The report of Education, Training and Workforce Issues Subgroup of the
Framework highlighted education and workforce deficiencies and concerns within maternity care professionals in Scotland. This concluded that local solutions combined with significant resources are required to ensure a high quality maternity service to all women in Scotland irrespective of geography. The Education and Clinical Competencies subgroup of EGAMS was tasked with identifying educational requirements and providing innovative approaches to meeting the educational needs of professionals involved in maternity care. For the initial 2 meetings, the groups met separately but shared the notes of the respective meetings, for the remaining two meetings the groups amalgamated and a professional consensus was reached.
Context
The
Framework identified the midwife as the most appropriate professional to care for low risk women during the pregnancy episode, and stressed the benefits of one-to one midwifery care in labour. The existing evidence base surrounding the promotion of 'normality' highlights that avoidance of interventions in low risk women has positive outcomes. Studies highlight that the key component in promoting spontaneous vag
inal birth is the cont
inuous presence of the midwife (Chamberla
in, Steer 1999, SAPMEL, Hodnett 2002). Evidence suggests that not all midwives have the competencies to provide all elements of maternity care for low risk women (Prakashban, Hisock, Mitchell 1997) and many argue that the 'medicalisation' of childbirth has resulted in midwives losing core skills (Johansan et al 2002, Rosser 2001). Regardless of whether or not midwives have these skills, many midwives have lost confidence in their ability to take responsibility for the care low risk women.
Maternity care differs from other aspects of health care provision because in the majority of cases the clients are healthy, but this makes the identification and management of 'ill' or at risk women all the more critical. Attention should be paid to non obstetric-medical risk factors such as socio-economic status and domestic violence etc as cited by the fifth report of CEMD (2001), which highlighted 60.4% of direct deaths as having some form of substandard care. CEMD recommended that continuing professional development should be accepted as the responsibility of the practitioner, as well as the employer, and knowledge and skills should be regularly updated using current research evidence. Units should organise regular drill for obstetric emergencies such as cases of massive haemorrhage and these drills should include all members of staff.
More recently the
Review of the Scottish Medical Workforce (Temple 2002) highlighted that the medical workforce in Scotland is under pressure and suggested that the service will only survive with change.
"Travel time increases clinical risk for emergency care, but so can lack of capacity, critical mass or experience in a small unit …this applies across the whole of Scotland." (Temple 2002). Implicit in this is multiprofessional working and a service re-design, which involves a regional approach to care. Central to this is a cohesive and well resourced paramedical service.
Education
There are a number of academic institutions in Scotland which provide undergraduate courses in medicine and midwifery and there are some examples of shared learning by medical and midwifery students (eg Dundee). Currently a limited number of institutions also provide an 18 month shortened midwifery course for registered nurses. There is much debate about the efficacy of direct entry midwifery programmes, but all the available evidence concludes that, regardless of educational preparation (3 year or 18 month), all newly qualified midwives are capable of providing care for women and babies in normal midwifery situations (Fleming et al, 2001, Fraser et al 1997, Maggs C 1989, Maggs 1994, Maggs & Rapport 1996). However, there is a paucity of evidence to identify midwives' competence in caring for
at risk or ill women during the pregnancy episode and professionals within both groups highlighted the importance of all midwives being able to recognise and care for 'ill' women during their pregnancy episode. This was considered particularly important for midwives working in isolation or in remote units.
The educational opportunities available for qualified midwives tends to be in the form of top-up degrees of postgraduate diploma and degree courses. Only one university in Scotland (Napier) offers an Advanced Neonatal Nurse Practitioner course (which has a clinical component and set at Masters level), whilst another is developing Masters level courses which will have clinical components (Dundee). The majority of clinically focused courses are offered and delivered by local Trusts. Some are in-house and may involve partnership with academic institutions whilst others are 'bought in' examples of the former include IV cannulation for nurses and midwives and obstetric emergency 'drill' courses for all maternity care professionals. The most popular courses to fit into the latter category include ALSO and NALS. Traditionally universities in Scotland have not offered postgraduate courses with a clinical focus.
Core Maternity Competencies
Core competencies necessary for all staff providing intrapartum care were identified and a team approach was considered crucial to the delivery of maternity services in each unit. Once competencies are achieved it is vital that the level of skill and expertise is maintained. All competencies correlate to established good practice; implicit in this is maintaining patient safety and clinical governance. It is important that all professionals working in these environments have the confidence, clinical governance, skills and professional judgement to provide a consistently high standard of care for the woman and her baby. Core and additional competencies required by practitioners working in all types of maternity units are specified.
Promote Normality
- supporting normal labour and childbirth birth
This includes providing psychosocial and physical support to women in labour and the majority of existing skills inventories include technical skills and competencies necessary in an emergency. The identification and prioritisation of these skills is central to a quality midwifery service, ensuring that midwives will have the confidence to work in these environments and make clinical decisions about care (Downe, S, 2001). The range of core skills required mainly by midwives but relevant to all staff in order to keep birth normal are as follows Hunter (2000):
Promoting normality also includes the use of available evidence to support care (one-to-one care in labour)There are a variety of ways of ensuring that midwives have and maintain these essential skills - but implicit in this must be the use of evidence based care. Central to this is team working and peer and multiprofessional support.
Clinical judgement and decision making skills
All maternity care professionals must have the clinical judgement and decision making skills required to work in Level I areas. In many instances midwives may be aware of the appropriate line of diagnosis and care, but will refer to a midwife or doctor for assurance that the decision is right. The appropriate referral mechanism should be utilised. This option may not be available to a midwife working in a CMU. (However even though the unit may be geographically distant to the consultant unit, there should always be an explicit network for advice and management of increasing levels of care.)
Maternal history taking
CEMD (2001) highlighted the importance of good history taking at booking. It stressed the importance of a risk and needs assessment at booking which should be reviewed regularly. Crucial to ensuring a quality service for each woman and her family is the management of risk and identification and prevention of complications.
Counselling and communication skills
The professional must have the skill to communicate clearly with women, their partners and maternity care team members particularly when problems become evident. These skills are also central to obtaining good maternal history and providing informed choice about care options.
Risk assessment and management skills
Although midwives working in maternity units have many of these skills, the nature and environment of a CMU will mean that the type of risk management and decisions about care will differ to those of a midwife working in an obstetric maternity unit. Frequent updating and 'emergency drill' scenarios will be necessary. Included in this is the management of uncertainty. All health service professionals who are involved in maternity care in remote areas must have these skills
Venepuncture and intravenous cannulation and the subsequent management of IV fluid replacement
Not all midwives have this skill although most units run courses and there are anatomically correct models which can be used for practise purposes. Both subgroups stressed that as well as being able to cannulate the professional must have the skills to manage IV fluid replacement. There are opportunities for professionals to refresh these skills in areas such as day surgery.
Recognition of the ill mother and baby
Substandard care is sometimes difficult to evaluate but CEMD assessors for 1997-1999 Enquiry classified 60.4% of direct deaths and 22% of indirect deaths as having some form of substandard care. CEMD (2001) identified that for the first time the number of indirect deaths from medical conditions exacerbated by pregnancy was greater than from conditions which directly arise from pregnancy. Nearly half of the deaths in the indirect category were from diseases of the central nervous system, including cerebral haemorrhage and epilepsy. The remainder died of mainly infectious diseases, asthma, diabetes and blood disorders. The report highlighted the importance of identification and support of women with higher risk pregnancies who appear unsuitable for midwife-led care and made the explicit statement that midwives should be prepared to decline to take responsibility for high risk cases where involvement of an obstetrician is essential. Integral to the provision of a quality maternity service is the ability to identify and care for ill women and babies. All maternity care practitioners must have the necessary skills to recognise and initiate appropriate care for ill women and their babies.
Adult resuscitation
CEMD (2001) stressed the importance of managing emergencies such as severe haemorrhage. This is a core skill of every midwife and health care professional but in order to maintain competency midwives must attend an annual update course. This course must include early identification of and care of the ill woman, including the recognition of sepsis.
Management of obstetric emergencies
Obstetric emergencies such as severe haemorrhage, cord prolapse, shoulder dystocia, breech delivery and postpartum haemorrhage are addressed in the ALSO course (see Annex F), however many units have now introduced their own obstetric life support courses which all maternity care professionals must attend and then refresh annually.
Neonatal resuscitation
All staff must have the skills and competencies to assess, resuscitate and stabilise the neonate prior to on-going management. The appropriate skills would include ventilatory support by
bag and mask as opposed to tracheal neonatal intubation. Particular emphasis should be paid to the recognition of the ill neonate.
Examination of the baby.
Currently this examination is completed by a paediatrician and in some cases a GP. In order to provide a seamless service, especially in remote areas and with early postnatal discharge, midwives and GPs must be able to complete the gross initial inspection and detailed examination of the baby. The healthcare professionals must be able to understand the relevance of the examination, to examine assess and identify normality and abnormality, and be able to refer appropriately.
Pain management
Units in remote areas will not offer epidural analgesia so midwives and GPs must have sound understanding of pain assessment and management. Included in this is a knowledge of the variety of pain management techniques (pharmacological and otherwise) which are appropriate and effective for intrapartum care (e.g. use of hydrotherapy). It was noted that the route of administration of diamorphine should be reviewed in the light of available evidence, currently diamorphine is administered intramuscularly by midwives but intravenous administration of small divided doses was considered more effective.
Assessment, suturing and management of perineal injury
This should include management of perineal pain, adequate assessment of perineal trauma, skilled technique to repair the perineum and to refer appropriately.
Prescription of Drugs
This is an area of concern as current systems (PGDs and Nurse/Midwife prescribing codes) do not cover drugs that midwives might require to prescribe in a CMU. Work in this area is ongoing. The maternity care professional working in an CMU must have the skills and ability to prescribe and dispense appropriate drugs, especially analgesia in labour, drugs used in resuscitation and those involved in normal childbirth such as Konakian and Anti D.
Additional competency which will be required for remote units
In remote areas the following areas of competencies should be achieved by at least one team member:
This unit will have the facilities and a team of professionals capable of caring for any woman, fetus or baby irrespective of risk or morbidity. The maternity team should have specialist obstetric, anaesthetic, intensive care, paediatric surgery, neonatal and midwifery staff with the skills and competencies to care for women and babies and are able to carry out specialist investigations and procedures.
Maintaining Clinical Skills and Competencies
Having achieved the requisite competencies appropriate to work in these specific levels of care, it is essential that maternity care professionals maintain and wherever possible develop these skills. In the larger units with a high throughput of women this may be relatively easy to achieve. However, even in the Level III units it is important not to be complacent about maintaining skills as these units may have many professionals vying to obtain and maintain experience in specific clinic areas. Thus it is crucial for all professionals to be responsible for their personal updating and maintenance of clinical skills. Some of the skills required by maternity care professionals are not specifically 'maternity' skills, examples include: risk assessment and management, care of the 'ill' woman, cannulation and fluid replacement, suturing, counselling, emergency drills such as severe haemorrhage. In such cases every opportunity should be used to work with other disciplines and health care professionals
For professionals working in small or remote clinical areas it may be more difficult to maintain competence in elements of maternity care. These individuals should utilise computer based simulation programmes as 'drill' scenarios to help maintain competence and skills and will need to spend allocated blocks of time in larger maternity units within their region. Video conferencing was identified as a way in which maternity care professionals can get support and maintain skills without actually being on-site.
Manpower in CMUs will largely consist of qualified midwives, some student midwives, maternity care assistants and where relevant allied health care professionals (AHPs) such as physiotherapists. In certain areas there may be GP involvement and support. All CMUs be part of an explicit and linked referral network but will not have on site access to obstetricians, paediatricians or anaesthetists, although these will be part of the referral network. Integral to this is teamwork, multiprofessional and interdisciplinary working, communication and education. A vital support and emergency backup for midwives and GPs in remote areas will be the paramedic service. Annex G provides a description of the existing courses available in Scotland and the potential for further development.
Education and training for the Scottish Ambulance Service
Although paramedic training has recently improved a multiprofessional maternity care course would provide paramedics with sufficient background information and training to ensure effective care for maternity and neonatal care.
The maintenance of skills is crucial and given the low exposure of ambulance staff to this client group, it is an area that must be addressed. Inclusion in local peer support groups, training and multidisciplinary exercises would help support the initial training, and would allow the individual to address any training or confidence difficulties they may have.
Additional training will be required by Paramedics to enable them to provide an appropriate level of care either to the expectant mother or the newly born baby. This training must reflect a more multidisciplinary approach than is currently taken. Areas of training that need to be covered are NLS, NALS, ASLO and early recognition of obstetric emergencies. Integral to this are frequent refresher courses.
There is little opportunity for paramedics to have supervised "hands-on training". Core training can be delivered using mannequins. However, this style of training may not provide sufficient experience to promote confident practice. Therefore training should be more practical in focus and include in-hospital exposure under the mentorship of a lead clinician, such as the Midwife or Obstetrician.
Role and Function of Professionals
It is important that maternity care professionals receive the education and support required to ensure sufficient confidence in the decision-making process about providing intrapartum care and referral when appropriate. This requires clinical leadership to ensure skills maintenance and networking with other maternity units in the region. The changing health care environment and the available evidence, combined with enhanced and extended roles and medical manpower concerns (Temple 2002) has resulted in a blurring of professional boundaries. There should be multiprofessional maternity courses for midwives, GPs, paramedics and other appropriate heathcare professionals, especially for those working in remote and rural areas. The existing role and function of some professions should be reviewed as it is evident that many midwives undertake a significant number of non-midwifery duties, such as being the scrub nurse at caesarean sections. The majority of GPs will be involved directly or indirectly in the delivery of maternity care to low risk women, especially with women who have existing co-morbidities or intercurrent illness which may require GP input. It was suggested that 'by default' GPs should have minimum set of maternity skills to manage such situations. It was acknowledged that GPs in rural and especially remote areas must have the education and competencies to care for a pregnant woman and her baby.
Remoteness presents particular challenges for the provision of maternity care in Scotland and innovative ways to accommodate and support pregnant, labouring and postnatal women in remote parts of Scotland must be considered. Professionals in Scotland have always acknowledged the diverse patterns of healthcare provision which exist, but are now in a position to devise innovative solutions to local problems. These might include developing skills and competencies not necessarily historically associated with that specific profession. Although there is no specific evidence related to maternity care, a meta analysis of care by nurse practitioners versus general practitioner care found that increasing availability of nurse practitioners in primary
care is likely
to lead
to high levels of patient satisfaction and high quality
care (Horrocks, Anderson & Salisbury 2002).
Summary
The main issues centre on the competencies required in caring for low risk women and the management of obstetric emergencies within remote and low tech units. It was agreed that
all midwives, obstetricians and general practitioners involved in intrapartum care, irrespective of location, should have and maintain these core skills. Each level of maternity care should have the appropriate skill mix for that level and every professional working in a maternity unit achieving and maintaining identified core competencies. The identification and management of risk was identified as crucial to successful maternity care, with training vital to support maternity care professionals in successfully managing obstetric emergencies as well as caring for 'ill' women. Confidence and decision making skills will be enhanced if professionals (midwives, obstetricians, paramedics and where relevant GPs) are equipped with the necessary skills and competencies, have the professional backup and resources to support their role irrespective of demographics. The importance of a team and multiprofessional approach to education, training and service provision on a local and regional basis was emphasised as being crucial. All maternity care professionals must possess core competencies and have the necessary skills to cope with obstetric and neonatal emergencies and manage uncertainty. As well as providing the appropriate courses to meet professional needs, innovative ways of maintaining skills and competencies are advocated.