NHS Borders clinical guidelines
- Suspected fetal compromise
- Cord prolapse
Assisted Birth Practitioner (ABP) Midwife - Guideline
Warning
Objectives
The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the post-partum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant, Nursing and Midwifery Council (NMC) 2018. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.
As skilled, experienced midwives the Assisted Birth Practitioner (ABP) Midwives will use their expertise to safely facilitate spontaneous vaginal delivery where appropriate whilst having the necessary skills to perform ventouse/vacuum/kiwi deliveries if the clinical scenario dictates. ABP midwives must adhere to the unit guidelines and standard operating procedures at all times and work within the standards set out by the NMC in The Code, Standards for Competence for Registered Midwives (NMC 2018) This document complies with the need for the employing authority to have a locally agreed guideline, which meets the NMC standards. It should be reviewed triennially or sooner as changes dictate.
This guideline must only operate in circumstances where the role can reasonably be performed without compromising the midwife’s usual responsibilities.
These guidelines and a signatory form for each midwife assisted birth practitioner should be filed in the personnel record along with a copy of the qualification.
Training
While the practitioner is training, she must be enrolled on an approved course and work under medical or qualified Assisted Birth Practitioner supervision. This may be either direct or indirect according to her acquired knowledge and skills. A mentor / assessor will be appointed and will determine and agree the level of clinical supervision required with the trainee ABP midwife as training progresses. The trainee and qualified Assisted Birth practitioner can accompany the Consultant Obstetrician to theatre for training opportunities. A specific SOP for the ABP trainee undertaking Forceps deliveries has developed.
Qualification
The midwife must have successfully completed a recognized training course to become an Assisted Birth Practitioner. She must have a certificate or other proof of completion, indicating that she has competence in the knowledge, experience and skills necessary to use the instruments and manage the complications that may arise.
Duties/Responsibilities
A full job description for this advanced clinical role is embedded in this document. It is recognized that ABP midwives are highly skilled, have developed specialist knowledge, and possess advanced clinical decision making skills, which are utilized across clinical boundaries between medical and midwifery care. This allows the post holder to take on some of the roles and responsibilities of the middle grade medical staff.
Maintaining Competence
After qualification, the ABP midwife must continue to keep evidence of ongoing professional development for this role by maintaining a personal logbook of cases to aid reflective practice. The ABP midwife will continue to have access to medical mentorship, guidance and clinical supervision as required. At least annually, an appropriately qualified medical practitioner will undertake a competency review of instrumental delivery (ventouse) and an assessment of continued competence made (Appendix 1) and recorded in e-portfolio/TURAS.
Role Development
The ABP midwife role was introduced in NHS Borders in 2010. As new skills/procedures are identified as necessary or desirable for the ABP midwife it is important that the following process be adopted prior to new skills being practiced;
- The rationale for each skill/procedure should be discussed with the Lead Consultant and Head of Midwifery
- The skill/procedure should be added to Appendix 1
- A training plan should be developed in conjunction with the Lead Consultant and Head of Midwifery
- All theory and teaching practice should be documented.
- Final assessment should be undertaken and signed off by medical mentor and a record retained in the ABP personal log.
- A standard operational procedure (SOP) should be adopted and published on the intranet
- Completion of training log (Appendix 1)
- In view of the dynamic nature of the role, it is recommended that the ABP team meet with the SCM twice yearly
- Maternal exhaustion
- Prolonged second stage
- Failure to progress in second stage
- Malpresentation
- The position of the fetal head is unknown
- Incomplete dilatation of the cervix
- The vertex is more than 1/5th palpable abdominally
- Fetal clotting disorders
- Inability to achieve correct application
- In gestation < 36 weeks because of the risk of intracranial haemorrhage
- In face presentation
- If there is a significant degree of caput that may preclude correct placement of the cup.
- 36 completed weeks
- Cephalic presentation
- Singleton
- Vertex (fully engaged) i.e. 1/5th or 0/5ths palpable
- Membranes ruptured
- Good contractions
- Vertex 1cm below the ischial spines
- Well flexed vertex
- Cervical os –fully dilated
- Bladder emptied
- Position – occipito anterior
- No moulding and degree of caput noted
- Adequate analgesia
- Verbal consent obtained
The practitioner may choose vacuum extraction according to the clinical circumstances, advantages of each technique and clinical competencies. If a forceps is deemed more appropriate this should be performed by an appropriately trained medical practitioner.
Using the acronym ABCDEFGHIJ, promoted by the Advanced Life Support in Obstetrics (ALSO 2010) program, is recommended.
A: address the woman. Explaining briefly the reasons for the procedure and that her participation in her expulsive efforts is an integral part of the procedure. Verbal consent should be obtained.
A: abdominal palpation – Vertex (fully engaged) i.e. 1/5th or 0/5ths palpable.
A: adequate analgesia can be achieved using local infiltration, pudendal block or epidural top up
The perineum should be prepared and cleaned using aseptic technique.
B: bladder is catheterized.
C: cervix must be completely dilated.
D:define position (should be well flexed occipito anterior) and confirm the flexion point. Assess station of the presenting part and the degree of caput on the head. In known occipitoposterior (OP) position, the consultant must be present.
E: equipment ready.
F: posterior fontanelle. The outside of the cup is smeared lightly with obstetric cream and the perineum retracted with two fingers. The cup is then inserted gently, in-between a contraction, over the saggital suture, to the flexion point. This is located on the sagittal suture, 3cms in front of the posterior fontanelle. The operator checks that there is no vaginal tissue trapped and the vacuum pressure is increased to 0.2kg/cm2 (yellow zone). Again, the operator must check that there is no vaginal tissue trapped and then increases the pressure to 0.8kg/cm2 (green zone).
G: gentle steady traction is applied at right angles to the cup, the axis of traction following the pelvic curve. This can commence as soon as a contraction starts and the mother encouraged to push. During this period, the operator should be using one hand for traction and the other to monitor descent. Traction is discontinued between contractions and if an audible, hissing is heard, as this signal’s loss of vacuum and imminent cup detachment. If detachment occurs, the cup can be replaced only if the operator is sure that there is no cephalo-pelvic disproportion and that the scalp has not been injured.
H: halt and ask for help if no descent with first traction or the cup detaches more than twice.
I: evaluate for incision.
J: release the pressure valve when the jaw is visible, deliver onto the mothers abdomen deliver the placenta and repair any vaginal trauma.
The mother should be debriefed and reassured that the chignon is a harmless swelling and will resolve in a few hours. Details of the procedure, maternal and fetal outcome should be documented and signed by the operator.
The attempt at instrumental vaginal delivery should be abandoned if:
- there is difficulty in applying the instrument
- there is no descent with first traction
- delivery is not imminent following three pulls of a correctly applied instrument
Situational awareness is important and to avoid errors, all members of the team must maintain awareness by communicating with each other. This will help to ensure that guidelines are followed, equipment is in working in order and safe delivery is achieved.
Good record keeping is important for audit, risk management and medico-legal purposes; therefore, the following should be documented for each instrumental delivery:
- indications for intervention
- consent
- fifths palpable (abdominal examination)
- degree of moulding
- adequacy of maternal pelvis
- fetal heart rate
- assessment of uterine contractions
- ease of application of instruments
- number of pulls
- number of detachments
- duration of instrumentation
In order to facilitate reflective practice and audit, the practitioner should keep a log of;
- all assisted births
- potential assisted births
- case based discussions
- direct observational procedures
- annual operative vaginal delivery
The practitioner will undertake clinical supervision sessions with middle grade or consultant obstetric staff or with other ABP’s.
The practitioner will provide expertise, advice and guidance to the midwifery team in accordance with unit guideline and under the clinical supervision of the Obstetric Consultant.