high risk pregnancy atsm 2018 - rcog€¦ · web viewthese are the ultrasound competencies for...

Colour key: Common competency framework competencies Medical leadership framework competencies Health inequality framework competencies

High Risk Pregnancy (2018) – approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018AimTo prepare the clinician for the recognition and management of high-risk pregnancy for both fetal and maternal conditions.

PrerequisitesSuccessful completion of an Obstetric Emergency Course, for example a MOET course or equivalent.

Key componentsThe ATSM comprises 5 Advanced Skills Modules (ASM). All 5 ASM are required to award 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 1. Advanced Obstetric Ultrasound. Identical to the ASM of the same name in the Fetal Medicine ATSM.

ASM 6. Management of Key Obstetric Medical Conditions. Identical to the ASM of the same name in the Obstetric Medicine ATSM.

ASM 7 High-risk secondary to Environmental, Social and Lifestyle Factors.ASM 8 High-risk secondary to Medical and Obstetric Factors. ASM 9 Effective Communication and Clinical Governance Skills for High-Risk Pregnancy.

Educational SupportAttendance at the annual RCOG/BMFMS High Risk Course or an equivalent course prospectively approved by your Regional Preceptor is mandatory.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 also provided by the RCOG.

Clinical SupportThe 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 intensityFor pre-CCT trainees the ATSM has been allocated a work intensity score of 2.0.

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GMC Good Medical Practice (GMP) Domains: Domain 1: Knowledge, skills and Performance Domain 2: Safety and quality Domain 3: Communication, Partnership and Teamwork. Domain 4: Maintaining Trust


ASM 1 Advanced Obstetric Ultrasound

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

assessment

(1.01) Effective and safe use of imaging modalities

(1.02) Optimise image for 2D ultrasound.

(1.03) Optimise image for Doppler ultrasound.

(1.04) Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.Uterine artery Doppler

(1.05) Umbilical artery Doppler

(1.06) Middle Cerebral artery Doppler, including vMax

(1.07) Ductus Venosus Doppler

(1.08) Cervical lengthUltrasound competency for the screening, diagnosis and

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(1.01)Understand the risks associated with the different ultrasound modalities and how to limit them. Understand mechanical index (MI) and thermal index (TI).

(1.02-1.03)Be familiar with the full range of optimisation controls including, Power, gain, focal length, magnification, sector width, frame rate, pulse repetition frequency, colour and power Doppler modes.

(1.04)Be familiar with local policies for the use and interpretation of 3D/4D ultrasound and fetal MRI.

(1.05- 1.07)Doppler ultrasound: understand when to use Doppler ultrasound and its interpretation

Understand how these assessments are used to monitor growth restriction.

Understand how fetal anomalies may influence the waveforms (for example cardiac arrhythmias, fetal anaemia,

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(1.01-1.04)Appreciates the limitations of antenatal ultrasound.

Understands the appearances of artefacts and how these might be misinterpreted.

Able to explain the use of antenatal ultrasound and the benefits of the different modalities along with the transabdominal and transvaginal route.

(1.05-1.12)Able to apply ultrasound finding to local and Regional guidelines, referring as appropriate.

(1.14)Able to liaise appropriately to explore option of amniodrainage for polyhydramnios.

(1.09-1.15)Able to explain ultrasound findings and management options in a manner that is non-judgemental and easy to

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(1.09-1.10)RCOG Green top guideline No. 57 (2011) Reduced fetal movements.

No.31 (2013) Small for gestational age fetus, investigation and management.

(1.13)Scientific impact paper No.33 Preterm labour, antibiotics and cerebral palsy.

(1.16)RCOG Green top guideline No. 20a ECV to reduce breech presentation.

(1.11-1.12)NICE Clinical Guideline CG 129 Management of twin and triplet

(1.01-1.16)These are the ultrasound competencies for high-risk pregnancy (rather than for fetal anomaly which is covered in ASM2.)

Your evidence should be supported by a log of sessions attended and work-placed based assessments demonstrating good communication skills, documentation and recording of growth and anatomy.

(1.05-1.5)Work-placed based

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assessmentmanagement including timely referral of:

(1.09) Severe early onset fetal growth restriction

(1.10) Late onset fetal growth restriction

(1.11) Twin pregnancy with growth discordance

(1.12) Twin-twin transfusion syndrome

(1.13) Suspected preterm ruptured membranes

(1.14) Polyhydramnios

(1.15) Low lying placenta

(1.16) Ultrasound guided procedures: ECV for Breech

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hydrops, and twin-twin transfusion syndrome).Understand how MCA vMax is used to monitor for signs of anaemia

(1.08)Cervical length: transcervical measurement of cervical length, the criteria for accurate and reproducible measurement.

Recognises when cervical length should be offered.

(1.09-1.10)Management of growth restriction according to National Guidelines. When to refer to the Tertiary Centre.

(1.11-1.12)Multiple pregnancies: able to recognise and manage growth discordance. Understand the influence of chorionicity.For monochorionicity to be able to monitor for signs of TTTS and refer to the tertiary centre in accordance with local guidelines.Aware of the ultrasound features of TRAP (Twin reverse arterial perfusion sequence) and conjoined twins.

(1.13)Aware of the role and limitations of ultrasound in the management of suspected preterm ruptured membranes.

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understand.

(1.09-1.16)Able to formulate a suitable management plan, liaising where appropriate and always considering the individuals hopes and expectations for the pregnancy.

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pregnancies in the antenatal period.

RCOG Green top guideline N0.51 Monochorionic twin pregnancy.

STRATOG Advanced, Clinical Case Studies eLearning: Management of the SGA fetus (2016).

assessments should include abnormal values and explore the antenatal management.

These are common findings and should be based upon direct patient care.

OSAT

CBD

Reflective Practice

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assessment

(1.13-1.14)Able to accurately and reproducibly estimate liquor volume using maximum vertical pocket.

Understands the associations of polyhydramnios with poor maternal glucose control, fetal anomalies, and its significance in monochorionic pregnancies.

(1.15)Able to identify the lower edge of the placenta and measure the distance from the internal cervical os.

Recognises when there is an increased risk of morbidly adherent uterus (such as previous scar to uterus with overlying placenta).

(1.16)Practical experience of performing successful ECV according to local guidelines. Aware of contraindications to ECV.

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ASM 1 - Advanced Obstetric Ultrasound Part of the Fetal Medicine ATSM and the High Risk Pregnancy ATSM

LogbookCompetence level Not required

Level 1 Level 2 Level 3ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature

Effective and safe use of imaging modalities

Optimise image for 2D ultrasound.

Optimise image for Doppler ultrasound.

Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.

Uterine artery Doppler

Umbilical artery Doppler

Middle Cerebral artery Doppler, including vMax

Ductus Venosus Doppler

Cervical length

Ultrasound competency for the screening, diagnosis and management including timely referral of:

Severe early onset fetal growth restriction

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Level 1 Level 2 Level 3ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature

Late onset fetal growth restriction

Twin pregnancy with growth discordance

Twin-twin transfusion syndrome

Suspected preterm ruptured membranes

Polyhydramnios

Low lying placenta

Ultrasound guided procedures:

ECV for Breech

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Training Courses or sessions

Title Signature of educational supervisorDate

Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

Completion of ASM 1: Advanced Obstetric Ultrasound Date Signature

Comprising the safe and effective use of imaging modalities, the screening, diagnosis and management of the at risk fetus. Level 3 is to the level expected within Secondary Care and includes timely liaison with the MDT and Tertiary Centre when appropriate.

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ASM 6 Management of Key Obstetrical Medical Conditions


assessment

Hypertension(6.01) Chronic hypertension

Renal(6.02) Hydronephrosis

Gastrointestinal(6.03) Obstetric cholestasis(6.04) Hyperemesis gravidarum

Endocrinology(6.05) Pre-existing diabetes without complications

(6.06) Gestational diabetes

Respiratory(6.07) Asthma

Dermatology(6.08) Eczema

Neurological(6.09) Headache

(6.10) Epilepsy

Haematological(6.11) Thrombocytopenia

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(6.01-6.12)Detailed knowledge of the aetiology, incidence, recurrence risks, obstetric, medical & neonatal complications of these key medical problems in pregnancy

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

Understand the pathophysiology, presentation and implications for maternal &/or fetal health of common late pregnancy complication.

Know the aetiology, incidence, pathophysiology, diagnosis, management, obstetric, medical & neonatal complications, and recurrence risks of each condition.

(6.13- 6.15)Understand the interpretation of each of these investigations and how they are influenced by pregnancy.

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(6.01-6.12) 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

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1,2

1,2,3

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(6.01)NICE (2011) Hypertension in Pregnancy diagnosis and management (CG07).

(6.06) 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 Clinical Green Top Guidelines:10A (Management of preeclampsia/

These represent the core medical conditions with which you should have a thorough knowledge based upon direct clinical experience.

The evidence should support this and may include the full range of work placed based assessments along with a record of any relevant clinics courses or meetings attended.

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assessment(6.12) Previous thromboembolic disease

Investigations(6.13) ECG interpretation

(6.14) CXR interpretation

(6.15) Blood gas interpretation

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eclampsia)

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

No. 20 (Breech presentation, management)

No.27 (Placenta Praevia and Placenta Praevia Accreta: Diagnosis and Management)

No. 43 (Obstetric cholestasis)

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

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ASM 6. Management of Key Obstetric Medical Conditions.

Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM


Level 1 Level 2 Level 3

ASM 6. Management of key obstetric medical conditions

Date Signature Date Signature Date Signature

HypertensionChronic hypertension

RenalHydronephrosis

GastrointestinalObstetric cholestasis

GastrointestinalHyperemesis gravidarum

EndocrinologyPre-existing diabetes without complications

EndocrinologyGestational diabetes

RespiratoryAsthma

DermatologyEczema

NeurologicalHeadache

NeurologicalEpilepsy

HaematologicalThrombocytopenia

HaematologicalPrevious thromboembolic disease

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ASM 6. Management of key obstetric medical conditions


ECG interpretation

CXR interpretation

Blood gas interpretation



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Completion of ASM 6: Management of Key Obstetric Medical Conditions Date Signature

Appropriate management of the key obstetric medical conditions in each trimester to the level expected within secondary care and liaison with the tertiary centre when appropriate.

ASM 7 High Risk Secondary to Environmental, Social and Lifestyle Factors

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assessment

Substance misuse(7.01) Current alcohol misuse

(7.02) Obstetric management for current opiate misuse

(7.03) Obstetric management for current stimulant misuse.

(7.04) MDT assisted conversion to an opiate replacement programme

1,2 (7.01-7.03) Know the incidence, pharmacology, obstetric, medical & neonatal complications and legal consequences for the abuse of: alcohol, cannabis, opiates, cocaine and crack cocaine, heroin, benzodiazepines, amphetamines, LSD, phencyclidine (angel dust), solvent misuse and not forgetting cigarette smoking.

Know their interactions with prescribed drugs and analgesia during labour.

Understand the organization of dependency services and links with psychiatric and social services; the theories of addiction and self-harming behaviours prevalence of psychiatric co-morbidity and its detection.

(7.01-7.04) Manage cases of alcohol or substance abuse in pregnancy; arrange and interpret appropriate maternal & fetal investigations refer, where appropriate, for further assessment. (7.02-7.03)Knowledge of the law regarding class A and class B drugs.

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

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(7.01-7.03) Provide sympathetic support.

Respect confidentiality.

Recognise if there are issues relating to child protection and where to seek advice.

Achieve harm minimisation in partnership with women.

Take an appropriate history and examination.

Plan pregnancy, delivery and postnatal care within a multi-disciplinary team.

Talk to the drug dependency team, psychiatrists, social services, pharmacists, midwives and neonatologists understand their services and your role in supporting the care they deliver.

Counsel appropriately about: drinking / drug cessation maternal, fetal and neonatal risks: long-term health implications, viral and other infections breast-feeding / contraception, effects of

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(7.01-7.04)RCOG Statement 5 (Alcohol consumption and the outcomes of pregnancy).

(7.01-7.04)Record of attendance at drug / alcohol abuse clinic or relevant psychiatry clinic.

Work alongside drug liaison midwife or community team.

OSAT

CBD

Reflective Practice

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assessmentmisuse.

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

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risk taking behaviour.

(7.02)Be able to explain the features of neonatal withdrawal.

Teach the parents how to recognise signs of neonatal withdrawal.

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assessmentCare of the Pregnant Teenager (7.05) Mother <18 years

Social vulnerability (7.06) Care plan for recent arrival to the UK

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(7.05 - 7.06) Know the incidence, associated obstetric, medical & neonatal complications and legal consequences of social disadvantage with respect to: domestic violence, teenage pregnancy and asylum seekers.

Understand the influence of ethnic & religious background on obstetric expectations and outcome.

Knowledge of the law in relation to seeking asylum.

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(7.05) Ability to effectively communicate and respond to the hopes and concerns of pregnant teenagers.

(7.06) Understand when and how to use the different agencies involved in processing claims for asylum status and meeting their practical needs (Police, Home Office, Social Services).

Be sensitive to the potential for psychological and emotional traumas previously experienced by many asylum seekers.

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

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(7.06)NICE guideline CG110. (2010) Pregnancy and complex social factors

Obesity (BMI >40)(7.07) Assessment of maternal risks and counselling at booking.

(7.08) Fetal assessment.

(7.09) Intrapartum obstetric and anaesthetic care plan.

1,2(7.07 -7.09)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

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(7.07-7.09)Liaise with midwives and other health professionals to optimise patient management.

Provide care with sensitivity and empathy.

Provide specific practical advice

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(7.07-7.09) CMACE/RCOG Joint Guideline (2010) Management of women with obesity in pregnancy.

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assessmentmanaging 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; the place of weight reduction strategies and nutrition

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to reduce the maternal and fetal risks of obesity during pregnancy and birth.

Use appropriate referral pathways and local protocols.

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Scientific impact paper No.18 Nutrition in pregnancy.

NICE Guideline Intrapartum Care for High Risk Women (in development 2017).

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assessment

Domestic violence(7.10) History taking and MDT care plan

1,2,3,4

(7.10)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.

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1,2

(7.10)Recognise the impact of domestic violence on the physical, psychological and emotional health of women and their families.

Be able to describe the role of support agencies and encourage engagement if appropriate.

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(7.10)STRATOG Core training: (2016) Domestic abuse and substance misuse.

Women who decline blood products(7.11) Care-plan specific to individual circumstances, for example Jehovah’s Witness.

1,2 (7.11)Understand those Religious beliefs and customs that may affect healthcare or consent for medical interventions.

Knowledge of the alternatives to blood transfusion.

Be familiar with the set up and use of cell-salvage during surgery.

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(7.11) Assist in the construction of an advanced directive detailing the acceptability or not of blood and blood products and their use in acute circumstances.

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(7.11) www.noblood.org (No blood: blood management and avoidance)

RCOG Green top guideline No. 47 Blood transfusion in Obstetrics.

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http://www.noblood.org/








Substance misuseCurrent alcohol misuse

Substance misuseObstetric management for current opiate misuse

Substance misuseObstetric management for current stimulant misuse

Substance misuseMDT assisted conversion to an opiate replacement programme

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Care of the Pregnant Teenager Mother <18 years

Social vulnerability Care plan for recent arrival to the UK

Obesity (BMI >40)Assessment of maternal risks and counselling at booking

Obesity (BMI >40)Fetal assessment.

Obesity (BMI >40)Intrapartum obstetric and anaesthetic care plan.

Domestic violenceHistory taking and MDT care plan

Women who decline blood productsCare plan specific to individual circumstances, for example Jehovah’s Witness.

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Completion of ASM 7: High Risk Secondary to Environmental, Social and Lifestyle Factors Date Signature

Appropriate management and liaison with the MDT for those pregnancies where environment, social or lifestyle factors present significant risks. Experience supplemented by sessions outwith Obstetrics and Gynaecology in high-risk clinics specialising in the treatment of substance misuse.

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ASM 8 High Risk Secondary to Medical and Obstetric Factors


assessment

Psychiatric Disorders(8.01) Chronic psychotic illness

(8.02) Mood disorder: chronic depression / anxiety

(8.03) Bipolar illness

(8.04) Postpartum psychosis

1,2 (8.01-8.04)Know the prevalence, effects of pregnancy, management strategies and prognosis of these psychiatric conditions. Know the pharmacology, maternal, fetal, neonatal and long-term effects of tricyclics, SSRIs, phenothiazines, butyrophenones (e.g. haloperidol), benzodiazepines, lithium and carbamazepine.

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

Neonatal management (incl. withdrawal and long term risks of drugs), legal issues (incl. Mental Health Act and consent, child protection).

(8.05) Recognise the potential for haemolytic disease of the new-born, the antenatal monitoring required and investigations needed after delivery.(8.06- 8.11)

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(8.01-8.04) Take an appropriate history from a woman with psychiatric illness.

Be able to construct a differential diagnosis and advise on the influence of the illness on pregnancy and pregnancy on the illness.

Understand the concept of mental capacity, and how it is evaluated.

Be able to advice on breast-feeding.

Be able to discuss the role of local specialty teams in the community and hospital setting.

Understand the process for liaison and the criteria for referral to specialist mother and baby units.

Understand the role of primary care and liaise appropriately with the General Practitioner.

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(8.01-8.04)Mental Health Act (1983)

RCOG Good Practice Guideline No 14. Management of Women with Mental Health issues during pregnancy and the postnatal period.

NICE guideline CG192 (2015) Antenatal and Postnatal Mental Health: clinical management and service guidance.

(8.01-8.04)Evidence of attendance at: obstetric psychiatry or adult psychiatry clinics and perinatal psychiatry services where available.

(8.06-8.07)OSAT Cervical cerclage.

(8.01-8.16)

Reflective practice

OSAT

CBD

Evidence of eLearning

These are relatively common scenarios and your evidence should wherever

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assessmentThe ability to weight the evidence as it relates to the patient’s previous obstetric history for these common late pregnancy complications.

(8.12-8.16)Know the incidence, risk factors, transmission risks, neonatal consequences, long-term prognosis and management strategies to reduce vertical transmission of: Herpes Simplex (HSV), HIV, Hepatitis B & C (HBV, HCV), Group B Streptococcus (GBS).

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.

Know when and how to refer for further assessment or treatment (especially HIV, HBV HCV)

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

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

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Be aware of the variety of treatment options: supportive, pharmacological, psychotherapy, ECT.

Be able to discuss recurrence risks and how best to prepare for future pregnancies.

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possible be based on your direct clinical experience.

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assessment

(8.14-8.15)Assess risk for HBV or HCV infections and arrange HBV vaccination ± immunoglobulin appropriately for at risk groups according to local protocol.

(8.16)Understand how to construct a management plan for pregnancy and delivery in a woman found to be a carrier of GBS.

1,2,3

1,2

Haematological(8.05) Red cell alloimmunisation with normal fetal surveillance

1,2 (8.05) Recognise the potential for haemolytic disease of the new-born, the antenatal monitoring required and investigations needed after delivery.

1,2,3(8.05) Able to liaise with paediatric colleagues to ensure timely delivery and assessment of HDN following delivery.

1,2,3RCOG Green top guidelineNo.22 Use of anti-D. No.65 Management of red cell antibodies in pregnancy.

Obstetric History

(8.06) Previous preterm delivery (<34 weeks)

(8.07) Previous recurrent second trimester loss

(8.08) Previous or suspected cervical incompetence

1,2 (8.06- 8.11) The ability to weight the evidence as it relates to the patient’s previous obstetric history for these common late pregnancy complications.

1,2Liaise with midwives and other health professionals to optimise patient management.


Explain correctly and put into the clinical context the ultrasound &

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1,2,3

RCOG Green top guidelines: (8.06-8.07)No. 7. Antenatal steroids.

(8.08) No. 60 Cervical cerclage.

(8.06-8.09) NICE

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assessment

(8.09) Suspected preterm rupture of the membranes

(8.10) Previous shoulder dystocia

(8.11) Recurrent antepartum haemorrhage

Doppler findings.

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

1,2,3,4

1,2,3

Guideline NG25 (2015) Preterm labour and birth.

(8.07-8.09)No 1b Preterm labour and tocolytic drugs.No.44 Preterm prelabour rupture of membranes.

RCOG Scientific impact paper No.33 Preterm labour antibiotics and cerebral palsy.

(8.10)Green top guideline No.42 Shoulder dystocia

(8.11)Green top guideline No. 63. Antepartum haemorrhage.

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assessment

Infection(8.12) Genital Herpes diagnosed before or during pregnancy

(8.13) HIV diagnosed before or during pregnancy

(8.14) Hepatitis B diagnosed before or during pregnancy

(8.15) Hepatitis C diagnosed before or during pregnancy

(8.16) New diagnosis of Group B Haemolytic Strep.

(8.17) New infection of varicella zoster in pregnancy

1,2 (8.12-8.16)Know the incidence, risk factors, transmission risks, neonatal consequences, long-term prognosis and management strategies to reduce vertical transmission of: Herpes Simplex (HSV), HIV, Hepatitis B & C (HBV, HCV), Group B Streptococcus (GBS).

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.

Know when and how to refer for further assessment or treatment (especially HIV, HBV HCV)

(8.13)Give appropriate advice to an HIV positive woman about interventions available to reduce vertical HIV transmission in pregnancy Advise on the use of acyclovir for symptomatic treatment of genital HSV or for prophylaxis against recurrent attacks in late pregnancy

(8.14-8.15)Assess risk for HBV or HCV infections and

1,2

1,2

1,2,3

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1,2,3,4

1,2

(8.12-8.16)Formulate, implement and where appropriate modify a multidisciplinary management plan for HIV, HSV or Hepatitis positive women.

Counsel women and their partners om their management options including:

- 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.

1,2,3

1,2,3,4

4

(8.12 -8.17)

RCOG Green Top Clinical Guidelines:No.30: Management of genital herpes during pregnancy.

No. 36: Prevention of Early Onset Neonatal Group B Streptococcal Disease.

No. 39: Management of HIV in pregnancy.

No. 13 (2015) Chicken Pox in Pregnancy.

RCOG Patient information (2013) HIV in pregnancy.

No 64a Sepsis in pregnancy and No64b. Sepsis following pregnancy.

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assessmentarrange HBV vaccination ± immunoglobulin appropriately for at risk groups according to local protocol.

(8.16)Understand how to construct a management plan for pregnancy and delivery in a woman found to be a carrier of GBS.(8.17) Give appropriate advice to women exposed to varicella zoster and instigate the appropriate management for those with confirmed infection.

1,2

1,2,3,4

Scientific Advisory Committee Opinion paper 3 (Intrauterine infection & perinatal brain injury)

NICE Guidelines (Antenatal Care, Caesarean Section)

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ASM 8. High Risk Secondary to Medical and Obstetric Factors






Psychiatric DisordersChronic psychotic illness

Psychiatric DisordersMood disorder: chronic depression / anxiety

Psychiatric DisordersBipolar illness

Psychiatric DisordersPostpartum psychosis

HaematologicalRed cell alloimmunisation with normal fetal surveillance

Obstetric HistoryPrevious preterm delivery (<34 weeks)

Obstetric HistoryPrevious recurrent second trimester loss

Obstetric HistoryPrevious or suspected cervical incompetence

Obstetric HistorySuspected preterm rupture of the membranes

Obstetric HistoryPrevious shoulder dystocia

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Obstetric HistoryRecurrent antepartum haemorrhage

InfectionGenital Herpes diagnosed before or during pregnancy

InfectionHIV diagnosed before or during pregnancy

InfectionHepatitis B diagnosed before or during pregnancy

InfectionHepatitis C diagnosed before or during pregnancy

InfectionNew diagnosis of Group B Haemolytic Strep.

InfectionNew infection of varicella zoster in pregnancy

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Completion of ASM 8: High Risk Secondary to Medical and Obstetric Factors Date Signature

Appropriate management and liaison with the MDT for those pregnancies where obstetric medical problems present significant risks. Experience has been supplemented by sessions outwith Obstetrics and Gynaecology in high-risk perinatal psychiatric clinics, Mother and Baby Unit, haematology, infectious diseases and Genitourinary clinics.

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ASM 9 Effective Communication and Clinical Governance Skills for High-Risk Pregnancy


assessment

Effective Communication

(9.01) Explain any implications for the pregnancy and childbirth for strongly held parental beliefs.

(9.02) High risk for Fetal Genital Mutilation.

(9.03) Early or pre-pregnancy counselling for on-going substance misuse.

(9.04) Early or pre-pregnancy counselling for on-going maternal alcohol misuse.

1,2,3,4

1,2,3,4

1,2,3,4

1,2,3,4

(9.01-9.04)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.

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

1,2,3,4

1,2,3,4

1,3,4

1,3,4

1,2

(9.02)Be able to explain the UK law as it relates to female genital mutilation.

(9.03-9.04)Respect confidentiality.

Liaise effectively with the MDT.

Be able to discuss risk taking behaviour and harm minimisation in an informative, helpful but non-judgemental manner.

1,2,3,4

4

1,2,3

1,2,3,4

(9.01)www.noblood.org/ (No blood: blood management and avoidance)

(9.02)RCOG Statement 3 (Female Genital Mutilation)

RCOG Green top guideline N0.53 (2015) FGM and its management.

Department of Health factsheet: FGM in the serious crime Act 2015.

(9.04)NICE Guideline (2011) CG115. Alcohol use disorders, diagnosis assessment and management of harmful drinking

(9.01-9.0)

These are communication skills and the evidence should demonstrate this. Suitable evidence is:

Reflective practice

OSATS

CBD

Evidence of eLearning

These are relatively common scenarios and your evidence should be based on your direct clinical experience.

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assessmentand alcohol dependence.

(9.05) Communication of the risks of morbid obesity during pregnancy and childbirth.

1,2,3,4

(9.05) Knowledge of the risks associated with increased BMI in pregnancy and postpartum and how these may be minimised.

Knowledge of the steps that can be taken pre-pregnancy to reduce the risks of morbid obesity during pregnancy.

1,2

1,2

(9.05)Ability to quantify the risks during the pregnancy and minimise risks through use of thromboprophylaxis and support services.

Able to discuss harm minimisation constructively and provide accurate and accessible information.

Construct an individualised care pathway for labour and delivery.

1,2,3,4

1,2,3,4

1,2,3,4

(9.05)CMACE/RCOG Joint Guideline (2010) Management of women with obesity in pregnancy.

RCOG Patient information (2011) Why your weight matters during pregnancy and after birth.

STRATOG Advanced, Generic Skills Case Studies eLearning: Female obesity in obstetrics and gynaecology a primary care perspective (2015).

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assessment

(9.06) Care plan for previous stillbirth or adverse neonatal outcome.

(9.07) Debrief after stillbirth or adverse neonatal outcome.

1,2

1,2,3,4

(9.06-9.07)Construct a suitable care plan through an understanding of the aetiology of stillbirth and the future monitoring and management of such high-risk pregnancies.

1,2,3(9.07)Be able to communicate effectively and sensitively with colleagues, patients and relatives.

Be able to break bad news appropriately and support distress.

1,2,3,4

1,3,4

(9.06-9.07)RCOG Clinical Green Top Guideline No.31 Small for gestational age: fetus: investigation and management.

No. 55 (2010) Late intrauterine death and stillbirth.

RCOG Good Practice Guidelines No.4 Registration of stillbirth before 24 weeks and No.5 Disposal following pregnancy loss before 24 weeks.

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assessment

(9.08) Discuss child protection concerns within MDT.

1,2,3 (9.08)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.

Achieve minimization of harm in partnership with women.

Identify and deal appropriately with domestic violence and child protection issues.


(9.08)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).

1,2,3

1,2,3,4

1,2,3,4

1,2,3

1,2,3

1,2

1,2

(9.08)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.

1,2,3

1,2,3

1,2,3,4

1,2

1,2,3

1,2,3

1,2,3,4

1,2,3

(9.08)NICE Clinical guideline CG.89 (2009) When to suspect child maltreatment.

(9.08)Achieve a minimum of level 1 child protection competence.

Reflective practice within ePortfolio.

Governance (9.09) (9.09) (9.09-9.14) (9.09-9.14)

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assessment(9.09) Demonstrate effective reflective practice across a range of scenarios (attach supporting evidence).

(9.10) Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence).

(9.11) Lead Risk Management case review.

(9.12) Work effectively within the MDT.

(9.13) Know when and how to refer to support services (such as psychiatric, medical, social services, counselling)

(9.14) Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.

1,2,3

1,2

1,2,3

1,2,3

1,2,3

1,2,3

Understand the definition of reflective practice, and those models that may be used to support reflection

(9.11-9.14)Knowledge of team working: Team dynamics, with different roles and responsibilities for individual members.

Influences, both positive and negative, on team development.

Understand the principles of delivering effective support, mentoring and motivation.

Implementing changes and progressing as a team.

Leadership styles and behaviours.

1,2

1,2,3

1,2,3

1,2,3,4

1,2,3

1,3

Ability to use reflective practice to demonstrate positive changes learnt as a consequence of challenging clinic encounters.

1,2,3,4

RCOG Clinical Governance Advice No.1c Producing a clinical practice guideline.

No.2 Improving patient safety. Risk management for maternity and gynaecology.

No.5 Understanding Audit.

No.6 Obtaining valid consent.

GMC Leadership and Management for all doctors (2012)

GMC Good Medical Practice (2013).

Reflective practice.

Relevant Audit or other Quality Improvement Project.

Log of risk management cases.

ASM 9. Effective Communication and Clinical Governance Skills for High-Risk Pregnancy


34







Explain any implications for the pregnancy and childbirth for strongly held parental beliefs.

High risk for Fetal Genital Mutilation.

Early or pre-pregnancy counselling for on-going substance misuse.

Early or pre-pregnancy counselling for on-going maternal alcohol misuse.

Communication of the risks of morbid obesity during pregnancy and childbirth.

Care plan for previous stillbirth or adverse neonatal outcome.

Debrief after stillbirth or adverse neonatal outcome.

Discuss child protection concerns within MDT.

GovernanceDemonstrate effective reflective practice across a range of scenarios (attach supporting evidence).

Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence).

Lead Risk Management case review.

Work effectively within the MDT.

35







Know when and how to refer to support services (such as psychiatric, medical, social services, counselling)

Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.



36





Completion of ASM 9: Effective Communication and Clinical Governance Skills for High-Risk Pregnancy

Date Signature

The full range of communication, professionalism and governance skills have been demonstrated within the context of high-risk pregnancy.

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