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Catherine Robinson and Cathy Armstrong

Introduction

In addition to the central role of training anaesthetic trainees in obstetric anaesthesia, working on the delivery unit presents many opportunities for the anaesthetist to become involved in education of the multidisciplinary team. Areas of education particularly pertinent to the skills and expertise of anaesthetists are:

Training midwives and junior doctors in delivering critical care on the delivery unit and recognition and management of the sick parturient
Skills/drills or simulation team training for emergencies on the delivery unit
‘Pain relief for childbirth’ education for midwives, including regional analgesia/anaesthesia.

One of the main challenges in education provision on the delivery unit is the ability to allocate adequate time for staff, away from clinical duties, to attend training. It is known that when units are busy and understaffed, staff are unable to take up scheduled teaching sessions. Anaesthetists should help champion education needs at management level and also consider strategies to deliver education in novel ways that can be accessed more flexibly, for example, with e-learning packages or video podcasts of lectures.

Education on the sick parturient

Care of the sick parturient on the obstetric unit has been closely examined in recent years. Recurrent themes in the triennial reports from the Centre for Maternal and Child Enquiries (CMACE) have included:

Late recognition by midwifery and medical staff of the seriously unwell woman
Inadequate and infrequent performance of basic observations
Inappropriate or no action taken in women found to have abnormal observations.

Obstetric anaesthetists should be prominent in the education of midwives and junior doctors in the recognition and management of the critically ill obstetric patient.

Midwives must be able to accurately measure and record observations, recognize when they are abnormal and alert the appropriate staff. Many midwives now qualify after a direct-entry degree course and often have had no prior general nursing exposure. While skilled in many areas of parturient management, they often lack the experience of caring for sick medical or surgical patients, and may have an incomplete understanding of the relevance of abnormal physiological observations. The current undergraduate midwifery courses focus mainly on well women, with less emphasis on sick patients or those with pre-existing medical conditions. Future curriculum development within undergraduate midwifery training should aim to address this.

With the 2011 document: ‘Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman’ (see Further reading), we now have national guidance on the competencies required for midwifery and medical staff caring for critically ill obstetric patients. Critically ill parturients should have the same standard of care, whether in a general critical care unit or a maternity unit. Midwives and medical staff on the delivery unit must have the competencies outlined in the Department of Health document ‘Competencies for Recognising and Responding to Acutely Ill Patients in Hospital’.

These competencies are wide-ranging and require significant educational input. Courses on acute illness recognition and management have been developed, which can help units achieve some of these staff competencies, but to cover all of them requires a co-ordinated educational strategy. These acute care competencies are not specific to obstetrics, so training on specific obstetric problems and management of medical illness during pregnancy needs to be incorporated into the training provided. There are also practical skills outlined in the document which may be best taught and assessed by in-house hospital training (Table 27.1).

Table 27.1 Suggested minimum acute care practical skill competencies to be undertaken by midwives (those in italics could be taught to a subgroup of ‘maternal critical care trained midwives’)

System	Practical skill
Cardiovascular	Can set up 3-lead ECG monitoring Can perform a 12-lead ECG Successfully completed arterial line competencies including: assisting with insertion, checking components of arterial line system, checking for complications, common causes of inaccuracy Taking out arterial lines Successfully completed central venous line competencies including: assisting with insertion, checking components of CVP line system, checking for complications, common causes of inaccuracy. Taking out CVP lines
Respiratory	Can set up and administer oxygen via: non-rebreathing mask, MC mask, nasal cannulae Can set up and administer nebulized medication Can set up, check and use suction equipment including portable suction Can perform peak flow monitoring (PEFR) and act on abnormality Can set up, check and use equipment for administering humidified oxygen
Renal	Can accurately complete fluid balance chart
Neurological	Can complete basic neurological observations, including pupillary responses and conscious level (AVPU or GCS), recognize and act on abnormality
Haematological	Completed local blood administration competencies
Communication	Gives structured handover of acutely unwell patient, including clear communication of management plan

The training required for midwifery and medical staff caring for the acutely unwell parturient can be provided with a combination of the following:

Courses on acute illness recognition and management
Maternal early warning score training
Life support training
Specific obstetric critical care training courses: formal courses available, some with postgraduate qualification or in-house formal obstetric critical care training
Communication training
Obstetric emergencies training: skills/drills training, simulation training
Practical skills teaching (see Table 27.1).

All midwifery and junior medical staff need to be competent in the recognition and management of the acutely unwell parturient, management of obstetric emergencies and life support in the pregnant woman. A subset of midwives should be given further formal training in care of the critically ill woman on the delivery unit, including competence in caring for women with invasive monitoring.

A designated group of clinicians (obstetric, anaesthetic, midwifery and critical care) need to take on the role of facilitating this training and ensuring that the competencies are met. Ongoing audit is essential to identify how many staff have achieved these competencies. The Department of Health document states that there should be a board-level sponsor for the implementation of these competencies. Support at senior management level is essential to facilitate the provision of time and resources for the competencies to be achieved.

Obstetric early warning scores

A top 10 recommendation in the 2003–2005 CMACE report was to introduce a specific early warning score system for obstetric patients, in order to aid detection of the patient who is becoming unwell, and trigger the appropriate response.

Early warning scores (EWS) were introduced over 10 years ago in the non-obstetric setting. It is known that physiological abnormalities are a marker for clinical deterioration. A ‘track and trigger’ early warning score system consists of periodic recording of a set of physiological variables, such as heart rate, respiratory rate, blood pressure, temperature (track) with pre-defined criteria then triggering an appropriate response, i.e. the right personnel attending within an agreed time frame.

Non-obstetric EWS are not appropriate for the obstetric population as the normal physiological changes of pregnancy would result in inappropriate triggering. Scores must also be altered to detect pathology specific to the parturient, such as pre-eclampsia.

There is potential for any woman to be at risk of physiological deterioration in the peripartum period, this cannot always be predicted. ‘Equity in Critical Care’ recommends that all women have physiological observations done on admission. Following labour and delivery, observations should be done a minimum of 12-hourly.

Over the last few years, many obstetric units across the UK have independently introduced modified early warning scores for obstetric patients (MEOWS). This has unfortunately resulted in a wide variety of charts being used throughout the country – some using a colour-coded scheme and others producing a numerical aggregate score that determines the response triggered. The physiological variables included also vary: most systems track heart rate, respiratory rate, blood pressure and temperature. Some also include urine output, oxygen saturations, pain score and conscious level.

This lack of consistency in early warning systems between hospitals can cause confusion and is a potential patient safety issue. Movement of staff between hospitals necessitates further education on the new track and trigger system. This same problem occurred in the non-obstetric setting and resulted in the development of a National Early Warning Score (NEWS), launched in 2012 (see Further reading). This means training can be standardized and national education training tools set up – the NEWS e-learning package can be accessed for free.

Most obstetric early warning scores have not yet been validated, but Singh et al. have studied the validity of the obstetric early warning score system recommended by CEMACH and found that the system had good sensitivity and reasonable specificity for predicting morbidity in obstetric patients.

Agreement on a national obstetric early warning score would be welcomed. A standardized training program similar to the NEWS on-line training package would equip staff with transferable skills and avoid duplication of training if a healthcare professional moves hospital.

MEOWS training for midwives and medical staff needs to include:

How to accurately measure and document observations
Clinical relevance of abnormal physiological observations
How to calculate overall MEOWS score
Ability to trigger an appropriate response, including correct personnel contacted to review in an appropriate time frame and changes to the frequency of observations if indicated
What to do if MEWS reassuring, but staff member still concerned about patient.

When teaching staff about the track and trigger system it must be emphasized that a full set of observations must be completed to produce an accurate score and that once the patient has triggered then a response must be activated.

Early warning scores may help in the early recognition of the sick obstetric patient, but we must teach the midwives and junior medical staff not to be totally reliant on them. Early warning scores shouldn’t replace thinking about the whole clinical picture. Most pregnant women initially compensate well physiologically so may have a falsely reassuring early warning score. Women with any concerning symptoms or signs need full assessment, even if their early warning score is normal.

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