Pre-hospital obstetric incidents account for a significant number of emergency calls to the ambulance service, with obstetric emergencies being one of the most challenging situations that pre-hospital practitioners encounter. The mortality associated to obstetric emergencies has shown significant decline over recent years due to improved obstetric education, advances in surgery and improved maternal care. Additionally, the development of the Confidential Enquiry into Maternal and Child Health (CEMACH) has identified patterns of sub-optimal practice and has provided recommendations on how to improve the maternity services and obstetric care available to all pregnant patients. One of the most influential recommendations to come out of this document was the apparent need to improve education of basic, intermediate and advanced life support in obstetric emergencies, which lead to the introduction of advanced obstetrics and gynaecology becoming compulsory elements within the paramedic curriculum. The need for organisation and ambulance trusts to provide specialist training into obstetric emergencies was also identified within this enquiry (Confidential Enquiry into Maternal and Child Health, 2007; Advanced Life Support Group, 2010).
In order facilitate the development of pre-hospital obstetric education; several programmes have been written which allowed for paramedics to maintain their continuous personal development through the competition of a short ‘crash course’ in obstetric care. One of the most successful courses of this type available to pre-hospital clinicians is the pre-hospital emergency training course (POET) delivered by the advanced life support group. Within this article, a review of this course will take place in order for readers to gain an understanding into the course content and the benefits of undertaking such course as part of the clinician's continuous personal development. The authors of this article have recently completed the POET course, held in Manchester, which was the inspiration for this piece.
The advanced life support group
The advanced life support group (ALSG) became a registered educational charity in 1992 and runs a variety of educational courses throughout the year (Box 1). The ethos of the organisation is to ‘preserve lives by providing training and education’.
ALSG's pre-hospital obstetric emergency training (POET) course has been available since 2008 and aims:
‘…to teach the practical procedures necessary to save the mother and fetus in life threatening circumstances before admission to hospital’.
The course is suitable for all advanced-life support level practitioners and is deemed to be particularly beneficial for paramedics and pre-hospital nurses and doctors. To date, 73 people have completed the course in the UK. The charity also has centres in Holland and Switzerland. The course comprises of approximately 10 hours online learning, covering 32 topics in seven modules. This is ratified by an online multiple choice question paper, where a pass mark of 80 % is expected. Following completion of online learning, candidates are required to complete a two day face-to-face course taught by a mixture of consultant obstetricians, doctors, midwives and paramedics. Over these two days learning is achieved through group discussion, simulations and skill workshops.
VLE
E-learning is effectively used by this course to deliver the theoretical aspect of pre-hospital obstetrics prior to the face-to-face delivery. The approximate learning time of 10 hours is a true estimation. However, if candidates wish to have a full understanding of the relevant background literature and reports, most notably Confidential Enquiry into Maternal and Child Health (CEMACH), then additional time is needed. While this additional material may not be specifically tested on the course, the resources are included in the topics and they allow the candidate to have further understanding of why such procedures are used. Knowledge of these materials can only allow the candidate to be more sensitive to further publications as more evidence evolves.
While topics are available online, a book is also available which has the same content. This incurs an additional cost, which many clinicians may be adverse to paying on top of the already pricey course fee. However, the booklet sets out the management of obstetric emergencies as a checkpoint list, which provides an easy refresher which may be useful to review while en route to a maternity call or as a reference point when attending with a student paramedic. In addition, the glossary and list of abbreviations would be particularly beneficial when faced with maternity notes. If nothing else, the slim A5 sized book is an exceptionally handy size and can be easily fittted into a bag.
From theory to practical application
Before commencing training concerning the management of obstetric emergencies, the basic principles of an obstetric primary and secondary survey are covered. This is very beneficial as it imprints the fundamentals of an obstetric assessment and allows the candidate to grasp such assessment prior to dealing with more difficult simulations. While algorhythmic thinking is common place for paramedics, assessment here is encouraged to use an initial ‘hands off’ approach before proficiently applying a full assessment to include exposure. Instructors are geared to appreciate that this is not something every paramedic is comfortable with, and encouragement is given until each candidate feels comfortable in exposing the introitus to identify delivery or time critical problems. The benefits of having the confidence to complete this part of the secondary survey are beyond compare, and this is something this course (and its instructors) is able to bestow completely.
Similarly, the mechanism of normal delivery is covered and demonstrated. While this may seem an obvious part of the course, it is essential that this mechanism is fully understood in order to identify time critical emergencies as they occur. This section is particularly useful for clinicians who have managed few deliveries on the road and gives the opportunity to ask questions and share anecdotal advice for dealing with this stage of labour.
Emergencies in late pregnancy
The skill stations covering emergencies in late pregnancy include:
While this list may appear daunting at first, the stations are structured in thirty minute sessions which include demonstration and scenarios where each person plays a part. It is at this point that material already learned from the VLE becomes most valuable.
Good theoretical knowledge allows the candidate to identify the risk factors for maternal emergencies in the session brief, allowing them to gain much more from acting out in the scenario.It was without doubt that each session was taught by practitioners experienced in dealing with such emergencies and their enthusiasm for the subject was infectious to say the least.
In addition, the instructors were geared to deal with different operational equipment and drugs available to each ambulance trust. This was beneficial as, while they presented what equipment and drugs would be optimal for each session, they also appreciated that these were not necessarily available in each individual ambulance trust across the UK and overseas, therefore allowing alternatives to be discussed and an optimal finding for each candidate allowed for. While this was beneficial, it became somewhat frustrating to be tested on the administration of drugs such as magnesium sulphate and symtometrine, which are not widely available in pre-hospital care. This may initially seem unfair, but when the benefit of these drugs is discussed alongside the evidence for using them, the frustration soon becomes directed towards the ambulance trusts which do not support the use of them.
The only fault apparent was the time limit of thirty minutes. While the groups were small (with up to five candidates in each), this timeframe was not quite enough for each candidate to have a go at each scenario and have some feedback. Although some clinicians may not wish to take part in each scenario, having the opportunity to be able to do so should be incorporated into each session. With this time constraint, feedback was also limited to instructors only and sometimes it may have been further advantageous for a peer review to take place and allow further discussion to evolve.
Emergencies after delivery
The skill stations covering emergencies after delivery include:
Again, these stations were delivered in thirty minute sessions. Perhaps it was due to the nature of these sessions, but each candidate was able to have a go at running the scenario and practicing the key skills. Since most candidates were from a paramedic background, newborn resuscitation was offered as revision for some and a discussion on the use of airway adjuncts was employed. This was, however, due to the nature of the experience of candidates in the group and with those less confidence at such resuscitation, this session would be run as a full scenario. The way sessions could be adapted to fit the needs of the group was something that was particularly valuable, as it allowed candidates to build on skills and experience they had already acquired or indeed to start the foundations of such proficiency.
It would be fair to say that there is currently much controversy over the use of taxis to replace an inverted uterus and bimanual uterine compression to compress catastrophic post partum haemorrhage. Despite the controversy over the use of such techniques in the pre-hospital field, this course presents these subjects well. Taught specifically by obstetricians with extensive experience in both procedures, these skills are demonstrated and then taught in a stepwise approach.
In addition to this, the evidence for using such techniques (and the benefits for using them in the pre-hospital environment) is examined. Since current guidelines state that deliverance of such procedures can only be used by practitioners with additional training (Fisher et al. 2006), this course delivers that additional training and confidence in performing these life saving skills. Each candidate is observed undertaking the skill in a scenario and the technique is observed and evaluated by the obstetric instructor to deem whether it is effective enough. This quickly builds confidence on a newly acquired technique and additional discussion surrounding the legal and professional use of these skills by paramedics allows the candidate to have a good all–round view of the procedure.
Management of non-obstetric emergencies
During the two day course, the management of patients who experience non-obstetric emergencies is also covered in some considerable depth. Pre-hospital clinicians who encounter pregnant patients with on-going health issues, traumatic injury or new illness need to consider whether they need to adapt their patient management in order to provide optimal care to pregnant patients. The most common nonobstetric emergencies which are covered within the POET programme include:
A variety of scenarios from the above list were presented in a case study and discussion format to individual groups. During these group discussions, the advantage of having candidates from a variety of clinical backgrounds was most apparent.
During these sessions, candidates were able to learn from each other, gain an appreciation of other professions concerns and discuss the relevant topics. For example, the discussion regarding the availability of obstetric and neonatal services at regional trauma centres was particularly interesting, with staff from emergency medicine and obstetric backgrounds debating the benefits of trauma versus obstetric care complex cases.
This session emphasised the importance of having a variety of different clinical, midwifery, nursing and pre-hospital specialities to maximise the ability to learn from peers and effectively used each instructor on the course.Skill stations also featured one of the aforementioned presentations. While this gave some good scenario experience (completing the maternal primary survey; assessing history taking), this was possibly the least beneficial scenario for paramedics since treatment follows specific care pathways and it akin to what paramedics encounter on a day to day basis. Discussion appeared more effective as it provoked debate on current research; current treatment pathways and additional tools that would further aid care.
Testing
The opportunity for candidates to be assessed on the POET course begins during the VLE. Candidates who progress through the online material will encounter questions in order to ensure the key learning points have been achieved. This allows progression on to the next topic. Prior to attending the course, candidates must attain a pass mark of 80% in the VLE multiple course questions (MCQ). While the MCQ is online, candidates are timed to complete this, making any chances of ‘cheating’ and researching answers quite difficult and obviously producing an extended time limit. This test can be retaken should the initial result be less than the expected 80 %. This simple method of testing is effectively used here to ensure candidates have read the required material prior to attending the course: The need for good theoretical knowledge of the subject is obvious. The MCQ features 100 questions, however as with any examination, this does not cover the entire depth of the course. More depth of questioning in this area would be more reflective on what is covered in the course, though it is a suggestion that may not appeal to the clinician who gets examination anxiety.
During the face-to-face elements, the assessment of candidates on the POET course is a continuous process, which accumulates into two simulation based OSCES on the skills imparted during that day. Candidates are assessed on their ability to carry out a patient assessment, perform the relevant clinical intervention and their overall management of an obstetric emergency. These simulations can include any of the aforementioned conditions. One of the most important elements of the assessment is the need for candidates to identify a life-threatening emergency, identify the need for definitive care at an appropriate obstetric unit and the treatment administered during this crucial journey. Candidates can then learn whether they have been successful in their simulation, following brief moderation by the assessors. Candidates, who successfully complete the POET course, receive their certificate at their home address which is valid for a four year period.
As with any of the available courses on offer through the ALSG, the faculty is keen to identify candidates who perform exceptionally well during their assessments, and show instructor potential. These candidates are subsequently recommended for the generic instructor's course, provided by the ALSG.
Conclusions
The pre-hospital emergency training course is a fantastic course to enhance the practitioner's ability to assess a pregnant patient, identify complications of pregnancy early and manage these situations accordingly. The management of obstetric emergencies taught during this programme is based upon literature, the latest evidence–base and professional consensus to ensure dynamic tuition. Practitioners receive peer support in order to achieve the learning outcomes of the course, whilst engaging in face-to-face and virtual learning environments. The POET course allows pre-hospital practitioners to gain a greater understanding of the various roles involved in maternal care and their individual assets in an obstetric emergency. Paramedics are able to learn, perform and be assessed on life-saving emergency techniques, such as bimanual compression and the management of uterine inversion, which would typically fall outside a paramedic's scope of practice, prior to attending an advanced CPD course. The advanced life support group provides a multi-disciplinary approach in the delivery of this course, and ensures candidates receive a fluent learning experience. The pre-hospital obstetric emergency training course is an enjoyable CPD opportunity which enables clinicians to improve the management of obstetric emergencies and hopes to reduce the number of unnecessary deaths due to poor pre-hospital obstetric care.