SECOND EDITION
Advanced Life Support Group
EDITED BY
Mark Woolcock
This edition first published 2019 © 2019 by John Wiley & Sons Ltd
Edition History
Wiley‐Blackwell (1e, 2009)
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Cover images: © ideabug/iStockphoto; Jade and Bertrand Maitre/Getty Images; sturti/Getty Images; Mark Woolcock, NHS Cornwall 111
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| Sam Fournier | Paramedic, Educator, Ecole Supérieure d'Ambulancier et Soins d'Urgence Romande, Lausanne, Switzerland |
| Kim Hinshaw | FRCOG |
| Consultant Obstetrician and Gynaecologist, Director of Research & Innovation, City Hospitals Sunderland NHS Foundation Trust | |
| Visiting Professor, University of Sunderland | |
| Paul Holmes | MRCOG |
| Consultant Obstetrician and Gynaecologist, NHS Forth Valley | |
| Denise Mace | MSc Advanced Clinical Practice, BSc(Hons) Midwifery |
| Delivery Suite Coordinator, City Hospitals Sunderland NHS Foundation Trust | |
| Faye Rodger | FRCOG |
| Consultant Obstetrician and Gynaecologist, NHS Borders | |
| Fiona Scarlett | BSc (Hons) Healthcare Practice, MCPara |
| Emergency Practitioner (Paramedic), Surrey and Sussex Healthcare NHS Trust | |
| Helen Simpson | MRCOG |
| Consultant Obstetrician, South Tees Hospitals NHS Foundation Trust | |
| Martin Smith | FRCEM |
| Consultant Emergency Medicine, Salford Royal NHS Foundation Trust, Salford | |
| Martin Thomas | MD FRCS(A&E)Ed. MRCP FRCEM |
| Consultant in Emergency Medicine, Emergency Department, Salford Royal NHS Foundation Trust, Salford | |
| Aarti Ullal | MRCOG |
| Consultant Obstetrician and Gynaecologist, City Hospitals Sunderland NHS Foundation Trust | |
| Susan Wieteska | CEO, Advanced Life Support Group, Manchester |
| Mark Woolcock | Consultant Paramedic, Cornwall |
Contributors to second edition
| Sally Buller | Registered Nurse RM Registered Midwife RM |
| Senior Specialist Midwife/Project lead for Maternity notes, Perinatal Institute | |
| Brigid Hayden | FRCOG |
| Obstetrician & Gynaecologist, Member of MOET Working Group, Member of POET Working Group | |
| Amanda Mansfield | Consultant Midwife |
| Medical Directorate, London Ambulance Service | |
| Jonathan Wyllie | FRCPCH FRCP |
| Professor of Neonatology and Paediatrics, University of Durham | |
| Consultant Neonatologist, Clinical Director of Neonatology, South Tees NHS Foundation Trust | |
| Vice President Resuscitation Council UK |
Contributors to first edition
| Sally Evans | Midwifery, Middlesbrough |
| Kim Hinshaw | Obstetrics and Gynaecology, Sunderland |
| Helen Simpson | Obstetrics and Gynaecology, Middlesbrough |
| Mark Woolcock | Pre‐Hospital Care, Truro |
| Malcolm Woollard | Pre‐Hospital Care, Coventry |
| Jonathan Wyllie | Neonatology, Middlesbrough |
With thanks to our families and friends for their tolerance, support and understanding during the review and rewriting of this second edition manual and its associated course.
I am privileged to have been asked to write this introduction to the second edition of the POET manual. Over the last 9 years POET has offered pragmatic advice and skills training to a wide range of practitioners working in the pre‐hospital environment. The manual and course encompass the full range of situations found in maternity care, from normal delivery to complex antenatal and intrapartum complications which put both the mother and fetus at risk.
In total more than 1500 professionals have benefited from this training and this has included paramedics, ambulance technicians, midwives, emergency department teams, primary care physicians and others. The first edition of the manual has been translated into Polish (2011) and Japanese (2014) and courses are run regularly in the UK, the Netherlands and Switzerland under the auspices of the Advanced Life Support Group (ALSG), Manchester, UK. The Working Group is also multi‐national with members from across the UK and Europe. Experienced faculty now includes ambulance personnel working closely with obstetricians, neonatologists and midwives to deliver high‐quality practical training to increase both confidence and skills to the multidisciplinary team in the pre‐hospital setting. The dedication of faculty ensures the ongoing success of the course, with many teaching enthusiastically in their own time.
The manual has been comprehensively updated. It now includes a review of the UK maternal mortality reports produced annually by MBRRACE (https://www.npeu.ox.ac.uk/mbrrace‐uk) and highlights the importance of non‐technical skills (clear communication, decision making and team working) in the area of pre‐hospital maternity care. This new edition continues to offer clear and practical advice to all professionals involved in pre‐hospital maternity care – congratulations to the wider POET team.
Many people have worked hard to produce this book and the accompanying course. The editor thanks all the contributors for their efforts and all POET providers and instructors who took the time to send their comments during the reviews of the text and the course, in particular Brigid Hayden who completed a very detailed review of the manual.
We are all greatly indebted to Kate Wieteska for producing the line drawings that illustrate the text, and Kirsten Baxter at ALSG for her support and organisational skills. We thank the ALSG/CAI Emergency Maternal and Child Health (EMCH) programme, the ALSG Managing Obstetric Emergencies and Trauma (MOET) course and the Resuscitation Council for the shared use of some of their line drawings and algorithms. We gratefully acknowledge the written information and guidance received from the Perinatal Institute. Also, we thank the Consultant Midwife Amanda Mansfield from London Ambulance Service and Matthew Davis Clinical Fellow in Primary Care from South Western Ambulance Service for sharing their organisations’ photographs.
We would like to thank all of those in advance who attend the POET course and others using this text for their continued constructive comments regarding the future development of both the course and the manual.
2009…
Looking back at the preface to the first edition, a clear picture was painted depicting a distinct gap in the paramedic curriculum and the paucity of exposure to bespoke obstetric training and education. The 2009 manual was thus intended to support those working in the pre‐hospital arena. The principles were set firmly in the didactic realms of paramedic practice and whilst this assisted those working in the 999 services, it had less appeal to other healthcare professionals working in unscheduled and urgent care settings, and an increasing amount who worked ‘in‐hospital’.
Some 9 years later, the paradigmatic shift of paramedic education from in‐house training schools to academic institutions is producing highly autonomous, degree‐educated practitioners who demand detailed, evidence‐based texts and materials to underpin focused learning.
Concurrently, the centralisation of obstetric services has placed an increasing requirement on Emergency Department staff to manage patients with obstetric emergencies without any specialised cover. The need has never been greater for a multidisciplinary course that prepares healthcare professionals to promptly recognise and effectively manage a wide range of obstetric emergencies.
Now…
As hinted above, the term ‘pre‐hospital’ in the title of the manual and course suggested a narrow field of practice. The working group has spent many hours debating what the most descriptive title would be, enabling immediate acknowledgement of what and whom this manual is for. It was tremendously difficult to settle on a title that recognises midwives, paramedics, nurses and doctors, who may encounter patients in their own houses, in ambulances or in hospitals without any obstetric services. It was decided that the term ‘pre‐obstetric emergency training’ was most encompassing and would provide guidance for managing patients when no obstetric staff or facilities were available.
The future…
The face of modern healthcare is changing rapidly. In primary care and out‐of‐hours services, the models are now GP lead as opposed to exclusively GP delivered and the use of advanced nurse and paramedic practitioners is burgeoning. It is expected that within the next 5 years one‐third of all registered paramedics will be working outside of ambulance trusts in a range of settings and roles never previously associated with this profession.
The second edition manual, the updated course and powerful e‐learning have all been updated and revamped to assist the modern generalist clinician develop confidence when dealing with specialist situations, building a foundation for future safe practice.
Pre‐hospital obstetric incidents make up a significant proportion of the more costly litigation claims against UK ambulance services. These claims are based either on an alleged failure to identify and manage a problem or lack of appropriate equipment for the treatment of a preterm baby.
For a number of years after the UK national paramedic curriculum was introduced in the UK, it included no specific training on the management of obstetric emergencies at an ‘advanced life support’ level. Most staff received only a half‐day of lectures during their initial ambulance technician training at the beginning of their career. Since 1999, advanced obstetrics and gynaecology became a mandatory part of the paramedic course for new entrants but with the expectation that existing paramedics would receive update training. Our experience has indicated, however, that paramedics in many parts of the UK have not had the opportunity to do so.
A confidential enquiry into maternal and child health (CEMACH) report has indicated that many of the pregnant women dying ‘had chaotic lifestyles and found it hard to engage with maternity services’. The ambulance service may be the initial contact with the health service for these patients and their peers who become unwell but are fortunate enough to survive. The CEMACH report identifies the need for a widened awareness of the risk factors and early signs and symptoms of potentially serious problems in pregnancy, and makes a number of key recommendations that could be addressed in part by appropriately trained pre‐hospital practitioners. For example, it states:
All clinical staff must undertake regular, written, documented and audited training for:
There is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance.
This manual and its associated Advanced Life Support Group training course (also called POET) hope to meet these educational needs for a range of pre‐hospital practitioners. Both the text and the course have been developed by a multi‐disciplinary team of senior paramedics, consultant obstetricians and midwives, all of whom are practicing clinicians and experienced educators. POET course teaching teams have a similar multi‐professional membership with a shared philosophy of combining pre‐hospital and obstetric expertise. Although we anticipate that paramedics and pre‐hospital physicians will make up the bulk of our readership and course candidates, POET will also be of value to nurses working in walk‐in and unscheduled care centres and to midwives and to GPs – particularly those working at a distance from further support.
It is our sincere hope that POET will build the confidence and competence of pre‐hospital practitioners and thus contribute to reducing the incidence of maternal and fetal mortality and morbidity.
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:
Advanced Life Support Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0) 161 794 1999
Fax: +44 (0) 161 794 9111
Email: enquiries@alsg.org
The material contained within this book is updated on approximately a four‐yearly cycle. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for updates (www.alsg.org/uk/poet).
To access references visit the ALSG website www.alsg.org – references are on the course pages. To access country‐specific Legal and Ethical Issues for POET, visit the ALSG website www.alsg.org/legal.
It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after his or her course has taken place asking for on‐line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants.
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Around 700 000 women a year use obstetric services. The birth rate in the United Kingdom (UK) has slowed in recent years following a rise throughout the last decade. Multidisciplinary teams provide maternity services with midwifery and obstetric medical staff working together to provide optimal care. Community midwives perform the majority of care in the out‐of‐hospital setting. Inpatient antenatal care is now uncommon and not usually for long periods. Similarly, the postnatal length of stay for all women, including those delivered by caesarean section, has been reduced with the majority of care occurring in the community.
General practitioners (GPs) have in recent years become less and less involved in all aspects of pregnancy care, although there are still a small number who are involved in care in labour.
The Maternity Matters report confirmed that women should be the central focus of obstetric care, emphasising the need for those providing obstetric services to support women in making informed choices and to provide easy access to care (DoH, 2007). Women undergo a risk assessment prior to delivery to help them choose where to deliver. This assessment is undertaken by their midwife in conjunction with medical staff, if required, and will involve assessment of previous medical history, previous obstetric history and the progress of the current pregnancy. The women will then be offered advice to help them choose the place of birth.
A woman may choose to have a home birth; deliver in a midwife‐led unit, which may be either ‘stand‐alone’ or attached to a consultant‐led unit (co‐located); or deliver in a consultant‐led unit. Women may also choose to ‘free birth’: a growing phenomenon in which the baby is delivered unassisted and unattended by a healthcare professional. Whilst this is perfectly legal, one should note it is illegal for someone without midwifery qualifications to assist in the birth unless in an emergency.
The 2011 Birthplace in England study identified that nulliparous women (those having their first baby) were more at risk for adverse perinatal outcomes (stillbirth, neonatal encephalopathy, brachial plexus injury, clavicle fracture, etc.) with a planned home birth than multiparous women (BECG, 2011). There was no statistical increase in risk for adverse outcomes for nulliparous women delivering in a midwife‐led unit. It was found that for multiparous women, there is no increased risk for adverse outcomes between each planned place of delivery. It was also found that women who plan to deliver at home or in a midwife‐led unit are more likely to have a ‘natural’ birth with reduced interventions compared with those who deliver in an obstetric unit. Choosing an appropriate place of delivery relies on effective communication between healthcare professionals and women regarding any specific risk factors.
In the majority of cases, women choose the appropriate place to deliver their baby. Midwives have a duty of care to support the woman’s final choice of place for delivery even if there are factors that make this a high‐risk decision. Occasionally this causes difficulties, for example, in home delivery where access is poor, there is no phone signal or the home environment is less than ideal. Some women with a high‐risk pregnancy also request home delivery. As long as the woman has capacity (see Chapter 2), is informed of the risks to herself and her baby and is not under duress, she is entitled to make that decision.
The majority of deliveries are uncomplicated, however the national caesarean section rate is 26.2% of births. In contrast, the rate in 1990 was only 12%. Caesarean section delivery requires major surgery and can have significant associated risks for both mother and baby.
Transfer may be necessary where risk factors develop before or during labour and after birth that necessitate moving the woman or baby from one location to another. Transfer may be required from all places of delivery.
In the 2011 Birthplace in England study, it was found that for the three non‐obstetric unit settings (home, stand‐alone midwifery unit and co‐located midwifery unit), transfer rates were much higher for nulliparous women (36–45%) than for multiparous women (9–13%).
Common reasons for transfer from home or from a midwife‐led unit are concerns about the progress of labour, fetal or maternal well‐being, or neonatal well‐being. A common reason for transfer between consultant‐led obstetric units is the need to access a neonatal cot for the baby either because the unit they are in does not have the appropriate neonatal facilities or all the cots are full. In these situations, the outcome is better for the baby if they are transferred while still in utero rather than after delivery. Occasionally, women need to be moved to other units for maternal specialist care.
Generally, a midwife (or medical staff) will accompany the woman and will be an invaluable source of advice and knowledge if problems occur during transfer. See Table 1.1 for the roles undertaken by clinical staff.
Table 1.1 Roles of healthcare staff
| Paramedic | Midwife | GP (if on scene) | Obstetrician (via telephone) | |
| Clinical condition | Assess | Assess | Assess | |
| Initiate holding treatment | Advanced life support (ALS) Obstetric support |
Assist with ALS Obstetric expertise |
Assist with ALS Obstetric support* |
Advise on treatment |
| Transfer | Provide transportation Liaise with receiving unit Confirm exact location of receiving obstetric unit within hospital |
Advise on most appropriate receiving unit Liaise with receiving unit Advise on timing/need for transfer |
Advise on most appropriate receiving unit Liaise with referring crew Advise on timing/need for transfer |
|
| Advice | Transportation options/positioning in the ambulance | Obstetric expertise | General issues | Obstetric expertise |
*Some GPs have specific expertise in obstetrics.
Further information on the management of inter‐hospital transfers generally and neonatal transfers specifically can be found in the Neonatal Adult Paediatric Safe Transfer and Retrieval (NAPSTaR) manual (Fortune et al., 2019).
These depend on local policies. Obstetric patients are usually admitted directly to the obstetric service via a triage assessment unit or delivery suite. In the case of major trauma, obstetric patients should be transferred to the emergency department or major trauma centre depending on the systems in place locally. In the case of medical problems admit via urgent care pathways.
In many units, women with problems in early pregnancy will be admitted to the gynaecology department via an early pregnancy assessment unit.
Most maternity units in the UK provide women with their own maternity hand‐held notes. Figure 1.1 shows an example of the national pregnancy notes that are currently used by approximately 60% of obstetric units in England (produced by the Perinatal Institute www.preg.info; accessed February 2018).
Figure 1.1 Example of national patient hand‐held records.
(Reproduced with kind permission of the Perinatal Institute)
The pregnancy notes aim to facilitate a partnership between the mother, her family and the care provider, placing emphasis on patient safety and informed choice. They are designed to ‘support comprehensive history taking, promote effective communication between the mother and the multidisciplinary care team and between members of that team’. The notes are given to the woman by her midwife at her booking appointment in early pregnancy, enabling the expectant mother and her family to be informed and involved in decisions that affect her and her baby. To deal with special issues during pregnancy, a personalised management plan will outline specific outline specific treatment and care agreed between the mother and her care team. This plan will be reviewed at each antenatal contact and updated if the mother’s risks/needs change.
The woman’s medical/obstetric and social details are available to all healthcare professionals who may care for her during her pregnancy.
The notes enable effective communication within the multidisciplinary team, including ambulance clinicians who may attend the woman in her home or the community. All clinicians should document clinical care in these notes when they attend a woman during pregnancy if she is not transferred. Contemporaneous record keeping is a fundamental component of good clinical practice. Therefore the hand‐held pregnancy notes are an important link for healthcare professionals to improve care and reduce error.
Although there is variation in maternity hand‐held notes throughout the UK, the same general principles apply throughout:
It is paramount that the hand‐held notes accompany the woman for all hospital admissions and routine antenatal visits. However, the notes may not have been issued to a woman in very early pregnancy if she has not booked through her midwife.