APPENDIX 7
Memorandum by Professor Robert Shaw (MS
12)
I recently received the Maternity and Neonatal
Workforce Working Group Report and include those issues within
these comments.
1. General Issues—should we be endeavouring
to provide a maternity service that is desired or merely one that
is dictated by current workforce projections and availability
of medical staff. Surely the workforce number should be geared
to the appropriate development of the service not vice-versa which
seems to be the current pressure for a number of changes.
2. The majority of reports confirm that
most patients wish to have maternity services provided as close
as possible to their place of residence and have access to Consultant-provided
service, especially when risk factors are identified, but also
in many instances, low risk patients.
Availability of high tech epidural analgesia
services is clearly a further pointer to the wish to be cared
for by medical professionals as well as midwifery care.
3. It seems highly unlikely that the current
caesarean section rates up to be 20% will fall. If anything pressures
may continue to try to push these levels further up, particularly
the management of patients with previous caesarean sections, pre-term
labours, breech presentations and multiple pregnancies, moving
more and more towards elective caesarean sections as the preferred
choice for delivery.
4. In certain areas there is scope for some
amalgamation of units—in parts of the country two units
may be sited within 10 miles of each other. However, much of this
amalgamation has already occurred or occurring and further closures
would lead to major deficits in service.
5. It has to be recognised that obstetricians
are also gynaecologists (at least for the time being) and that
the maternity services as provided by the medical staff are part
of total women's health service provision, unlike midwifery which
is easily separated from gynaecological nursing, this is not so
for the medical specialities. Hence the issues related to staffing
numbers etc.
6. The RCOG has been at the forefront of
developing evidence-based guidelines. These have equally been
strong in the fields of obstetrics as well as gynaecology and
have informed major changes.
7. The Confidential Enquiry into Stillbirth
Deaths in Infancy (CESDI) as well as Confidential Enquiry into
Maternal Death (CEMD) are long-standing confidential enquiries,
the recommendations from which have been vitally important in
forming changes in provision of care.
8. CNST standards—the standards are
set by the College clearly indicated the need for and proven increased
number of Consultant sessions on labour ward. There is scope to
continue this further expansion and this is essential particularly
in the larger high risk units, moving towards 24-hour Consultant
provided service in these units.
9. It would be appropriate to divide Consultant-provided
service into three levels. Level 1 where low-risk obstetric cases
are booked for delivery, instrumental and caesarean sections can
be undertaken but neonatal service is not provided. Full gynaecological
service is also provided. Level 2 added expansion of obstetric
services and sub-speciality screening issues available, neonatal
care to a limited level provided. Level 3 high-risk subspeciality
centres and regional referrals, full neonatal services including
surgery. Such centres also providing regional subspeciality services
in gynaecology as well as obstetrics.
10. The only way for future change is to
be the development and introduction of Consultants resident on-call,
particularly in high-risk unit and spreading down the line to
the level 2 units. For too long the speciality has relied upon
trainees to provide out-of-hours service but if standards are
to be maintained, never mind improved, this can no longer be the
case.
11. It is essential that appropriate data
collection from maternity data sets as part of the HES data sets
are swiftly introduced.
12. Obstetrics is a prime example of team
working apparent over many years. Midwifery managed care of cases
within and adjacent to hospital based units, would be preferable
to completely isolated midwifery units. However, it is recognised
that geographical issues may necessitate some isolated midwifery
units. Clear cut guidelines on selections of patients and management
of problems in labour must be in place if these are to provide
safe care in the first decade of the 21st century and data to
substantiate such changes.
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