Labour Ward Lead The labour ward is an area of complexity within any hospital. At any time there may be women experiencing normal childbirth, as well as others, fortunately fewer in number, who may be suffering complications of pregnancy. It is also an area where successful multidisciplinary working is vital for patient safety. A key recommendation of the Safer Childbirth Report from the RCOG is the designation of a lead obstetrician, a consultant midwife and a clinical manager for the labour ward in each hospital. These people will have overall responsibility for the organisation, standard setting and audit on the labour ward and for training and support of staff medical, midwifery and ancillary. Completion of the Advanced Labour Ward Practice ATSM is compulsory, but can be done concurrently. It is expected that trainees will have successfully completed an obstetric emergency training course (e.g. MOETor equivalent) prior to embarking on the ATSM. Attendance at a suitable Management of the Labour Ward course is a compulsory requirement of the module. This includes day 4 at the RCOG and BMFMS course and the first three days may have been attended as part of the Advanced Labour Ward Practice ATSM. In order to meet the requirements of this ATSM, attendance cannot have been more than three years prior to the completion of this ATSM. This ATSM has been designed to prepare individuals towards becoming lead obstetricians. Specifically, once trained, individuals should: Understand staffing structures and needs across the whole of the labour ward Understand the physiology of normal labour and delivery, how to actively support it and how to avoid negative influences Work well as part of a multidisciplinary team, including service users Be clinically competent and confident in the management of high dependency care on the labour ward Be clinically competent in the transfer of women to and from HDU/ITU Have a thorough understanding of neonatal resuscitation, intensive care and outcomes Be able to supervise, teach, appraise and assess junior medical and midwifery staff on the labour ward Have a thorough understanding of clinical governance, including the process of risk management, clinical incident reporting and investigation, and of the litigation process Be able to undertake and use audit Be able to write evidence based guidelines Be able to risk assess their unit against a National Enquiry or Report The ATSM must be undertaken under the supervision of an identified supervisor, who must be in a position to directly supervise and assess competence. In order to ensure exposure to the required case mix the Unit must be of a sufficient size to ensure completion of the training, and must have achieved CNST Level I, or equivalent and have a level 2 neonatal unit on site. A minimum of two sessions per week should be dedicated to this ATSM, and during the course of the ATSM the trainee must attend HDU / ITU sessions, neonatal sessions, develop or update a labour ward guideline, conduct or supervise a relevant audit, attend the labour ward forum and risk management meetings, and set up and run skills and drills training, scenario-based training and fire drills. 1
1. Organisation Learning outcomes: To understand the organisation / staffing structure / equipment needs of the Labour Ward To be expert in triaging clinical cases and allocating staff appropriately To be proficient in writing evidence-based guidelines and performing audit relevant to the Labour Ward To be able to analyse and understand Labour Ward workload and statistics To be able to implement and manage change effectively Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Organisation - staffing structures - equipment needs - relationship with neonatologists - relationship with anaesthetists - relationship with users Understand - how to triage clinical cases - how to allocate staff - the role of LW Forum - the role of guidelines - audit (incl. collection / analysis of LW workload) and how this influences practice Co-ordinate the clinical running of the LW at a daily level including; staff allocation appropriate triaging of clinical cases Perform clinical audit relevant to Labour Ward define standard based on evidence prepare project & collate data re-audit and close audit loop formulate policy implement change based on audit results Develop and implement a clinical guideline relevant to Labour Ward purpose and scope identify and classify evidence formulate recommendations identify auditable standards introduce into practice Interpret LW workload / statistics Ability to co-ordinate the LW appropriately and communicate effectively all plans and decisions to team members write evidence-based guidelines (relevant to LW) perform audit (relevant to LW) review LW workload and statistics implement change Observation of and discussion with senior medical / midwifery staff Appropriate postgraduate courses e.g. Management of the Labour Ward Management course Attendance at: LW Forum Guidelines group Audit meeting Perinatal mortality meetings National enquiries / reports e.g. Maternal death CEMACE Log of experience and competence Team observations 2
2. Normality Learning outcomes: To understand the physiology and mechanisms of normal labour and delivery To understand, support and respect the role of the midwife as an expert in normality To be able to actively promote the ethos of normality To recognise and avoid negative influences, and avoid unnecessary interventions Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Understand - the role of the midwife as an expert in normality - the physiology and mechanisms of normal labour and delivery - intermittent auscultation - how to actively promote the ethos of normality - negative influences on the process of normality and how to avoid them - how to avoid unnecessary interventions - the impact of the birth environment Be able to manage a normal labour and delivery Be able to perform intermittent auscultation Ability to understand and actively promote normality avoid negative influences avoid unnecessary interventions recognise the midwife as an expert in normality respect and support midwifery staff Observation of and discussion with senior medical / midwifery staff Appropriate postgraduate courses e.g. Management of the Labour Ward Log of experience and competence Team observations 3
3. Intensive care Learning Outcomes : To understand the organization and role of high dependency and intensive care To understand the indications for and methods of invasive monitoring To understand the management of organ failure Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment Organisation - structure and organization of high dependency care intensive care - role of outreach teams - indications for high dependency and intensive care in obstetrics Management - methods of invasive monitoring oxygenation / acid base arterial pressure cardiac output, preload and contractility - organ failure (incl. principles/techniques of supportive therapy) respiratory failure cardiac failure renal failure hepatic failure coagulation failure Take an appropriate history and perform an examination to assess critically ill woman Manage a woman with organ failure; undertake resuscitation arrange and interpret appropriate investigations to confirm diagnosis / cause and monitor organ function arrange transfer to HDU / ITU where appropriate arrange appropriate investigations Perform (under supervision) or refer, where appropriate, for same insertion of CVP line endotracheal intubation insertion arterial line / PA catheter (optional) Ability to; formulate, implement and where appropriate modify a management plan including transfer to HDU/ITU liaise with intensivists, physicians, anaesthetists, neonatologists counsel women and their partners accordingly - management options, including therapeutic interventions - maternal and fetal risks - debrief family and staff Observation of and discussion with senior medical staff Appropriate postgraduate courses e.g. Management of the Labour Ward MOET/PROMPT or equivalent Attendance at sessions in Anaesthesia Intensive Care Attendance at; Medical clinics Log of experience & competence Case based discussions Team Observations 4
4. Neonatology Learning outcomes: To be proficient at neonatal resuscitation and assess acid-base balance To understand and be able to counsel about gestation related outcomes To understand the intra partum factors that influence neonatal outcome To understand the short and long term consequences of HIE Knowledge criteria Clinical competency Professional skills and attitudes Understand the principles of basic and advanced neonatal resuscitation conditions requiring admission to NICU the implications of prematurity intrapartum factors that influence neonatal outcome acid-base balance Outcome neonatal complications of HIE (incl. seizures, abnormal neurological function, organ failure) gestation related outcomes long term health implications of HIE (incl. cerebral palsy) Ability to: assess a neonate at birth perform basic neonatal life support assist in advanced neonatal life support interpret cord gases and assess acid-base balance Be able to follow the admission process of a neonate to NICU counsel parents about the outcomes of prematurity counsel parents about the outcomes of HIE Training support Evidence / Assessment Attendance at: resuscitations NICU ward rounds neonatal followup clinics ALSO course or equivalent Log of experience and competence Team observations 5
5. Communication, team working and leadership skills Learning Outcomes: Demonstrate effective communication with colleagues Demonstrate good working relationships with colleagues Demonstrate the ability to work in clinical teams and have the necessary leadership skills Knowledge criteria Clinical competency Professional skills and attitudes Communication - how to structure a staff interview to identify: concerns & priorities expectations understanding & acceptance - breaking bad news - joint decision making Team working - roles and responsibilities of team members - factors that influence & inhibit team development - ways of improving team working incl. objective setting & planning motivation and demotivation organization respect - contribution of mentoring and supervision Leadership - qualities and behaviours - styles - implementing change / change management Be able to communicate both verbally and in writing with colleagues Ability to communicate effectively with: junior medical staff senior medical staff midwifery staff patients & relatives obstetric anaesthetists neonatologists Ability to communicate effectively with colleagues Ability to break bad news appropriately and support distress Ability to: work effectively within a multidisciplinary team lead a clinical team respect other s opinions deal with difficult colleagues Be able to recognise and positively influence a dysfunctional team Training support Observation of and discussion with senior medical / midwifery staff Communications skills course Leadership course e.g. Trust-based or approved by DoH. Evidence / Assessment Log of experience and competence Team observations 6
6. Training / Assessment / Skills and Drills Learning outcomes: To understand different methods of training and learning Demonstrate the ability to assess competencies / set objectives / deal with difficult learners To understand and use different methods of assessment, and feed back effectively To utilise and deliver skills training, scenario training and fire drills appropriately Knowledge criteria Clinical competency Professional skills and attitudes Training - how to assess basic competencies deficiencies strengths understanding of level of skills - how to set objectives - how to support and facilitate training - understand different methods of adult learning - how to deal with difficult learners Assessment - formal assessment of individuals using different assessment tools OSATS DOPS Mini-CEX Case based discussions Labour ward assessment tool - assessment of team performance - feedback techniques eg Pendleton s rules Skills & Drills - understand the differences between skills training, scenario training and firedrills, and when to use them - how to set up, deliver and assess each of the above Be able to assess basic competencies of different members of staff Be able to set objectives and assess against these objectives Be able to deal with difficult learners Be proficient in the use of the various assessment tools OSATS DOPS Mini-CEX Case based discussions Labour ward assessment tool Ability to: - - use different assessment tools - feed back effectively Ability to: - understand different methods of training - understand different methods of learning - set up and run skills training, scenario training and fire drills - know which method to use depending on training session objective Lead training sessions / emergency drills on LW set up & running of skills training set up & running of scenario training set up & running of fire drills Training support Evidence / Assessment Observation of and discussion with senior medical / midwifery staff Management of the Labour Ward course Training the Trainers course Instructor training courses (e.g. MOET/PROMPTinstructor courses or equivalent) Log of experience and competence Team observations 7
7. Clinical governance and risk management Learning outcome: Understand and demonstrate appropriate knowledge and skills in relation to CG and risk management Knowledge criteria Clinical competency Professional skills and attitudes Clinical Governance - organizational framework at local, SHA and national levels - standards e.g. NSF, NICE, RCOG guidelines - clinical effectiveness - principles of evidence based practice - grades of recommendation - guidelines and integrated care pathways formulation advantages and disadvantages - clinical audit - patient / user involvement - types of clinical trial/evidence classification Risk management - incidents/near miss reporting - methods of analysing incidents including root cause analysis - complaints management - litigation and claims management The CNST scheme and how to obtain certification CNORIS and Welsh Pool Risk for Scotland and Wales Participate in risk management investigate a critical incident by reviewing the case and taking appropriate statements write a time line perform a root cause analysis assess risk formulate recommendations write a response/report feed back to staff & families Investigate and respond to a complaint Perform appraisal Understand the Clinical Negligence scheme for NHS Tusts Ability to practice evidence based medicine Ability to report and investigate a critical incident Ability to respond to a complaint in a focused and constructive manner. Ability to perform appraisal Ability to lead a multidisciplinary team to prepare for maternity CNST accreditation Training support Evidence / Assessment Observation of and discussion with senior medical / midwifery staff and clinical governance team. Attendance at risk management meetings DH, RCOG and Trust publications An Organisation with a Memory (DoH 2000) NPSA Website Human Error: models and management. Reason, BMJ 2000; 320, 768-770 CNORIS website Log of experience and competence CbD Appraisal and revalidation - principles - process Risk management on LW - principles of risk management - critical incident reporting 8
MODULE Leadership on the Labour Ward General Guidance Below is a list of competencies expected to be achieved during this training module. These must be signed up by your supervisors. It is advised that you meet with your preceptor at the start of the post, At this meeting you should divide skills easily achieved and less readily achieved. Later in post, cover any residual less readily achieved skills using appropriate other methodologies. For this module examples of Other methodologies acceptable for learning relatively uncommon skills include: leadership skills courses, case-based discussions (CBD) and video/web e-learning resources. For practical skills every effort must be made to back up theory-based methodologies with practical learning aids. Skill Competence level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Labour Ward Management Co-ordinate daily running of the LW Staff allocation Appropriate triaging of clinical cases Normality Participate in a midwife led labour and delivery Perform intermittent auscultation appropriately HDU/ITU Assessment/counselling high risk case Assessment of the sick patient Assessment of respiratory function Interpretation of arterial gases 9
Skill Competence level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Assessment of renal function Management of fluid balance Assessment of maternal cardiac function Assessment of haemodynamic status Management of transfer to/from HDU/ITU Neonatology Basic neonatal resuscitation Advanced neonatal resuscitation Admission of a baby to neonatal unit Assess acid-base balance Counsel parents about the outcomes of prematurity Counsel parents about the outcomes of HIE Communication, team-working and leadership skills Communicate effectively with colleagues Work well within a multidisciplinary team Lead a multidisciplinary team Recognise and positively influence a dysfunctional team 10
Skill Competence level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Training, assessment, skills and drills Assess basic competencies Set objectives Assess against objectives Deal with difficult learners Use OSATS effectively Use DOPs effectively Use Mini-CEX effectively Perform case-based discussions Use the Labour Ward Assessment Tool effectively Give feedback appropriately Set up and run skills training Set up and run scenario training base training Eclampsia drill Obstetric collapse drill including CPR Shoulder dystocia drill Massive haemorrhage drill 11
Skill Competence level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Crash section drill Neonatal resuscitation drill Clinical Governance / Risk Management Investigate complaint / conflict re intrapartum care Collate information in response to complaint Draft response letter to complaint Be involved in a multidisciplinary serious adverse event investigation (maternal) Be involved in a multidisciplinary serious adverse event investigation (neonatal) Develop a time line Participate in root cause analysis Formulate recommendations Feed back to staff / family Perform appraisals 12
Sessions Attended Date Supervisors Signature ITU/HDU ITU/HDU ITU/HDU ITU/HDU ITU/HDU ITU/HDU NICU/resuscitations NICU/resuscitations NICU/resuscitations NICU/resuscitations NICU/resuscitations NICU/resuscitations Neonatal follow-up clinic Neonatal follow-up clinic Neonatal follow-up clinic Neonatal follow-up clinic Labour Ward Forum Labour Ward Forum Labour Ward Forum 13
Sessions Attended Date Supervisors Signature Labour Ward Forum Risk Management Meeting Risk Management Meeting Risk Management Meeting Risk Management Meeting Root cause analysis completed Audit completed Guideline completed Response to National Enquiry / Report Completed 14
Uncommon clinical condition/procedure not seen/not undertaken. Examples of other learning methodologies employed: Case-based discussions (CBD) Mannequins Video/web e-learning resource You must specify and give details Date Supervisor s Name/Signature 15
Training course or sessions Title Signature of Educational Supervisor Date 16