<br />
Polyhydramnios<br />
Maternal infection (HIV, Hepatitis<br />
carrier, Hep B, Hep C, Group B<br />
streptococcal)<br />
Active viral infections such as<br />
chickenpox, rubella, measles, parvovirus<br />
page 35
Exit examples Level Ia-d: intrapartum<br />
Maternal Neonatal<br />
Unstable lie<br />
Requirement <strong>for</strong> epidural analgesia<br />
Established labour >12 hours review<br />
evidence from partogram and<br />
guidelines (NICE/RCOG)<br />
Prolonged rupture of membranes<br />
>12 hours<br />
Abnormal fetal auscultation – fetal<br />
distress<br />
Malpresentation<br />
Exit examples Level Ia-d: postnatal<br />
Maternal Neonatal<br />
Postpartum haemorrhage<br />
Sepsis<br />
Mother gives cause <strong>for</strong> concern<br />
page 36<br />
Maternal pyrexia >38˚C<br />
on two occasions<br />
(30 mins apart)<br />
Intrapartum haemorrhage<br />
Meconium stained liquor<br />
Hypertension: diastolic of<br />
>100 mm/Hg on 2 occasions<br />
or a rise of 20/ suspicion of<br />
developing pre-eclampsia<br />
Prolonged active second<br />
stage<br />
3rd or 4th degree perineal<br />
tear<br />
Postpartum haemorrhage<br />
(>500 mls)<br />
Neonatal seizures<br />
Persisting hypothermia<br />
Retained placenta<br />
Feeding difficulties<br />
persisting at 36 hours of<br />
age<br />
Failure to pass urine in first<br />
24 hours<br />
Infants of 60/ min or<br />
requiring<br />
supplementary<br />
oxygen to maintain<br />
saturation >92%)<br />
Birth weight<br />
Exit examples Level IIa: past history<br />
Significant Respiratory Disease<br />
Significant asthma i.e. requiring<br />
previous hospitalisation or parenteral<br />
steroid therapy<br />
Cystic fibrosis<br />
Congenital abnormality<br />
Emphysema (COPD)<br />
Certain congenital abnormalities<br />
Haematological Disorders<br />
Haematological disease – e.g.<br />
thrombocytopenia, aplastic anaemia<br />
Coagulation abnormality –<br />
thrombophilia, disseminated<br />
intravascular coagulation<br />
(DIC) DVT or pulmonary embolus (any<br />
history)<br />
Reproductive/Genital Tract<br />
Cancer<br />
Infection<br />
Significant infection e.g. Group B<br />
haemolytic streptococci<br />
Any blood borne virus (HIV, Hep B, Hep C)<br />
Sepsis<br />
Drug or Alcohol Intake<br />
History of drug or alcohol abuse<br />
There should be a review if the woman<br />
uses therapeutic medication<br />
Special Needs in Pregnancy<br />
Will need to be independently<br />
considered e.g.<br />
Learning disability<br />
Social exclusion<br />
Refugee mother<br />
Significant Neurological Disease<br />
Neurological disorders, including ME,<br />
MS<br />
Epilepsy<br />
Spina bifida /hydrocephaly<br />
Paraplegia<br />
Endocrine Disorders<br />
Significant endocrine disease<br />
Significant medical disease especially<br />
if unstable (thyroid, adrenal disease<br />
e.g. Addisons)<br />
Diabetes (Type I)<br />
Musculo-Skeletal Disorders<br />
Significant connective tissue disorder<br />
Transplant Surgery<br />
Heart<br />
Lung<br />
Liver<br />
Kidney<br />
Surgery & Anaesthesia<br />
Any history of significant surgery or<br />
anaesthetic complication must be<br />
considered<br />
Neonatal History<br />
Any history of intrapartum asphyxia<br />
should be reviewed<br />
Previous neonatal birth injury<br />
Previous baby with haemorrhagic<br />
disease of the newborn<br />
Risk of, or known, inherited disease<br />
Previous iso-immunisation or ABO<br />
incompatibility<br />
Cardiac Disorders<br />
Congenital heart disease – corrected<br />
or uncorrected<br />
Acquired heart disease – ischaemic<br />
heart disease, cardiomyopathy<br />
Significant Gastro-intestinal<br />
Disorders<br />
Fatty liver of pregnancy<br />
Hepatobilary disease<br />
Crohn’s disease<br />
Ulcerative colitis<br />
Renal Disease<br />
Renal disease<br />
Renal failure, impairment dialysis<br />
Significant Mental Illness<br />
Diagnosed schizophrenia<br />
Manic depressive psychosis<br />
Genetic Disorders<br />
Marfan’s syndrome<br />
Ehlers Danlos syndrome<br />
It is not advisable <strong>for</strong> any ‘at risk’<br />
fetus to be delivered in a level IIa<br />
unit<br />
page 37
Exit examples Level IIa: present pregnancy<br />
Maternal<br />
Maternal choice<br />
New medical disease not previously<br />
identified<br />
Significant antepartum haemorrhage<br />
Cholestasis (including fatty liver of<br />
pregnancy and HELPP)<br />
Severe pregnancy induced<br />
hypertension<br />
Women at high obstetric anaesthetic<br />
risk<br />
Women at high risk of obstetric<br />
interventions which may require<br />
assistance of interventional radiology<br />
(e.g. placenta accreta) or severe PPH<br />
>4000 mls<br />
Raised AFP with abnormal growth scan<br />
at 34-36 weeks<br />
Placental abruption<br />
page 38<br />
Fetal/Combined<br />
Maternal infection (HIV,<br />
Hepatitis carrier, Hep B, Hep C, Group<br />
B streptococcal)<br />
Polyhydramnios<br />
Oligohydramnios<br />
Multiple pregnancy<br />
Preterm labour 40/52+10 days<br />
Suspected or proven fetal<br />
abnormality<br />
Intrauterine death
Exit examples Level IIa: intrapartum<br />
Maternal Maternal/Combined Fetus/Baby<br />
Postpartum haemorrhage (>500 mls) Intrapartum haemorrhage Birth weight 4000g<br />
Mother gives cause <strong>for</strong> concern Maternal pyrexia >38˚C on two<br />
occasions (30 mins apart)<br />
Retained placenta Newly diagnosed medical disease or<br />
morbidity<br />
Exit examples Level IIa: postnatal<br />
Postpartum haemorrhage<br />
Sepsis<br />
Mother gives cause <strong>for</strong><br />
concern<br />
Neonatal seizures<br />
Persisting hypothermia<br />
Feeding difficulties<br />
persisting at 36 hours<br />
of age<br />
Failure to pass urine in first<br />
24 hours<br />
Baby gives cause <strong>for</strong><br />
concern<br />
Apgar score 6 or less at 5 minutes<br />
of age<br />
Respiratory difficulties after<br />
resuscitation (respiratory rate<br />
>60/min or requiring supplementary<br />
oxygen to maintain saturation >92%)<br />
Placenta acreta Infant gives cause <strong>for</strong> concern<br />
Maternal Neonatal<br />
Persisting hypoglycaemia<br />
Failure to pass meconium in<br />
first 36 hours<br />
Jaundice in first 24 hours/<br />
positive Coombes test<br />
page 39
Exit examples Level IIb: past history<br />
Significant Respiratory Disease<br />
Emphysema (COPD)<br />
Cystic fibrosis<br />
Congenital abnormality<br />
Haematological Disorders<br />
Haematological disease – e.g.<br />
thrombocytopenia, aplastic anaemia<br />
Coagulation abnormality –<br />
thrombophilia, disseminated<br />
intravascular coagulation (DIC)<br />
Reproductive/Genital Tract<br />
Cancer<br />
Infection<br />
Significant infection e.g. Group B<br />
haemolytic streptococci<br />
page 40<br />
Significant Neurological Disease<br />
Spina bifida /hydrocephaly<br />
Paraplegia<br />
Endocrine Disorders<br />
Significant medical disease especially<br />
if unstable (thyroid , adrenal disease<br />
e.g. Addisons)<br />
Diabetes (Type I)<br />
Musculo-Skeletal Disorder<br />
Significant connective tissue disorder<br />
Genetic Disorders<br />
Marfan’s syndrome<br />
Ehlers Danlos syndrome<br />
Cardiac Disorders<br />
Congenital heart disease – corrected<br />
or uncorrected<br />
Acquired heart disease – ischaemic<br />
heart disease, cardiomyopathy<br />
Transplant Surgery<br />
Heart<br />
Lung<br />
Liver<br />
Kidney<br />
Renal disease<br />
Renal failure, impairment or dialysis<br />
Significant Mental Illness<br />
Manic depressive psychosis<br />
Fetus/Neonate<br />
Any history of low birthweight babies<br />
should be reviewed
Exit examples <strong>for</strong> Level IIb: present pregnancy<br />
Maternal Fetal Combined<br />
Maternal choice<br />
Malignancy identified in early<br />
pregnancy or any significant newly<br />
diagnosed morbidity<br />
Women at high obstetric anaesthetic<br />
risk<br />
Women at high risk of obstetric<br />
interventions which may require<br />
assistance of interventional radiology<br />
(e.g. placenta accreta) or severe PPH<br />
>4000 mls<br />
Below 10th centile <strong>for</strong> gestational age<br />
Suspected or proven fetal<br />
abnormality including cardiac,<br />
metabolic disorders, CNS or facial<br />
abnormality<br />
Ultrasound identified twin-twin<br />
transfusion<br />
Congenital diaphragmatic hernia Severe pregnancy induced<br />
hypertension (early onset,<br />
Exit examples <strong>for</strong> Level IIc: past history<br />
Significant Respiratory Disease Significant Neurological Disease Cardiac Disorders<br />
Significant infection<br />
Haematological Disorders<br />
Haematological disease – e.g.<br />
thrombocytopenia, aplastic anaemia<br />
Coagulation abnormality –<br />
thrombophilia, disseminated<br />
intravascular coagulation (DIC)<br />
Kidney Genetic Disorders<br />
Marfan’s syndrome<br />
Ehlers Danlos syndrome<br />
Exit examples <strong>for</strong> Level IIc: present pregnancy<br />
Maternal Fetal Combined<br />
Women at high obstetric anaesthetic<br />
risk<br />
Women at high risk of obstetric<br />
interventions which may require<br />
assistance of interventional radiology<br />
(e.g. placenta accreta) or severe PPH<br />
>4000 mls<br />
Malignancy identified in early<br />
pregnancy<br />
page 42<br />
Spina bifida /hydrocephaly<br />
Paraplegia<br />
Endocrine Disorders<br />
Significant medical disease if<br />
associated with severe complications<br />
Musculo-Skeletal Disorders<br />
Significant connective tissue disorder<br />
Suspected or proven fetal<br />
abnormality including cardiac,<br />
metabolic disorders, CNS or facial<br />
abnormality<br />
Congenital diaphragmatic hernia<br />
Abdominal wall defect<br />
Ultrasound identified twin-twin<br />
transfusion<br />
Viral infection<br />
Urogenital mal<strong>for</strong>mations (genital<br />
mal<strong>for</strong>mations, posterior urethral<br />
valves)<br />
Congenital heart disease – corrected<br />
or uncorrected<br />
Acquired heart disease – ischaemic<br />
heart disease, cardiomyopathy<br />
Transplant Surgery<br />
Heart<br />
Lung<br />
Liver<br />
Kidney<br />
Renal disease<br />
Renal failure, impairment or dialysis<br />
Severe pregnancy induced<br />
hypertension (early onset,<br />
Entry examples <strong>for</strong> Level III<br />
Maternal<br />
Renal failure, impairment or<br />
dialysis<br />
Transplant surgery:<br />
Heart<br />
Lung<br />
Liver<br />
Kidney<br />
Genetic disorders:<br />
Marfan’s syndrome<br />
Ehlers Danlos syndrome<br />
Fetal<br />
Suspected or proven fetal<br />
abnormality including, cardiac,<br />
metabolic disorders, CNS or facial<br />
abnormality<br />
Neonate<br />
Need <strong>for</strong> assisted ventilation<br />
beyond initial resuscitation<br />
Congenital diaphragmatic hernia Persistent central cyanosis<br />
Abdominal wall defect Congenital abnormality needing<br />
urgent surgical intervention<br />
Ultrasound identified twin-twin<br />
transfusion<br />
Necrotising enterocolitis<br />
(discretion of the consultant<br />
paediatrician)<br />
Viral infection Neonate less than 28 weeks<br />
gestation<br />
Skeletal mal<strong>for</strong>mations Need <strong>for</strong> specialist investigation<br />
and treatment e.g. metabolic<br />
problem which may require<br />
extraordinary therapies such as<br />
dialysis<br />
Urogenital mal<strong>for</strong>mations (genital<br />
mal<strong>for</strong>mations, posterior uretheral<br />
valves)<br />
page 43
Appendix 3<br />
Core Competencies <strong>for</strong> Health Professionals in<br />
Acute <strong>Maternity</strong> Services<br />
The EGAMS identified core competencies necessary <strong>for</strong> all staff providing intrapartum care in a<br />
CMU or low-risk setting. A team approach was considered crucial to the delivery of maternity<br />
services in each unit. Once competencies are achieved it is vital that the level of skill and<br />
expertise is maintained. All competencies correlate to established good practice; implicit in this is<br />
maintaining patient safety and clinical governance. It is important that all professionals working<br />
in these environments have the confidence, clinical governance, skills and professional<br />
judgement to provide a consistently high standard of care <strong>for</strong> the woman and her baby. This<br />
appendix describes the core competencies required by obstetric professionals working in any<br />
maternity facility and then identify additional competencies required by practitioners working<br />
in specific types of maternity unit, according to the levels of care set out in A <strong>Framework</strong> <strong>for</strong><br />
<strong>Maternity</strong> Services in Scotland.<br />
Promoting Normality – supporting normal labour and childbirth<br />
This includes providing psychosocial and physical support to women in labour and the majority<br />
of existing skills inventories include technical skills and competencies necessary in an emergency.<br />
The identification and prioritisation of these skills is central to a quality midwifery service,<br />
ensuring that midwives will have the confidence to work in these environments and make<br />
clinical decisions about care (Downe, 2001).<br />
The range of core skills required mainly by midwives but relevant to all staff in order to keep<br />
birth normal are as follows (Hunter, 2000):<br />
• Being confident to provide intrapartum care in a low technology setting<br />
• Being com<strong>for</strong>table to use embodied knowledge and skills to assess a woman and her baby<br />
as opposed to using technology<br />
• Being able to let labour ‘be’ and not interfere unnecessarily<br />
• Being confident to avert or manage problems that might arise<br />
• Being willing to employ other options to manage pain without access to epidurals<br />
• Being solely responsible <strong>for</strong> outcomes without access to on site specialist assistance<br />
• Being confident to trust the process of labour and be flexible with respect to time<br />
• Being a midwife who enjoys practising what the participants call ‘real midwifery’.<br />
Promoting normality also includes the use of available evidence to support care (one-to-one<br />
care in labour). There are a variety of ways of ensuring that midwives have and maintain these<br />
essential skills – but implicit in this must be the use of evidenced based care. Central to this is<br />
team working and peer and multi-professional support.<br />
page 44
Clinical judgement and decision-making skills<br />
All maternity care professionals must have the clinical judgement and decision-making skills<br />
required to work in Level I areas. In many instances, midwives may be aware of the appropriate<br />
line of diagnosis and care but will refer to a midwife or doctor <strong>for</strong> assurance that her decision is<br />
right. The appropriate referral mechanism should be utilised. This option may not be available<br />
to a midwife working in a CMU. However, even though the unit may be geographically distant<br />
to the consultant unit, there should always be an explicit network <strong>for</strong> advice and management<br />
of increasing levels of care.<br />
Maternal history taking<br />
CEMD (2001) highlighted the importance of good history taking at booking. It stressed the<br />
importance of a risk and needs assessment at booking which should be reviewed regularly.<br />
Crucial to ensuring a quality service <strong>for</strong> each woman and her family is the management of risk<br />
and identification and prevention of complications.<br />
Counselling and communication skills<br />
The professional must have the skills to communicate clearly with women, their partners and<br />
maternity care team members particularly when problems become evident. These skills are also<br />
central to obtaining good maternal history and providing in<strong>for</strong>med choice about care options.<br />
Risk assessment and management skills<br />
Although midwives working in maternity units have many of these skills, the nature and<br />
environment of a CMU will mean that the type of risk management and decisions about care<br />
will differ to those of a midwife working in an obstetric maternity unit. Frequent updating and<br />
‘fire drill’ scenarios will be necessary. Included in this is the management of uncertainty. All health<br />
service professionals who are involved in maternity care in remote areas must have these<br />
skills.<br />
Venepuncture and intravenous cannulation and the subsequent management of IV fluid<br />
replacement<br />
Not all midwives have this skill although most units run courses and there are anatomically<br />
correct models which can be used <strong>for</strong> practise purposes. Both subgroups stressed that as well as<br />
being able to cannulate the professional must have the skills to manage IV fluid replacement.<br />
There are opportunities <strong>for</strong> professionals to refresh these skills in areas such as day surgery.<br />
Adult resuscitation<br />
CEMD (2001) stressed the importance of managing emergencies such as severe haemorrhage.<br />
This is a core skill of every midwife and health care professional but in order to maintain<br />
competency midwives must attend an annual update course. This course must include early<br />
identification of and care of the ill woman, including the recognition of sepsis.<br />
page 45
Management of obstetric emergencies<br />
Obstetric emergencies such as severe haemorrhage, cord prolapse, shoulder dystocia, breech<br />
delivery and postpartum haemorrhage are addressed in the ALSO course. However, many units<br />
have now introduced their own obstetric life support courses which all maternity care<br />
professionals must attend and then refresh annually.<br />
Neonatal resuscitation<br />
All staff must have the skills and competencies to assess, resuscitate and stabilise the neonate<br />
prior to on-going management. The appropriate skills would include ventilatory support by<br />
“bag and mask” as opposed to tracheal neonatal intubation. Particular emphasis should be<br />
paid to the recognition of the ill neonate.<br />
Initial and discharge examination of the baby<br />
Currently this examination is completed by a paediatrician and in some instances a GP. In order<br />
to provide a seamless service, midwives (especially in remote areas) should be able to complete<br />
the first and discharge examination of the baby. In order to complete the examination the<br />
professional must be able to understand the relevance of the examination, examine, assess<br />
and identify normality and abnormality and be able to refer appropriately.<br />
Pain management<br />
Units in remote areas will not offer epidural analgesia so midwives and GPs must have sound<br />
understanding of pain assessment and management. Included in this is a knowledge of the<br />
variety of pain management techniques (pharmacological and otherwise) which are appropriate<br />
and effective <strong>for</strong> intrapartum care (e.g. use of hydrotherapy). It was noted that the route of<br />
administration of diamorphine should be reviewed in the light of available evidence, currently<br />
diamorphine is administered intramuscularly by midwives, but intravenous administration of<br />
small divided doses was considered more effective.<br />
Assessment, suturing and management of perineal injury<br />
This should include management of perineal pain, adequate assessment of perineal trauma,<br />
skilled technique to repair the perineum and to refer appropriately.<br />
Prescription of drugs<br />
This is an area of concern as current systems (Patient Group Directions and Nurse/Midwife<br />
prescribing codes) do not cover drugs that midwives might require to prescribe in a CMU. Work<br />
in this area is ongoing. The maternity care professional working in a CMU must have the skills<br />
and ability to prescribe and dispense appropriate drugs, especially analgesia in labour, drugs<br />
used in resuscitation and those involved in normal childbirth such as Konakian and Anti D.<br />
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Additional competency which will be required <strong>for</strong> remote units<br />
In remote areas in the following areas of competency should be achieved by at least one member<br />
of the team.<br />
• Ultrasonic scanning – currently, many midwives are involved in scanning. Basic scanning<br />
skills are required with the possible development of some level of fetal anomaly scanning<br />
with adequate expert support.<br />
• Ventouse lift-out delivery – a common complication and cause <strong>for</strong> referral in low-risk women<br />
is delay in the second stage of labour, it was agreed that Ventouse delivery should be a team<br />
competency.<br />
Competencies in Level II Units<br />
Level IIa<br />
In addition to the previously cited competencies, the following should available in a Level IIA unit:<br />
• Detailed ultrasonic scanning<br />
• Pre- and post-operative care of woman<br />
• Instrumental delivery (Ventouse/<strong>for</strong>ceps)<br />
• Caesarean section<br />
• Anaesthetic support (epidural and GA services)<br />
• Management of an ‘ill’ woman, including resuscitation and stabilisation<br />
• Neonatal assessment, resuscitation and stabilisation.<br />
Level IIb<br />
All above competencies should be available in these units, however, the additional competencies<br />
below refer to increased levels of care relating to the neonate.<br />
• Fetal blood sampling<br />
• Neonatal assessment and management of the ill baby<br />
• Intubation and stabilisation of ill baby prior to transfer<br />
• Care of pre-term baby<br />
• Care of baby with IUGR.<br />
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Level IIc<br />
Additional competencies required <strong>for</strong> maternity care professionals working in Level IIc units<br />
include:<br />
• Management of abnormal pregnancy and labour which will cover most obstetric morbidities<br />
and co-morbidities<br />
• Management of ‘ill’ neonate: competencies to care <strong>for</strong> all levels of neonatal care including<br />
neonatal intensive care required.<br />
Competencies in Level III Units<br />
These units will have the facilities and a team of professionals capable of caring <strong>for</strong> any<br />
woman, fetus or baby irrespective of risk or morbidity. The maternity team should have<br />
specialist obstetric, anaesthetic, intensive care, paediatric surgery, neonatal and midwifery<br />
staff with the skills and competencies to care <strong>for</strong> women and babies and are able to carry out<br />
specialist investigations and procedures.<br />
page 48
Glossary<br />
Accredited Certified as being of a prescribed quality.<br />
Acute <strong>Maternity</strong> Services Services providing care during labour and delivery.<br />
Amniocentesis A test carried out during or after 15 weeks of pregnancy <strong>for</strong> fetal<br />
abnormality. The test involves the removal of a small amount of<br />
fluid from the amniotic sac by aspiration through the abdominal<br />
wall, <strong>for</strong> diagnostic purposes.<br />
Antenatal Care Care of women during pregnancy by professionals in order to<br />
detect, predict, prevent and manage problems with women or their<br />
unborn babies. Care also includes education, advice and support.<br />
Audit The measuring and evaluation of care against agreed standards<br />
with a view to improving practice and care delivery.<br />
Caesarean Section An operation where the baby is delivered through an incision<br />
through the abdominal and uterine walls.<br />
Cardiotocograph A test of fetal well-being and uterine contractions. A combination<br />
of electro-cardiography and tocography. The fetal heart rate is<br />
obtained by a microphone placed on the woman’s abdomen or by<br />
an electrode attached to the fetal scalp during labour. At the same<br />
time contractions of the uterus are measured by a tocograph<br />
placed on the woman’s abdomen. Both are recorded on a<br />
monitoring device.<br />
Community <strong>Maternity</strong> Unit A maternity unit, midwife managed, occasionally with GP<br />
involvement, which may be a stand-alone unit or adjacent to a nonobstetric<br />
hospital or adjacent to a maternity unit.<br />
Competency Required level of skill and proficiency.<br />
Congenital Abnormalities An anomaly present at birth.<br />
Continuity of Care This term is used to describe a situation where all the<br />
professionals involved in delivery of care share common ways of<br />
working and a common philosophy. The aim being to reduce<br />
conflicting advice experienced by women, and the same<br />
philosophy of care is experienced by the woman throughout the<br />
period of her care.<br />
Continuity of Carer The same professional providing care throughout a woman’s<br />
contact with the maternity services. It can also be used to describe<br />
the same caregiver throughout a specific episode of care, such as<br />
during labour and childbirth.<br />
Demography The study of statistics on births, deaths and diseases.<br />
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European Community The Working Time Directive provides <strong>for</strong> minimum daily and weekly<br />
Working Time Directive rest periods, annual paid holidays, a limit on the working week of<br />
48 hours and restrictions on night work. It excludes from its scope<br />
transport, work at sea and doctors in training.<br />
Fetal Of the fetus.<br />
Fetus The unborn baby, usually referring to development from the<br />
seventh week of pregnancy until birth.<br />
Guidelines Systematically developed statements which assist in decisionmaking<br />
about appropriate health care <strong>for</strong> specific clinical<br />
conditions.<br />
Home Birth This is usually a planned event where the woman decides to give<br />
birth at home, with care provided by the midwife. It is normal <strong>for</strong> 2<br />
midwives to be present <strong>for</strong> the birth. Occasionally the GP is<br />
involved in the care and present at the birth.<br />
Integrated Care Pathways A coherent approach to providing health promotion, detection and<br />
treatment <strong>for</strong> a specific illness.<br />
Integrated Service A multi-disciplinary, multi-professional approach to service<br />
provision.<br />
Intrapartum The period during labour and delivery.<br />
In-utero In the uterus/womb, unborn.<br />
Lead Professional The professional who will give a substantial part of the care<br />
personally and who is responsible <strong>for</strong> ensuring that the woman has<br />
access to care from other professionals as appropriate.<br />
Local Health Care These co-operatives are GP-led and were set up to address the<br />
Co-operatives (LHCC) health needs of local communities through a multi-disciplinary and<br />
multi-agency <strong>for</strong>um.<br />
<strong>Maternity</strong> Services A committee set up within a NHS Board area which provides a<br />
Liaison Committee <strong>for</strong>um <strong>for</strong> all the professions involved in the provision of maternity<br />
care with representatives of the women who use the services to<br />
discuss issues relevant to the provision and development of<br />
maternity services in the area.<br />
<strong>Maternity</strong> Unit A building or group of buildings in which maternity care is<br />
provided. It can be located within, or adjacent to, a general<br />
hospital, or away from the general hospital.<br />
Multi-disciplinary An approach combining the knowledge, skills and expertise of a<br />
range of organisations and professionals.<br />
Multi-professional Care delivered by a team of health professionals.<br />
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Named Midwife A named, qualified midwife who will be responsible <strong>for</strong> women’s<br />
midwifery care.<br />
Neonatal Period The first 28 days of a baby’s life.<br />
Obstetric The branch of medicine and surgery that deals with pregnancy and<br />
childbirth.<br />
Postnatal After the birth.<br />
Postnatal Period A period not less than 10 days or more than 28 days after the end<br />
of labour, during which time the attendance on the mother and<br />
baby by a midwife is mandatory.<br />
Premature Baby Born be<strong>for</strong>e the due date (less than 37 weeks gestation).<br />
Primary Health Care Primary Health Care is health care at the first point of contact with<br />
the Health Service, addressing physical, social and psychological<br />
problems, but also providing continuity of care. The traditional<br />
Primary Health Care Team of General Practitioners working with<br />
nursing, administrative and other support colleagues has largely<br />
been expanded to include colleagues from other agencies and<br />
disciplines relevant to the delivery of care appropriate to the<br />
person’s needs.<br />
Principles A code of direction.<br />
Professional In this report, Professional usually refers to those who have been<br />
specially trained in health care such as the midwife, the GP, the<br />
obstetrician, the anaesthetist, the paediatrician/neonatologist and<br />
the health visitor.<br />
Protocol An adaptation of a clinical guideline or a written statement to meet<br />
local conditions and constraints, which has legal connotations.<br />
Resuscitation The revival of someone who is in cardiac or respiratory failure or<br />
shock.<br />
Screening Mass examination of the population to detect specific illnesses.<br />
Shared Care An agreed arrangement between a GP and an obstetrician, a GP<br />
and a midwife or an obstetrician and a midwife over care <strong>for</strong> a<br />
pregnant woman.<br />
Strategy A plan or a policy to achieve something.<br />
Supervisor of Midwives A statutory function whereby a midwife who has completed the<br />
appropriate training is appointed to the role of supervisor of<br />
midwives. The role encompasses the provision of support and<br />
guidance <strong>for</strong> midwives, protection of the public, contribution to the<br />
regulation of the practice of midwives and promotion of high<br />
quality care. Each midwife has a named supervisor of midwives.<br />
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Telemedicine Refers to any application of in<strong>for</strong>mation and communications<br />
technology which removes or mitigates the effect of distance in<br />
health care - sometimes now referred to as “Telehealth”.<br />
Ultrasound Scan An image created by the use of sound waves above the audible<br />
range of the human ear. It is useful in the confirmation of<br />
pregnancy, the determination of fetal size and wellbeing.<br />
Woman Centred The needs of the individual woman provide the focus <strong>for</strong> the<br />
planning, organising and delivery of maternity services.<br />
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