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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 />

page 49


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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