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Advanced Labour Ward Practice (2018)– approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018

Aim

To underpin the management at Consultant level of high-risk pregnancy both intrapartum and post-partum.

Prerequisites

Successful completion of an Obstetric Emergency Course, for example MOET or equivalent.

The Basic Obstetric Ultrasound modules must be completed prior to starting the ATSM.

Please note that this ATSM is a prerequisite for the Labour Ward Lead ATSM.

Key components

The ATSM comprises 5 Advanced Skills Modules (ASM). Completion of all 5 ASM is required to be awarded the ATSM as part of CCT. Outwith CCT, individual ASM may be recognised separately as part of continuing professional development towards your CPD programme.

ASM 10 Key Intrapartum Obstetric Medical Disorders

Identical to the ASM of the same name in the Obstetric Medicine ATSM

ASM 14 Key intrapartum scenarios and the technical and non-technical skills necessary for their management.

ASM 15 Ultrasound to support intrapartum care.

ASM 16 The range of conditions encountered on Labour Ward.

ASM 17 Effective communication and governance skills for the Labour Ward.

Educational Support

Attendance at the annual RCOG/BMFMS Advanced Labour Ward Course or an equivalent course prospectively approved by your Regional Preceptor.

Attendance at the course must be after registering for the ATSM and no more than three years prior to completing the module.

TOG, STRATOG and e-portfolio support is provided by the RCOG.

Clinical Support

The ATSM should be undertaken under the supervision of an identified Obstetric Consultant supervisor, who must be in a position to directly supervise and assess competence as well as approve appropriate professionals to train for the wider curriculum components.

An average of least two sessions per week is required to work towards the targets.

Additional, specific, themed sessions relevant to the ATSM are listed in the module.

Work intensity

For pre-CCT trainees the ATSM has been allocated a work intensity score of 1.0.

ASM 10Key Intrapartum Obstetric Medical Disorders

Clinical competency /

GMP

/

Knowledge criteria

/ GMP / Professional skills and attitudes /

GMP

/

Training support

/

Evidence/

assessment

(10.01) Severe preeclampsia
(10.02) Eclampsia
(10.03) HELLP syndrome / 1,2
1,2
1,2 / (10.01-10.3)
Understand best practice for the management of severe pre-eclampsia. Including its definition, diagnosis, acute management and associated complications.
Understand the pathophysiology and pharmacology for the condition.
Be able to interpret investigations
Understand the acute and long-term maternal and fetal risks associated with the condition. / 1,2,3
1,2
1,2 / (10.01)
Take an appropriate medical history and examination of a woman with symptoms of severe disease.
Be able to interpret and act appropriately upon investigations.
Be able to construct a differential diagnosis and recognise symptom and signs of co-existing maternal disease (HELLP, chronic hypertension, pre-existing renal damage.)
(10.01-10.02)
Manage cases of complex severe pre-eclampsia with:
(a) HELLP
(b) eclampsia
(c) pulmonary oedema
(d) acute renal failure
(10.01-10.02) Institute / modify drug therapies, plan delivery and postnatal care refer, where appropriate, for further assessment / treatment.
Be able to give accurate advice for future pregnancies.
(10.02 -10,3)
Be proficient in the acute management of eclampsia and HELLP according to best practice guidelines. Liaise effectively with the wider MDT. / 1,2,3,4
1,2,3
1,2
1,2,3
1,2,3
1,2,3,4
1,2,3 / (10.01-10.03)
RCOG Green to guideline N0.10a Pre-eclampsia /eclampsia management.
RCOG Patient information (2012) Pre-eclampsia. / (10.01-10.12)
Each condition within ASM.10 is core to the understanding of medical problems during labour.
For each of the 12 conditions your supporting evidence must be based upon more than one case in which you have been directly involved.
Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.
In addition to direct exposure, CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover the breadth of the condition.
(10.04) Diabetes Mellitus
(10.05) Gestational Diabetes / 1,2
1,2 / (10.04)
Understand how pregnancy influences diabetes and how diabetes can impact upon the pregnancy for both complicated and uncomplicated diabetes.
Pre-existing diabetes: pathogenesis & classification, prevalence, complications (metabolic, retinopathy, nephropathy, neuropathy, vascular disease).
Know how to undertake pre-pregnancy assessment and screening for complications.
Know how to monitor and optimise glucose control in pregnancy and postpartum.
Know how to manage hypoglycaemia and ketoacidosis in pregnancy.
Know how to appropriately monitor the fetal condition at all stages of pregnancy.
(10.05)
Understand how GDM is identified in pregnancy, its impact and how to mitigate its effects. Understand its short and long term implications. / 1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (10.04)
Perform, under supervision, appropriate assessment and management of women with pre-gestational diabetic complications
Ability to take an appropriate history and conduct an examination to assess a woman with pre-gestational diabetes.
Ability to perform and interpret appropriate investigations formulate, implement and where appropriate modify a multi-disciplinary management plan.
(10.04-10.05)
Liaise with diabetologists, diabetic nurse specialists, dieticians, and other specialists where appropriate, counsel, maternal and fetal risks, importance of good glycaemic control (including use of insulin in GDM)
Discuss long-term risks, contraception options and the management future pregnancies. / 1,2,3
1,2,3,4
1,2,3
1,2,3,4
1,2,3,4 / (10.04 -10.05)
RCOG Scientific impact paper No. 23 Diagnosis and treatment of Gestational diabetes.
NICE Guideline NG3 (2015) Diabetes in Pregnancy: management from preconception to the postnatal period.
RCOG Patient information (2013). Gestational diabetes.
Attendance at Obstetric Medical clinics / adult diabetes clinics.
STRATOG Advanced, Maternal Medicine eLearning: Gestational diabetes mellitus (2016).
STRATOG Advanced, Maternal Medicine eLearning: Pre-existing diabetes without complications (2015).
(10.06) Known haemoglobinopathy / 1,2 / (10.06)
Understand how haemoglobinopathy impacts upon the antenatal and intrapartum care of the woman.
Understand the risks to the fetus and how these may be monitored.
Understand the genetic basis for the common haemoglobinopathies and what prenatal testing is available. / 1,2
1,2 / 10.06)
Manage thalassaemia or other haemoglobinopathy. Counsel on fetal and maternal risks, arrange and interpret appropriate investigations liaise regarding therapy, plan delivery and postnatal care.
Be able to explain the option of prenatal diagnosis. / 1,2,3,4
1,2,3,4 / (10.06)
Green top guideline No.66 Thalassemia in pregnancy.
RCOG patient information (2015). Beta Thalassemia and pregnancy.
(10.07) High risk for venous thromboembolism
(10.08) Prior thromboembolism / 1,2
1,2 / (10.07-10.08)
Understand how to quantify thromboembolism risk and how best to mitigate that risk. / 1,2 / (10.07-10.08)
Manage a case of thrombophilia and / or previous VTE in pregnancy, arrange and interpret appropriate investigations.
Be able to accurately risk score for thromboembolism, and to communicate that risk effectively.
Discuss and plan treatment accordingly. Institute/modify VTE prophylaxis where appropriate. / 1,2,3
1,2,3,4
1,2,3,4 / (10.07-10.08)
RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and after birth.
STRATOG Advanced, Maternal Medicine eLearning: Previous venous thromboembolism (2016).
(10.09) Renal disease in labour / 1,2 / (10.09)
Have an understanding of the effects of labour and the immediate postpartum period on chronic renal disease. / 1,2 / (10.09)
Perform, under supervision, appropriate assessment and management of a labouring woman with renal disease.
Arrange and interpret appropriate investigations, formulate, implement and where appropriate modify a multi-disciplinary management plan with appropriate liaison where necessary. / 1,2,3,4
1,2,3 / (10.09)
STRATOG Advanced, Maternal Medicine eLearning: Kidney Disease in Pregnancy.
(10.10) HIV including MDT approach to minimising potential sequelae. / 1.2 / (10.10)
Understand how HIV impacts upon the antenatal, intrapartum and postpartum care of the woman.
Understand the risks to the fetus and how these may be reduced.
Understand the transmission of HIV and how viral load may be monitored and the treatments available. / 1,2
1,2 / (10.10)
Manage a case of HIV in labour: plan mode of delivery and suitable treatment to minimise neonatal transmission. / 1,2,3 / (10.10)
RCOG Patient information (2013) HIV in pregnancy.
(10.11) Intrapartum pyrexia / 1,2 / (10.11)
Understand the causes of pyrexia in labour, their investigation and treatment as well the potential impact upon mother and baby. / 1,2 / (10.11)
Manage intrapartum pyrexia, coordinating midwifery, neonatal and microbiology assistance as required. / 1,2,3 / (10.11)
RCOG Green top guideline No.64 Sepsis in pregnancy.
No.64b Sepsis following pregnancy.
(10.12) Increased risk to new-born from Group B Haemolytic Streptococcus / 1,2 / (10.12)
Understand which groups are at increased risk of GBS and how to mitigate this increased risk. Understand the features of early and late onset neonatal GBS infection. / 1,2 / (10.12)
Explain risks and implement local policy to reduce risks of GBS in the new-born.
Liaise appropriately with neonatal team. / 1,2,3,4
1,2,3 / (10.02)
RCOG Patient information (2013). Group B streptococcus infection in new-born babies.
ASM 10: Intrapartum Obstetric Medical Disorders / Part of the Maternal Medicine ATSM and the Advanced Labour Ward Practitioner ATSM
Logbook / Competence level Not required
Level 1 / Level 2 / Level 3
ASM 10: Key Intrapartum Obstetric Medical Disorders / Date / Signature / Date / Signature / Date / Signature
Severe preeclampsia
Eclampsia
HELLP syndrome
Diabetes Mellitus
Gestational Diabetes
Known haemoglobinopathy
High risk for venous thromboembolism
Prior thromboembolism
Renal disease in labour
HIV including MDT approach to minimising potential sequelae.
Intrapartum pyrexia
Increased risk to new-born from Group B Haemolytic Streptococcus

Training Courses or sessions

Title

/

Signature of educational supervisor

/ Date
Authorisation of signatures (to be completed by the clinical trainers)
Name of clinical trainer (please print) / Signature of clinical trainer

Completion of ASM 10: Key Intrapartum Obstetric Medical Disorders

/ Date / Signature
Safe and effective management of these maternal medical conditions has been achieved through direct exposure and decision making for a range of clinical cases including timely liaison with the MDT and tertiary services if appropriate.

ASM 14: Key intrapartum scenarios: non-technical and technical skills

Clinical competency /

GMP

/

Knowledge criteria

/ GMP / Professional skills and attitudes /

GMP

/

Training support

/

Evidence/

assessment

Safely manage non-cephalic presentation.
(14.01) Non-technical: Recognition and informed counselling for breech presentation.
(14.02) Technical: Competency for the recognition of non-cephalic presentation.
(14.03) Delivery of vaginal breech (may use Other Methodology).
(14.04) Delivery at caesarean section for breech and transverse lie. / 1,2,3,4
1,2
1,2
1,2 / (14.01- 14.04)
Understand the appropriateness of the different modes of delivery for breech, transverse and oblique lie presentations.
Understand how management might differ for multiple pregnancy.
Understand the manoeuvres to minimise the risks for both assisted breech delivery and breech extraction for singleton and multiple pregnancies during vaginal delivery and also at caesarean section.
Understand when ECV in labour (for breech, transverse lie and second twin) may be considered and the techniques involved.
Understand when and how internal podalic version is appropriate for multiple pregnancy. / 1,2
1,2
1,2
1,2
1,2 / (14.01-14.04)
Be able to communicate effectively in a manner that can easily be understood the risks accompanying all non-cephalic presentations and the options available.
Be able to construct a safe birth plan and where appropriate modify this according to the clinical findings as they evolve.
Effectively liaise where appropriate, with anaesthetists, midwifery and theatre staff and neonatologists. / 1,2,3,4
1,2,3
1,2,3 / (14.01-14.04)
RCOG Green top guideline No. 20a (2006) ECV reducing the risk of breech presentation.
No.20b (2006) Management of Breech Presentation. / For this ASM each intrapartum scenario listed is core to the safe practice on the delivery suite.
For each of the scenarios your supporting evidence must be based upon more than one case in which you have been directly involved.
Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.
(14.01-14.02, 14.09) OSATS of External Cephalic version in labour
(14.03) OSATS of Vaginal breech delivery and OSATS of Manual Rotation
(14.05-14.06) OSATS of Cervical cerclage
(14.11014.12) OSTAS of Rotational instrumental delivery
In addition to direct exposure, CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover the breadth of the condition.
Safely manage preterm labour.
(14.05) Non-technical: Demonstrate expertise when balancing delivery with aiming to prolong pregnancy. Good communication with the family and wider MDT including paediatric team.
(14.06) Technical: Proficiency in intrapartum care for preterm vaginal delivery.
(14.07) Technical: Proficiency in preterm (<32 week) caesarean section. / 1,2
3,4
1,2
1,2 / (14.05-14.07)
Understand the pathophysiology, investigations and management of preterm labour and preterm premature rupture of membranes (PPROM).
Understand the symptoms, signs and range of presentations for acute chorioamnionitis.
Understand when and how to use tocolytics.
Understand the maternal risks associated with preterm delivery and the options that are available to minimise these risks.
Understand the risks of prematurity to the fetus and for the neonate both the short and long-term risks. / 1,2
1,2
1,2
1,2
1,2 / (14.05-14.07)
Ability to liaise effectively with neonatologists / microbiologists; to arrange in-utero transfer if appropriate.
Counsel women and their partners accordingly on the maternal, fetal and neonatal risks in a manner that is easy to understand.
Debrief and formulate a suitable management plan for future pregnancies. / 1,2,3
1,2,3,4
1,2,3,4 / (14.05)
RCOG Green top guideline No.7 (2010) Antenatal steroids to reduce preterm morbidity.
Green top guideline No. 1b Preterm labour and tocolytic drugs.
Scientific impact paper No.41 (2014) Perinatal management of the pregnant women at the threshold of fetal viability.
Scientific impact paper No.33 Preterm labour, antibiotics and cerebral palsy.
(14.06)
No. 60 (2011) Cervical cerclage.
RCOG Scientific impact paper No.29 (2011) Magnesium sulphate to prevent cerebral palsy following preterm birth.
(14.07) Green top guideline No.45 (2015) Birth after previous caesarean section.
Safely manage multiple pregnancy.
14.08) Non-technical: Formulate clear intrapartum care plans based on clear communication of all issues.
(14.09) Technical: Competency for the delivery of preterm multiple pregnancy.
(14.10) Technical: Competency for delivery by term caesarean section and term vaginal delivery. / 1,2
1,2
1,2 / (14.08-14.10)
Understand the influence of fetal growth restriction, discordant growth, prematurity, chorionicity and malpresentation on the recommendation and successful conduct for all modes of delivery for multiple pregnancies.
Understand the role of intrapartum ultrasound and CTG monitoring for multiple pregnancies. / 1,2
1,2 / (14.08-14.10)
Be able to construct a suitable intrapartum care plan, liaising appropriately.
Be able to explain the delivery options and any associated maternal and fetal risks in a manner that is easy to understand.
risks
Be able to run a multiple pregnancy skills drill that could include:
-Malpresentation of twin 1
-Malpresentation of twin 2 after vaginal delivery of twin 1.
-CTG concerns
-Preterm labour
-ECV in labour
-Internal podalic version / 1,2,3
1,2,3,4
1,2,3 / (14.08-14.10)
NICE Clinical Guideline CG 129 Management of twin and triplet pregnancies in the antenatal period.
RCOG Green top guideline N0.51 Monochorionic twin pregnancy.
RCOG Consent Advice No.7 (2009) Caesarean Section
Safe rotational vaginal delivery.
(14.11) Non-technical: Provide appropriate information to support informed choice for all method of delivery options.
(14.12) Technical: Competency in at least 2 of the following 3 methods to rotate to the occipito-anterior position: manual rotation, ventouse rotation, and Kiellands forceps. / 1,2
1,2 / (14.11-14.12)
Understand the indications and contra-indications for each form of instrumental delivery:
Neville Barnes forceps
Kiellands forceps
Kiwi cup ventouse
Soft cup ventouse
Metal cup ventouse including the posterior cup.
Understand how each of the techniques is used for safe vaginal delivery and the options available if unsuccessful at any stage of their application.
Understand which method is preferable across all of the common intrapartum scenarios. / 1,2
1,2
1,2 / (14.11-14.12)
Be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained.
Understand your own limitations for each method and liaise appropriately including seeking advice at an early stage if necessary.
Debrief after delivery; be able to record your findings and the procedure used accurately. / 1,2,3,4
1,2,3
1,2,3,4 / (14.11-14.12)
RCOG Green top guideline No.26 (2011) Operative vaginal delivery.
STRATOG eLearning and simulation for instrumental delivery (2016).
STRATOG Advanced, Generic Skills Case Studies eLearning: Risk management of rotational forceps delivery (2015).
Safe delivery for the morbidly obese.
(14.13) Non-technical: Good communication skills for the issues involved. Demonstrate MDT working and strategies to minimise risk.
(14.14) Technical: Competency in vaginal delivery for the morbidly obese (BMI > 40). / 1,2,3,4
1,2 / (14.13)
Understand what delivery options are most suitable for those who are morbidly obese and how the use of the MDT may minimise the risks involved.
(14.14)
Understand how to assess the suitability for assisted vaginal delivery where fetal macrosomia is a potential risk and where maternal obesity presents significant risks.
Be aware of the techniques available to facilitate both vaginal delivery as well as caesarean section.
Understand how caesarean section rand postpartum risks may be minimised and the operative strategies that may be used to overcome the difficulties that are often encountered. / 1,2
1,2
1,2
1,2 / (14.13 -14.14)
Be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained.
Liaise effectively with the MDT to minimise intrapartum and postpartum risks. / 1,2,3,4
1,2,3 / (14.13-14.14)
CMACE/RCOG Joint Guideline (2010) Management of women with obesity in pregnancy.
NICE Guideline Intrapartum Care for High Risk Women (in development 2017).
Safely manage PPH.
(14.15) Non-technical: Demonstrate good communication skills and the use of MDT.
(14.16) Technical: Acute resuscitation and medication for PPH
(14.17) Technique: Uterine balloon tamponade.
(14.18) Technical: B Lynch suture technique. / 1,2,3
1,2
1,2
1,2 / (14.15-14.18)
Understand the factors that predispose to PPH and how these risks may be minimised.
Understand the consequences of massive acute PPH and how the situation may be investigated and monitored.