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Advanced Training Skills Module – Advanced Antenatal Practice August 2010

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Advanced Antenatal Practice

This module is designed to prepare the future Consultant Obstetrician for dealing with complex problems in late pregnancy, especially cases which need to be managed in a multidisciplinary fashion in order to achieve optimal outcomes. In order to work best with other health professionals, it is good to experience patient management from their perspective too, so we encourage the trainee to spend time with these other groups (e.g. Social Workers, Drug and Alcohol Liaison Midwives, Infectious diseases specialists, Psychiatrists). The module is designed to enhance practical skills in the use of ultrasound-based fetal surveillance techniques. A pre-requisite for starting the Advanced Antenatal Practice ATSM is completion of the basic ultrasound modules. A suitable Advanced Antenatal Practice theoretical course is also highly recommended for this ATSM.

Specifically, once trained, individuals should:

Work well as part of a multidisciplinary team

Be able to plan and set up new multidisciplinary services to encompass the needs of particular groups during pregnancy

Be clinically competent and confident in all aspects of antenatal care

Be aware of their own clinical and professional limitations and comfortable with seeking advice from other specialists or professional groups

Be conversant with Community-based medical services, and social support agencies (including Voluntary Groups)

Be clinically competent in the use and interpretation of ultrasound-based fetal monitoring techniques (biometry, Doppler, biophysical assessment, Cardiotocography)

Be able to undertake and use clinical audit

Be able to write evidence based guidelines

The ATSM must be undertaken under the supervision of an identified educational supervisor, who must be in a position to directly supervise and assess competence. In order to ensure exposure to the required case mix, a Unit offering this ATSM must have a Pregnancy Day care facility for maternal and fetal health surveillance, with Ultrasound biometry and Doppler equipment.

A minimum of two sessions per week should be dedicated to this ATSM and during the course of the ATSM; the trainee must prepare a report for and attend a Child Protection Conference, attend an HIV clinic, an oncology / breast clinic, obstetric or adult psychiatry clinic, a prescribing clinic and spend time working alongside Community Drug & Alcohol team members. The trainee should develop or update an antenatal practice guideline, conduct or supervise a relevant audit and attend antenatal services management meetings.


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1. Pregnancy surveillance Learning outcomes: To understand and demonstrate appropriate knowledge, skills and attitudes in relation to surveillance of maternal and fetal health

Knowledge criteria Clinical competency Professional skills and attitudes

Training support Evidence/ Assessment

Know the aetiology, incidence, pathophysiology, diagnosis, management, obstetric, medical & neonatal complications, and recurrence risksof:

Pregnancy induced hypertension

Antepartum haemorrhage

Obstetric cholestasis

Fetal growth restriction

Placental abnormalities

Fetal haemolysis

Preterm labour

Preterm premature rupture of membranes

Multiple pregnancy

Prolonged pregnancy

Malpresentation

Take an appropriate history Counsel in pregnancy regarding previous obstetric problems. Manage cases with previous history of: Early-onset PET Early onset IUGR Red cell antibodies (excluding

treatment of fetal anaemia) Recurrent mid trimester pregnancy

losses Cervical incompetence Manage cases with current problems: Pre-eclampsia after 28 weeks Growth restriction after 28 weeks Dichorionic twins with growth

discrepancy Red cell antibodies (excluding

treatment of fetal anaemia)

Ability to: Empower and inform women to make appropriate choices for themselves and their families in pregnancy and childbirth Explain correctly, and place in context for the patient:

Red cell isoimmunisation Pre-eclampsia Tests of fetal wellbeing Recurrence risks for obstetric

complications Complications of premature

birth

Perinatal morbidity and mortality meetings

Risk assessment meetings

RCOG Clinical Green Top Guidelines:

10A (Management of preeclampsia/ eclampsia)

20 (a- External cephalic version and reducing the incidence of breech presentation)

20 (b- Breech presentation, management)

27 (Placenta Praevia and Placenta Praevia Accreta: Diagnosis and Management)

43 (Obstetric cholestasis)

StratOG e-turorials

Useful websites: www.nice.org.uk www.rcog.org.uk www.sign.ac.uk www.show.scot.nhs.uk

Log of experience and competence Mini-CEX Case-based discussions

TO1/TO2

http://www.nice.org.uk/

http://www.rcog.org.uk/

http://www.sign.ac.uk/


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Pregnancy surveillance (continued)

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence/ Assessment

Understand fetal cardiovascular and behavioural responses to:

hypoxia

anaemia

sepsis Know normal and abnormal transvaginal ultrasound appearances of the cervix

Engage in organisation and running of multidisciplinary pregnancy services to encompass needs of women with particular pregnancy complications / issues e.g. multiple gestation, risk of preterm labour Perform ultrasound scan for fetal surveillance, appropriate to the obstetric risks

Biometry

Cervical length

Biophysical profile

Doppler studies of umbilical artery middle cerebral artery (including MCA peak systolic velocity measurements for fetal anameia)

Understand principles of and interpret Doppler studies of uterine arteries, ductus venosus

Liaise with midwives and other health professionals to optimise patient management Use appropriate referral pathways and local protocols

Explain correctly and put into the clinical context the ultrasound & Doppler findings.

Use other fetal tests (e.g. cardiotocography) and maternal tests (e.g. blood investigations) in an appropriate fashion and be able to recognise deteriorating trends, which mandate action (e.g. need for delivery).

Appropriate postgraduate education courses RCOG Clinical Green Top Guideline 31 (Small for gestational age: fetus: investigation and management)

StratOG e-tutorials

Attend local management group for antenatal services Audit project Write evidence –based protocol OSATS for different ultrasound procedures


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2. Infections in late pregnancy Learning outcomes: To manage, under supervision, women in pregnancy with infectious diseases, so as to reduce the risks of vertical transmission.



Know the incidence, risk factors, transmission risks, neonatal consequences, long term prognosis and management strategies to reduce vertical transmission of:

HIV

Hepatitis B & C (HBV, HCV)

Herpes Simplex (HSV)

Group B Streptococcus (GBS)

Manage cases with viral / bacterial infections

Give appropriate advice to an HIV positive woman about interventions available to reduce vertical HIV transmission in pregnancy

Assess risk for HBV or HCV infections and arrange HBV vaccination ± immunoglobulin appropriately for at risk groups according to local protocol

Advise re use of acyclovir for symptomatic treatment of genital HSV or for prophylaxis against recurrent attacks in late pregnancy

Make management plan for pregnancy and delivery in a woman found to be a carrier of GBS

Refer for further assessment or treatment (esp HIV, HBV HCV)

Formulate, implement and where appropriate modify a multidisciplinary management plan for HIV, HSV or Hepatitis positive women. Counsel women and their partners accordingly

- management options

- risks / benefits of anti-retroviral therapy for HIV

- risks/benefits of acyclovir treatment for HSV

- neonatal treatment and/or vaccination

- long term outcome for mother and infant

Respect confidentiality

Observation of and discussion with senior medical staff Appropriate postgraduate courses Attendance at sessions in

HIV clinic / multidisciplinary team

RCOG Green Top Clinical Guidelines:

30: Management of genital herpes during pregnancy

36: Prevention of Early Onset Neonatal Group B Streptococcal Disease

39: Management of HIV in pregnancy

Scientific Advisory Committee Opinion paper 3 (Intrauterine infection & perinatal brain injury) NICE Guidelines (Antenatal Care, Caesarean Section)

Log of

experience and competence

Mini-CEX Case-based

discussions

TO1/TO2

Local meetings attended


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3. Triage of acute problems in late pregnancy Learning outcomes: To be able to reach a diagnosis in women presenting with various clinical problems in pregnancy and make an appropriate management plan



To understand the pathophysiology, presentation and implications for maternal &/or fetal health of common late pregnancy complications:

Pelvic girdle pain

Reduced fetal movements

Abdominal pain

Itching

Skin rashes

Proteinuria

Malpresentation

Take an appropriate history and conduct an examination in a woman presenting with the symptom / sign / abnormality

arrange appropriate investigations

counsel re maternal and fetal risks

plan pregnancy, delivery and postnatal care

refer for further assessment / treatment

Engage in organisation and running of maternal & fetal surveillance service for triage and surveillance of acute late pregnancy problems Perform ECV –at least 10 attempted ECVs.

Able to make a thorough assessment of a presenting problem with appropriate investigation and consideration of differential diagnoses Consider effects on fetus or neonate when prescribing drugs for mother

Liaise with midwives and other health professionals to optimise patient management Use appropriate referral pathways and local protocols

Observation of and discussion with senior medical staff Local multidisciplinary meetings Appropriate postgraduate education courses

Log of experience and competence Mini-CEX Case-based discussions

TO1/TO2 Audit project Write evidence –based protocol Attend local management group for antenatal services OSATS for ECV


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4. Malignant disease Learning outcomes: To be able to carry out, under supervision, appropriate assessment and management of women with previous/current malignant disease

Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence/ Assessment

Know the maternal & fetal effects of cancer therapies

Radiotherapy

Chemotherapy

Know the pathology, prevalence, maternal and fetal risks, management during pregnancy and postnatally, advice re breastfeeding & contraception, prognosis and recurrence risks for:

Breast cancer

Gynaecological cancer (cervical cancer, ovarian cancer)

Haematological malignancy

Other cancers (e.g. melanoma)

Know about the principles and practice of palliative care

Take an appropriate history from a woman with suspected / prior malignancy

diagnosis

previous procedures / operations

drug therapy Perform breast examination in pregnancy Understand how to manage a woman with a previous history of cancer during a subsequent pregnancy (eg gestational trophoblastic disease, trachelectomy for cervical cancer, breast cancer) Understand how to manage a case of cancer in pregnancy:

arrange appropriate investigations

counsel re maternal and fetal risks (incl. management options e.g. termination of pregnancy, preterm delivery)


refer for further assessment / treatment

Liaise with primary care, palliative care, surgeons and oncologists to optimise patient management Formulate, implement and where appropriate modify a multidisciplinary management plan Explain correctly and place in context:

- maternal and fetal risks

- management options

- prognosis & recurrence risks

- breastfeeding

- contraception Act with empathy, honesty and sensitivity when breaking bad news

Observation of and discussion with senior medical staff Appropriate postgraduate courses Attendance at -breast clinic -oncology clinic RCOG Clinical Green Top Guideline 12 (Pregnancy and breast cancer)

ATSM logbook Mini-CEX Case-based discussion


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5. Psychiatric disease

Learning outcomes: 1. To be able to carry out, under supervision, appropriate assessment and management of women with pre-existing psychiatric disease. 2. To be able to carry out, under supervision, appropriate assessment and management of women with pregnancy-induced/related psychiatric disease



Know the prevalence, effects of pregnancy, management strategies and prognosis of pre-existing psychiatric disease (incl. depression / bipolar disorders, anxiety disorders, schizophrenia)

Know the pharmacology, maternal, fetal, neonatal and long-term effects (incl. adverse effects) of drugs used for psychiatric disorders

Understand the legal issues (incl. Mental Health Act and consent, child protection)

Know the risk factors, diagnostic features, natural history and prognosis (incl. recurrence risks) of pregnancy-induced / related psychiatric disease

Take an appropriate history from a woman with psychiatric illness

previous history / drug history

risk factors Manage a case of chronic psychiatric disease, postnatal depression or puerperal psychosis in pregnancy;

identify high risk woman

refer for further assessment / treatment to psychiatric services

counsel re maternal, fetal and neonatal risks

institute/modify drug therapy, where appropriate


counsel re maternal and neonatal risks, long term outcome (incl risk of recurrence)

Take an appropriate history to assess a woman with suspected or proven psychiatric disease

formulate, implement and where appropriate modify a multi-disciplinary management plan

formulate list of differential diagnoses

liaise with psychiatrists, community psychiatric nurses & midwives

explain and put in context

- maternal risks

- risks / benefits of therapy

- long term outcome / recurrence risks

- breast feeding / contraception

Observation of and discussion with senior medical staff Appropriate postgraduate courses Attendance at:

obstetric psychiatry clinic

adult psychiatry clinic

and/or

Attendance at sessions in perinatal psychiatry if available, or adult psychiatry clinic

ATSM logbook Mini-CEX Case-based discussion


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6. Drug and alcohol abuse Learning outcomes: 1. To carry out, under supervision, appropriate assessment and management of women with previous / current history of alcohol abuse. 2. To carry out, under supervision, appropriate, assessment and management of a women with previous / current history of substance abuse / dependency

Knowledge criteria Clinical competence Professional skills and attitudes


Know the incidence, associated obstetric, medical & neonatal complications and legal consequences of the abuse of:

alcohol (incl. acute intoxication)

cannabis

opiates

cocaine and crack heroin

benzodiazepines

amphetamines

lysergic acid diethylamide (LSD), phencyclidine (angel dust)

toluene (glue sniffing)

cigarette smoking

Understand the pharmacology (incl. adverse effects) of drugs of abuse and those used during detoxification.

Understand the organization of drug/alcohol dependency services and links with psychiatric and social services.

Understand child protection procedures

Take an appropriate history from a woman with alcohol / substance abuse / dependence

agents and route used

social problems / support

previous or current detoxification

complications Perform an examination to assess suspected alcohol / substance abuse. Manage cases of alcohol or substance abuse in pregnancy;

arrange and interpret appropriate maternal & fetal investigations

refer, where appropriate, for further assessment / treatment

institute/modify supportive / drug therapy


Provide sympathetic support (suppress any display of personal judgement) Formulate, implement and where appropriate modify a multi-disciplinary management plan Liaise with drug dependency team, psychiatrists, social services, pharmacists, midwives and neonatologists Counsel appropriately about:

drinking / drug cessation

maternal, fetal and neonatal risks

long term health implications

viral and other infections

breast feeding / contraception

effects of harmful behaviour

Achieve minimisation of harm in partnership with women

Observation of and discussion with senior medical staff Appropriate postgraduate courses Attendance at

drug / alcohol abuse (prescribing) clinic or relevant

psychiatry clinic Work with drug liason midwife or community team RCOG Statement 5 (Alcohol consumption and the outcomes of pregnancy) StratOG.net resources

ATSM logbook Mini-CEX Case-based discussion Portfolio of child protection case(s)


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7. Child protection, social disadvantage, religious issues

Learning Outcomes: To assess and manage appropriately pregnancies in women socially disadvantaged due to age, family circumstances, culture or religion.

Knowledge criteria Clinical competence Professional skills and attitudes Training support Evidence/ Assessment

Know the incidence, associated obstetric, medical & neonatal complications and legal consequences of social disadvantage with respect to:

Domestic violence

Teenage pregnancy

Asylum seekers Understand the influence of ethnic & religious background on obstetric expectations and outcome Understand child protection procedures

Make relevant referral as a result of domestic violence. Use interpreting services appropriately. Conduct booking and follow up visits. Arrange and interpret appropriate investigations. Recognise health risks arising from previous / current social problems. Engage in organisation & running of multidisciplinary pregnancy services to encompass the needs of socially disadvantaged groups. Act as local obstetric liaison for groups with particular needs and social requirements. Engage in organisation & running of child protection procedures. Achieve a minimum of level 1 child protection competence

Liaise with midwives and other health professionals to optimise patient management. Empower and inform women to make appropriate choices for herself and her family in pregnancy and childbirth. Explain correctly, and place in context for the patient:

Risks of viral and other infections

Genetic problems

Effects of drugs and harmful behaviour

Consequences of religious beliefs (esp with respect to blood transfusion)

Achieve minimisation of harm in partnership with women. Identify and deal appropriately with domestic violence and child protection issues. Use appropriate referral pathways and local protocols.

Mandatory education and training sessions Appropriate postgraduate education courses Risk assessment meetings Time spent working with child protection midwife, community midwives working with teenagers & social workers RCOG Statement 3 (Female Genital Mutilation) Useful websites: www.nice.org.uk http://www.rcog.org.uk http://www.sign.ac.uk www.show.scot.nhs.uk http://www.nta.nhs.uk/ http://www.noblood.org/ (No blood: blood management and avoidance)

http://www.thewomens.org.au/

http://www.dfes.gov.uk/teenagepregnancy

ATSM logbook Local meetings attended TO1/TO2 Mini-CEX Case-based discussion Portfolio of child protection case(s) Audit project Write /modify management guidelines


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8. Obesity in Pregnancy Learning Outcomes: To assess and manage appropriately pregnancies in women who are obese.

Knowledge criteria Clinical competence Professional skills and attitudes Training support Evidence/ Assessment

Know the incidence, associated obstetric, medical & neonatal complications of the pregnant obese patient. Understand the endocrinology of obesity Understand the place of weight reduction strategies and appropriate nutrition in managing the pregnant obese patient. Understand the management of obesity and its complications during pregnancy

Conduct a booking risk assessment and plan follow up visits and care. Undertake antenatal (fetal and maternal) assessment of the obese patient. Arrange and interpret appropriate investigations including screening for gestational diabetes. Recognise and manage health risks associated with maternal obesity. Engage in organisation & running of multidisciplinary pregnancy services to encompass the needs of obese women

Liaise with midwives and other health professionals to optimise patient management. Provide care with sensitivity and empathy Explain correctly, and place in context for the patient:

Maternal and fetal risks of obesity during pregnancy and birth.

Optimum nutrition during pregnancy Use appropriate referral pathways and local protocols.

Mandatory education and training sessions Appropriate postgraduate education courses

Baker, Balen, Poston, Savtan et al. Obesity and Reproductive Health consensus views

Bariatric Surgery and Practice Bulletin. http://mail.ny.acog.org/website/SMIPodcast/BariatricSurgery.pdf

http://mail.ny.acog.org/website/FinalObesity.pdf

Useful websites: www.nice.org.uk http://www.rcog.org.uk http://www.cmace.org.uk/ http://mail.ny.acog.org/website/

ATSM logbook

Local meetings attended

TO1/TO2

Mini-CEX

Case-based discussion


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Advanced Antenatal Practice

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 conditions into „likely to see‟, „may not see‟ and „unlikely to see‟ The clinical conditions expected to be seen must be signed up when clinical exposure has enabled the achievement of stipulated competence levels. Use other learning tools for „unlikely to see‟/rare events/conditions. Later in post, cover any residual „may not see‟ issues which you have not acquired expertise in through clinical exposure. For these cases, sign up logbook using other methodologies (“OM”) in logbook. You must state and date the learning episode at which specific rare conditions were covered in the Other methodologies” table at the end of this log book. Examples of “Other methodologies” acceptable for learning relatively uncommon clinical events/conditions include:

Case-based discussions (CBD)

Mannequins

Video/web e-learning resources

For practical skills every effort must be made to back up theory-based methodologies with practical learning aids Competencies achieved in basic training can be applied to the ATSM. A trainee who has previously worked in a centre for management of a particular condition, and who undertakes his/her ATSM in a place with little exposure to that condition, should be able to apply their prior competency. However the ATSM preceptor should only accept this on verification that such prior competency was previously achieved. Where such exposure cannot be verified the trainee and preceptor should use “other methodologies” to ensure that such learning objective has been covered during this ATSM.


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Competence level

Level 1 Level 2 Level 3

Date Signature

Date Signature

Date Signature

Hypertension in pregnancy

Hypertension found at booking visit

Late onset pre-eclampsia (after 34 weeks)

Early onset pre-eclampsia (28-34 weeks)

Previous history of late onset pre-eclampsia

Previous history of early onset pre-eclampsia

Fetal growth restriction

Late onset growth restriction (after 34 weeks)

Early-onset growth restriction (28-34 weeks)

Previous history of late onset growth restriction

Previous history of early onset growth restriction

Previous obstetric problems

Previous difficult operative delivery

Previous stillbirth or serious neonatal compromise

Previous shoulder dystocia

Multiple gestation

Dichorionic twins with growth discrepancy


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Competence level


Date Signature

Date Signature

Date Signature

Placental abnormalities

Major placenta praevia

Recurrent antepartum haemorrhage

Malpresentation

Malpresentation found in late pregnancy

Unstable lie

Obstetric cholestasis

Confirmed Obstetric Cholestasis

Red cell antibodies

Red cell antibodies arising during index pregnancy

Previously recognised red cell antibodies

Identified antenatal red cell haemolysis

Prematurity

Previous preterm delivery (before 34 weeks)

Previous recurrent 2nd

trimester miscarriages

Cervical incompetence

Infections in late pregnancy

HIV infection diagnosed either before or during pregnancy

Hepatitis B diagnosed either before or during pregnancy


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Competence level


Date Signature

Date Signature

Date Signature

Hepatitis C diagnosed either before or during pregnancy

New diagnosis of Group B Streptococcus (GBS)

Previous obstetric /neonatal problems with GBS

Genital Herpes diagnosed either before or during pregnancy

Triage of acute problems in late pregnancy

Antepartum haemorrhage

Pruritis

Skin rashes

Suspected preterm rupture of the membranes

Suspected preterm labour

Pelvic Girdle pain

Reduced fetal movements

Abdominal pain

Malpresentation

Proteinuria

Malignant disease

Previous breast / other cancer


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Competence level


Date Signature

Date Signature

Date Signature

Active breast / other cancer (may not see, gain exposure through "other methodologies")

Psychiatric disease

Chronic Psychotic Illness

Chronic Depression / Anxiety

Postnatal Depression

Puerperal Psychosis (* may not see)

Drug and alcohol misuse

Current opiate misuse

Current amphetamine / cocaine / crack misuse

Current opiate detoxification

Current alcohol misuse

Domestic violence

Disclosure of domestic violence

Teenage pregnancy

Mother under age of 18 years

Asylum seekers

Recent arrival in UK, seeking asylum

Child protection

Concerns raised for child protection


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Competence level


Date Signature

Date Signature

Date Signature

Female genital mutilation

Previous female genital mutilation procedure

Issues about religious beliefs

Jehovah‟s Witness

Strongly held religious belief

Obesity during pregnancy

Assess and counsel a pregnant obese woman at booking

Undertake fetal assessment of the morbidly obese

Plan delivery of the obese parturient

Pre-operative anaesthetic assessment

Procedures

Ultrasound for biometry in 2nd

and 3rd

trimester

Ultrasound for assessment of presentation

Umbilical artery Doppler

Middle cerebral artery Doppler

Ductus venosus Doppler

Biophysical profile

Ultrasound for placental localisation


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Competence level


Date Signature

Date Signature

Date Signature

Cervical length measurement

External cephalic version

Sessions attended Date Supervisors Signature

HIV Clinic

HIV multidisciplinary team meeting

GU medicine clinic

Oncology / breast clinic

Oncology / breast multidisciplinary team meeting

Obstetric or adult psychiatry clinic

Perinatal Psychiatry Unit (in patient)

Perinatal Psychiatry Unit (in patient)

Prescribing / Substance Misuse Clinic

Community Drug and Alcohol team

Dietetics/Bariatric Surgery Clinic

Antenatal Services Planning Meeting




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Uncommon clinical condition/procedure not seen/not undertaken.

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

Written reports Date Supervisors Signature


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Report for Child Protection Conference

Audit Completed about

Guideline Completed about

Training courses or sessions

Title Signature of Educational Supervisor Date


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Appendix to ATSM Advanced Antenatal Practice Details of knowledge criteria Pregnancy complications:

Detailed knowledge of the aetiology, incidence, recurrence risks, obstetric, medical & neonatal complications of common and uncommon problems in pregnancy

Hypertension in pregnancy, both pre-existing and pregnancy-induced. Antepartum haemorrhage Preterm labour Preterm premature rupture of membranes Multiple pregnancy Malpresentation Fetal growth restriction Fetal haemolysis Prolonged pregnancy Placental abnormalities Obstetric Cholestasis Shoulder Dystocia

Knowledge of appropriate information to elicit from history and physical examination for the various problems presenting during pregnancy.

Knowledge of appropriate investigations to confirm / refute a diagnosis.

Knowledge of evidence-based management strategies for specific conditions, e.g.: Antihypertensive treatment, low dose aspirin Transvaginal ultrasound to improve diagnosis of placenta praevia Cervical cerclage as an elective procedure or in response to evidence of cervical incompetence (shortening & funnelling of the cervix, as determined

by transvaginal ultrasound) Use of screening tests for vaginal infections, PPROM, incipient preterm labour (e.g. fetal fibronectin, ACTIM) Appropriate use of Corticosteroids, Erythromycin, other antibiotics External cephalic version Ursodeoxycholic acid

Detailed knowledge about bacterial and viral infections with the potential for vertical transmission (HIV, HBV, HCV, HSV, GBS) and the strategies available to reduce maternal, fetal and neonatal harm Zidovudine and other retroviral agents for HIV Use of HBV vaccination ± immunoglobulin Use of Acyclovir used to treat symptomatic HSV and used prophylactically to reduce chance of active disease at time of delivery


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Use of intrapartum antibiotics to prevent neonatal GBS infection General strategies during labour to reduce transmission (avoidance of invasive fetal monitoring) Advice re breast feeding

Knowledge of differential diagnoses for common acute problems presenting in late pregnancy and their aetiology, incidence, recurrence risks, obstetric, medical & neonatal complications Pelvic girdle pain Reduced fetal movements Abdominal pain Itching Skin rashes (pre-existing or pregnancy-induced) Proteinuria

Knowledge of the causes, treatment and appropriate investigation of asymptomatic bacteruria and urinary tract infections in pregnancy, including cases for further investigation and/or referral to other specialists after pregnancy

Investigations for mother and fetus:

Understanding of appropriate tests for haematological, biochemical or microbiological investigations. Knowledge of pregnancy-related changes in these tests and application of pregnancy-specific reference ranges for their interpretation.

Understanding of appropriate radiological investigations (ultrasound imaging, Doppler ultrasound, X-ray, CT scan, MRI scan) for different problems identified in mother or fetus. Knowledge of risks, benefits and limitations of each investigation.

Understanding of the appropriate use and interpretation of fetal heart rate tracings (cardiotocograms) and other biophysical studies. Knowledge of changes in fetal cardiovascular function with gestation and pathological conditions (eg hypoxia, anaemia, sepsis).

Communication skills and team working:

Knowledge of communication skills: How to conduct an interview with a patient to identify their prior beliefs, expectations, comprehension, priorities and fears. How to lead a non-directive discussion of medical facts and explore the patient‟s responses and feelings to achieve joint decision-making. How to break bad news and discuss difficult issues or uncertainty. Bereavement processes and behaviour.

Knowledge of team working: Team dynamics, with different roles and responsibilities for individual members. Influences, both positive and negative, on team development. Support, mentoring and motivation. Implementing changes and progressing as a team. Leadership styles and behaviours.


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Malignancy:

Knowledge of teratogenic and fetal risks of radiotherapy and chemotherapy

Knowledge of drug pharmacokinetics and calculation of fetal doses of radiation

Understanding of effects of different contraceptives in women with previous or current malignant diseases

Knowledge about breast cancer: Diagnosis in pregnancy (clinical examination findings, fine needle aspiration, ultrasound) Management (surgery, adjuvant chemo/radio-therapy, indications for termination / preterm delivery)

Knowledge about gynaecological cancers:

Surgery (including hysterectomy and salpingo-oophorectomy) Adjuvant radio/chemotherapy

Knowledge about other cancers:

Effects of current or previous treatments (surgery, radiotherapy or chemotherapy) Psychiatric disease: Knowledge about pre-existing psychiatric disease (incl. depression / bipolar disorders, anxiety disorders, schizophrenia)

prevalence, functional impact of pregnancy, pregnancy / postnatal management, maternal and fetal risks

role of specialty team / community liaison / mother and baby units psychotherapy pharmacological therapy / risks of withdrawal

pharmacology (incl. adverse effects) in mother, fetus & neonate of drugs used to treat psychiatric disorders

tricyclics, SSRIs phenothiazines (e.g. trifluoperazine, chlorpromazine) butyrophenones (e.g. haloperidol) benzodiazepines lithium, carbamezepine

neonatal management (incl. withdrawal and long term risks of drugs)

legal issues (incl. Mental Health Act and consent, child protection)

Knowledge about pregnancy-induced / related psychiatric disease

risk factors, diagnosis (incl. differential diagnosis postnatal depression)

management role of specialty team / community liaison / mother and baby units support / psychotherapy pharmacological therapy / ECT

maternal and neonatal outcome (incl. recurrence risks)


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Drug and alcohol misuse:

Understanding of theories of addiction and self-harming behaviours.

Understanding of psychiatric co-morbidity and its detection.

Knowledge of the law regarding class A and class B drugs.

Knowledge of pharmacology of different drugs of abuse and those used in detoxification programmes, including overdose, interactions with prescribed drugs and analgesia during labour

Knowledge of the local and national strategies for reduction in drug and alcohol misuse.

Knowledge of detoxification programmes and prescribing clinics.

Knowledge of the available voluntary sector self-help groups.

Knowledge about neonatal management and outcome (incl. management of withdrawal and long term effects)

Knowledge regarding legal issues (child protection) Child protection:

Knowledge of the law relating to protection of children.

Knowledge of the role of different agencies in the care of children and investigation of concerns for their welfare (Social Services, Health Visitors, Police, GPs, Community Paediatricians, Community Psychiatric practitioners).

Knowledge of the process of child protection procedures. Domestic violence:

Knowledge of the role of different agencies (Social Services, Police, Voluntary groups) in the investigation of suspected domestic violence and the protection of vulnerable women and children.

Knowledge of the law in relation to physical and sexual assault, bodily harm and rape.

Knowledge of the impact of domestic violence on physical, psychological and emotional health of women and their families. Teenage pregnancy:

Knowledge of the law in respect to age of consent, sexual assault and rape.

Understanding of the emotional, psychological and educational needs of teenagers who are pregnant.

Understanding of the obstetric complications of teenage pregnancy. Asylum seekers:

Knowledge of the law in relation to seeking asylum.

Understanding of the psychological and emotional traumas previously experienced by many asylum seekers.

Knowledge of the role of different agencies involved in processing claims for asylum status and meeting their practical needs (Police, Home Office, Social Services).

Understanding the consequences of being displaced from home, community and country.


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Ethnic and religious issues:

Female Genital Mutilation (FGM) Knowledge of the UK and international laws and directives regarding FGM. Understanding of the various FGM procedures and their health consequences, including for pregnancy and delivery.

Jehovah‟s Witnesses (JW) Knowledge of the beliefs and implications for health care of a patient who is a practising JW. Knowledge of the alternatives to blood transfusion. Knowledge of the procedure and practice of cell-salvage during surgery.

Other religious beliefs and customs Knowledge of societal structure for different ethnic / religious groups and how this affects healthcare or consent for medical interventions. Understanding of key beliefs and customs regarding pregnancy, childbirth, newborn care, medical interventions, family life and death.

Obesity in pregnancy:

Knowledge of the incidence, associated obstetric, medical & neonatal complications of the pregnant obese patient.

Understanding the endocrinology of obesity

Understand the place of weight reduction strategies and appropriate nutrition in managing the pregnant obese patient.

Understand the management of obesity and its complications during pregnancy

advanced antenatal practice - royal college of · pdf file · 2014-04-02a suitable...

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