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Midwifery in the Millenium: the Midwifery in the Millenium: the Role of the Advanced Midwifery Role of the Advanced Midwifery Practitioner in the promotion of Practitioner in the promotion of
normality.normality.
Sue Briggs, Angela Chapman, Michelle Sue Briggs, Angela Chapman, Michelle BarfordBarford
On behalf of the team at Diana, Princess of On behalf of the team at Diana, Princess of Wales Hospital, GrimsbyWales Hospital, Grimsby
Northern Lincolnshire and Goole NHS Northern Lincolnshire and Goole NHS Foundation TrustFoundation Trust
Advanced Midwifery Practitioner
The role was developed in order to continue to provide a comprehensive quality service following :
An acute service review and Trust merger Implementation of WTD reducing junior doctors hours Role reconfiguration for junior doctors Plans at that time to relocate maternity services at Grimsby First cohort commenced training in 2001
Evolvement of the Role
The Political climate continues to influence the scope of midwifery practice and boundaries of care are constantly evolving.
The NHS modernisation programme: NHS Plan (DoH, 2000)
Making a difference (DoH 1999) Ideology that encourages exploration of new midwifery
roles Vision 2000 (RCM 2000) Maternity Matters (DoH 2007) Safe births, everybody’s business (Kings Fund 2007) High quality care for all (Darzi 2008) Standards for maternity care (RCOG 2008)
Evolvement of the Role
It was envisaged that the Advanced Practitioner would: Build on and enhance the service Develop practice according to service needs Have a dynamic and constantly evolving role Strengthen relationships with medical colleagues by
having enhanced clinical, diagnostic and decision making skills
Be empowered to increase their knowledge and expertise in managing birth and focusing on “women centred care”
Who is the Advanced Midwifery Who is the Advanced Midwifery Practitioner (AMP)?Practitioner (AMP)?
The AMP is a midwifery clinician who can advance and develop clinical knowledge and skills to promote excellence in maternity care. She is an experienced Labour Co-ordinator
While being trained to an advanced level and able to
undertake activities and procedures traditionally practiced by Medical staff the AMP still has a large role to play in the promotion of normality within the maternity services.
Training
Academic training through local University
Initially input into A33 now Autonomous practitioner programme at degree level
Clinical training with input from Clinical supervisor – lead Consultant for Labour
Competency booklet developed locally
Support from rest of senior medical team and AMPs
What extra does the role encompass?
Input into medical rota 10 sessions/40 hours per week
Carry 2nd on call bleep instead of SHOResponse to emergencies 1st assistant in theatre Ventouse practitionerOrdering of investigations/initiation of
treatment/care planning
Role Development
The role extended beyond the Labour Ward into antenatal, postnatal and neonatal care e.g. maternal admission and discharge; patients reviews e.g. 1st day following operative/ instrumental delivery, examination of newborn
Seamless service, enhanced continuity of care. Guardian of promotion of normality whilst
acknowledging and responding appropriately when deviations from normal occur
Understanding clinical challenges and supporting all colleagues
Role of AMP in Promoting
Normality
Supporter and enabler of staff
Promotes staff development
Promote ‘midwifery’ values and a ‘women
centred‘ service
Is an advocate for mothers and
midwives
Contributes to EB guidelines that support
practice and promote normality
Refrains from undertaking interventions unless clinically indicated and evidence based.
Encourages the A/N education of women
Acts as a catalyst for change
A ‘Team’ player working in partnership with midwives, nurses & medical colleagues
Challenges the bio-medical care model
Educates and facilitates
Promotes research awareness
Leads developments in professional practice
Promotes midwifery skills “rooted in
normality”
““Personal Considerations”Personal Considerations”The Advance Midwife Practitioners Promote a culture of care viewing pregnancy & birth as normal
physiological processes.
Are “guardians” of normality of childbirth, whilst acknowledging & responding appropriately when deviations from normal occur.
Through professional collaboration challenge an overly medical model of care.
Remember their “midwifery roots”/ be an advocate for mothers & midwives.
Collaborate with Midwives & Medics to develop EB guidelines supporting practice that promotes normality.
““Working with mothers”Working with mothers”The AMPs support midwives to:
Identify low risk women & where appropriate promote home birth & MLC.
Help women to view vaginal birth more positively & have confidence in their ability to give birth, breastfeed & be a happy parent.
Provide informal Antenatal education that promotes normality & realistic expectations. e.g. VBAC
Inform women of alternatives to unnecessary medical interventions / work with them to make evidence based informed decisions about their care.
““Creating a conducive Environment”Creating a conducive Environment”The AMPs:-The AMPs:-
Promote a relaxed atmosphere conducive to
normality.
Encourage a “low tech” approach to reinforce concept of minimal intervention.
Maintain a “culture of normality” even when intervention is required, e.g. promote skin-skin following uncomplicated ventouse delivery.
““Clinical Practice”Clinical Practice”The AMPs promote normality by:
Encouraging & supporting less intervention.
Support 1-1 labour care & continuity of care and carer.
Encouraging non supine positions in labour & mobilisation.
Discouraging inappropriate use of EFM Encouraging & supporting IA via Pinnards / doppler. (NICE, 2001)
Encouraging midwives to “get back to basics” by advocating good pressure area, bladder & perineal care.
Encouraging & supporting use of non-pharmacological methods of pain relief and coping mechanisms - relaxation, Tens, birthing ball, use of water / birthing pool.
Encouraging appropriate hydration / nutrition.
Supporting physiological management of 3rd stage of labour for low risk women.
Encouraging early skin - skin contact & breastfeeding support
Encouraging midwives to get mothers not in established labour / pre- lab ROM home
Encourage planned early discharge for low risk mothers (possibly facilitated by AMP/midwife discharge exam of newborn).
EducationalistsEducationalistsThe AMPsThe AMPs
Utilise opportunities for informal teaching.
Are proactive towards multidisciplinary education.
Educate staff about the AMP role (not just for the “abnormal”)
Promote mothers/ midwives educational resources that focus on normality
Facilitate the acquisition of skills/ knowledge in the care of normal low risk mothers.
Remind midwives that “1 intervention leads to another!”
Educationalists cont
The AMPs are actively involved in the in-house training programme which is multidisciplinary
CTGNeonatal resusObstetric emergencies including drillsHCA training
Staff DevelopmentStaff DevelopmentThe AMPs:-The AMPs:-
Lead & support the developing role of midwives in line with unit philosophy e.g. LDRP & Midwifery led care.
Empower Midwives to have confidence in their ability to manage normal birth using a “ low tech” approach.
Promote discussion around low intervention for low risk women.
Encourage Midwives to think critically & reflect on practice.
Support staff to question & change practice.
Research and AuditResearch and AuditThe AMPs promote normality by:-The AMPs promote normality by:-
Keeping up to date with contemporary issues that focus on normality.
Critically appraising the evidence base for midwifery knowledge & practice.
Considering other National / International
perspectives of care / practice.
Encouraging research awareness
Auditing , reviewing & reflecting on practice.
On going Training for AMPs
Regular update in ventouse delivery
ALSO refresher
NLS training
Perineal repair training
An overview of the AMP role in promoting normality An overview of the AMP role in promoting normality
Clinical &ProfessionalBe a visible, credible, role model
Support practice that promotes normality
Lead new initiatives to support normality.
Promote birth as “normal” life event.
CommunicationMaintain a good relationship with multidisciplinary team & network.Be an advocate for mothers and midwives.
Help develop supportive EB guidelines.
Facilitate mothers to make informed choice.
EducationUndertake formal/ informal teaching.
Act as a resource for staff
Facilitate the acquisition of skills/ knowledge in care of low risk mothers.
Remind midwives “One intervention leads to another”
Research & AuditCritically appraise research evidence
Encourage research awareness.
Keep up to date with contemporary issues.
Audit practice & review & reflect.
The effects are clear to see
Reduced CS rates 17.1% 2009 (16.3% 2008) SVD rate 71.2% 2009 (70% 2008) Birthrate plus in 2009 - 45.9% of all births in the
unit within the I and II category which is stated in the report as being “significantly higher than found in many units in England.”
Excellent working relationships with senior medical staff . True Team approach
The Effects cont
Support for junior doctors
Seamless approach to doctors rotation
Challenge practice e.g. induction of labour
Only undertake necessary investigations
Keep a record of cases
Acknowledgements
Special thanks to Sara Butcher for giving us the presentation and allowing us to adapt and add to it
The rest of the AMP team at DPOW Sara Butcher, Jeanette Rowe and Brenda Waite
The other Co-ordinators Tracy Martin and Carol Horsley The Consultants; Werner Mueller, Ian Stuart, Arabinda Saha, Ibrahim
Bolaji, Silas Gimba and Mahadeeva Manohar Staff Grades; Shanka Gangophady and Nasser Mohammed Sheila Youssef Acting HoM, PSM Obs, Gynae & Sexual Health The Midwives at DPOW, NLAG