The EGAMS identified core competencies necessary for all staff providing intrapartum care in a CMU or low-risk setting. 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. This appendix describes the core competencies required by obstetric professionals working in any maternity facility and then identify additional competencies required by practitioners working in specific types of maternity unit, according to the levels of care set out in A Framework for Maternity Services in Scotland.
Promoting Normality - supporting normal labour and childbirth
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, 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 evidenced based care. Central to this is team working and peer and multi-professional 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 her 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 skills 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 'fire 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.
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. 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.
Initial and discharge examination of the baby
Currently this examination is completed by a paediatrician and in some instances a GP. In order to provide a seamless service, midwives (especially in remote areas) should be able to complete the first and discharge examination of the baby. In order to complete the examination the professional must be able to understand the relevance of the examination, 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 (Patient Group Directions 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 a 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 in the following areas of competency should be achieved by at least one member of the team.
Competencies in Level II Units
Level IIa
In addition to the previously cited competencies, the following should available in a Level IIA unit:
Level IIb
All above competencies should be available in these units, however, the additional competencies below refer to increased levels of care relating to the neonate.
Level IIc
Additional competencies required for maternity care professionals working in Level IIc units include:
Competencies in Level III Units
These units 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.