The Scottish Government

Every professional working in a CMU must have and maintain the identified core competencies.

Each unit must identify the core team and individual competencies required for that level of care, consisting of generic, sub-specialist and specialist skills. These will include maternal fetal skills, non-maternal skills and non-clinical skills. The generic skills for low risk women include identification of the ill patient, resuscitation and stabilisation of the mother and baby and appropriate referral transfer and retrieval skills and competencies.

Skills maintenance and retention must be addressed for all staff.

Obstetric anaesthesia and neonatal care require specialist training.

There must be a multiprofessional approach to education and training to meet the individual needs of professionals providing different levels of maternity care. This should include: clinical placements and rotations, multiprofessional alliances between Trusts, professional bodies and postgraduate providers and have the potential of achieving a number of shared qualifications.

Paramedic education and training should be within a multidisciplinary setting and include supervised practical instruction within an acute hospital setting.

Consideration should be given to facilitating an attitudinal and cultural change to rolls, skill mix, team working and location of care.

Education should be provided on a national, regional and local basis. Consideration should be given to a National Maternity Services Educational Co-ordinator (possibly within NHS Education for Scotland).

The role and infrastructure of RARARI must be maximised to ensure that all professionals included in the delivery of intrapartum care in remote and rural settings have and maintain the necessary skills and competencies. There should include a comprehensive maternity care course for professionals working in remote and rural areas.

Primary care doctors and professionals require basic training in routine neonatal care, including examination of the newborn.

The recognition and acceptance that zero risk is impossible irrespective of the level of intrapartum care provision.

Risk is a dynamic and complex process which requires appropriate and regular monitoring, assessment and management and is a core function within intrapartum care. Protocols, guidance, a risk management strategy and fire drill scenarios should be part of the multiprofessional Labour Ward Forum identified within the Framework.

Risk factors must include clinical and non-clinical issues.

Risk is designed by process of exclusion and the exit and entry criteria for the levels of care should be used as a basis for intrapartum care provision.

There must be appropriate manpower planning within each unit. This should include a working group to consider the impact of manpower planning and contractual changes on the multiprofessional workforce in each unit.

Innovative approaches to manpower planning and service delivery should include:

A real multiprofessional approach to maternity care.

Regional contracts should be considereded for some staff.

A seamless provision of primary and acute care.

Recognition of the role, skills, competencies and potential of maternity care professionals whilst acknowledging the potential to enhance roles and improve quality of care and service provision.

Maximise the potential of specialist professionals, such as midwifery consultants, advance neonatal nurse practitioners, paramedics and others who contribute to intrapartum care provision.

A clarify of professional roles and responsibilities.

All women should be booked by a midwife and assigned to the appropriate level of care.

There should be a lead named professional for each birth - this will usually be the midwife for normal pregnancy and care, but will be the obstetrician for women with identified risk factors.

One to one skilled midwifery care should be provided in labour.

Women and their partners should receive unbiased evidence and advice regarding their intrapartum care options.

Intrapartum care should be provided locally as appropriate, feasible and practical.

Irrespective of the planned location of care, the Birth Plan should incorporate entry into the network for escalation of intrapartum care.

All maternity units and labour wards should have a lead named midwife, obstetrician, paediatrician and anaesthetist.

Local and regional planning of intrapartum care will result in a review of Levels I and II of intrapartum care and special and intensive care for infants.

The appointment of Regional Maternity Service Co-ordinators to support the National Co-ordinator.

The present identified Regional Planning Groups should set up Regional Maternity Planning Sub-groups, which should meet regularly as a National Group. However, the composition of the Regional Planning Group should be flexible to reflect the changing demographic and provision of intrapartum care throughout Scotland.

Maternity services should consider developing Managed Clinical Networks on a regional and/or local basis in line with the recent Health Department letter.

Each region must ensure that Levels I, II and III maternity and I-IV neonatal care are available to women.

A consensus has been reached regarding the appropriate apportionment of risk in case mix to each level of care and these should be considered in the light of local and regional circumstances.

The evidence relating to community midwifery units has been presented and supports the view, that they do have an integral role within the intrapartum care continuum in Scotland. They should be considered within the local intrapartum care context.

All units providing interpartum care must provide 24 hour neonatal resuscitation, short term support for sick infants, access to neonatal transfer and complete routine neonatal care. Optimal care is provided by a multi disciplinary core team consisting of midwife, neonatal nurse and paediatrician.

Consultant obstetric units require a 24 hour anaesthesia and analgesia service with consultant supervision, adult high dependency and access to intensive care, haemotology blood transfusion and other DGH support services and an integrated obstetric and neonatal care service.

Complex interpartum cases require integrated multi professional specialist management and direct consultant involvement. Significant neonatal morbidity may only be available in few specialist sites.

The 4 Level III centres in Scotland should develop a sub-network for the management of complex maternal fetal cases throughout Scotland.

The local and regional intrapartum care network must include the following:

Single entry into the network with clear communication channels for advice and the provision of escalating intrapartum care.

Criteria for care and transfer within levels of care with any transfer decision being made at a senior identified level.

Clear and consistent guidance for local resuscitation and stabilisation in all maternity units.

Criteria and provision for access to adult and neonatal special, high dependency and intensive care.

Criteria and provision for access to specialist neonatal services.

Planned prenatal in utero transfer is the method of choice.

Where it is likely that the ambulance staff may be part of the acute pregnancy care team (such as a rural high risk pregnancy) the mother should be given the opportunity to familiarise herself with the SAS provision including the equipped used. The possibility of a "named crew" in rural settings should be explored.

With the SAS reorganisation to 3 regionally based Emergency Despatch Centres and a single National Transport Centre for air transport must take account of the changing provision of intrapartum care throughout Scotland to ensure appropriate provision is made.

The implementation for the transfer of urgent or emergency in-uteral, intrapartum or immediately post-natal transfers must be specifically considered with the introduction of Priority Based Despatch. A one call entry system for clinicians to access the SAS for intrapartum transfer throughout the Transport Co-ordination Desk should be implemented. This would identify, within the discussion, the most effective and available method of transport for each individual case, including additional aspects, such as appropriate equipment, crew skill mix, police escort, possible clinical complications, and crew journey time and cover, especially within longer transports.

There should be a regional/local review of the vehicle fleet and air transport capability and suitability for transport function to meet the identified need.

The development of National Core Dataset for maternal fetal medicine must be consistent with the Scottish Birth Record and the Scottish Child Health Information Project. A National Hand-held Maternity Record should be developed.

A comprehensive system of local and regional maternity care audit and evaluation, especially intrapartum care, should be carried out to monitor the changes in intrapartum care throughout Scotland. This should include maternal and fetal care outcomes, location of care, modes of delivery, maternal and fetal post-natal care, access to maternal and fetal specialist care, transfer and transport support and critical incidence reporting to support local labour ward risk management programmes.

The role of telemedicine within maternity and intrapartum care should be explored, especially in remote and rural Level I facilities. Possible roles include support within the intrapartum care network, training and education courses, clinical skills programme, image transmission, communication and advice, direct patient care and professional support networks. Wherever possible CMUs should have direct access by video link to their incremental care referral centre.

Any consultation process on changes to maternity or intrapartum care should involve planners, providers and consumers of the service.

As identified within the Framework, each Health Board should already have a Maternity Services Liaison Committee and consideration should be given to strengthening their role and the possibility of a National Association of MSLCs has been suggested.

Develop a regional and local information and education process to inform all stakeholders of the content and implications of this EGAMS report. This should facilitate the changed management process to ensure a real, planning, incremental and appropriate change in intrapartum care occurs throughout Scotland consistent with a quality service.