Obstetrics at Royal Cornwall Hospital


Duration: 4 - 6 months
This pre-CCT speciality training module has been developed for trainees within the South West Peninsula Deanery with an interest in obstetric anaesthesia. The post involves four to six months of training on the Delivery Suite at the Royal Cornwall Hospital, Treliske, Truro.
Grade: Specialty trainee year 5- 6.
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Hospital:
The Royal Cornwall Hospital is a busy District General Hospital looking after the population of Cornwall and Isles of Scilly and dealing with a rising birth rate of  around 4,600 deliveries a year with approximately 4100 occurring at Royal Cornwall Hospital. There are five weekday 12 hour funded consultant obstetric anaesthetic sessions which consist of one consultant anaesthetist and one trainee, working independently, covering the delivery suite during the morning.  The daytime consultant care provision continues until 8:30pm for the night time handover.  There is a dedicated obstetric anaesthetic pre-assessment clinic. This is held once a week to provide antenatal anaesthetic assessment and peri-partum planning for women with complex co-morbidities, high BMIs and potential difficulties with neuraxial anaesthesia. In addition there is a monthly Obstetric Multi-Disciplinary Team clinic that runs for 45 minutes before the anaesthetic pre-assessment clinic and accesses the direct input form a visiting Cardiology Consultant (University Hospital, Bristol) who has a specialist interest in obstetric care.
Specialist Obstetric Experience:
There are additional opportunities for gaining experience in the management of complex and higher-risk women by attendance at 4-5 specialist obstetric antenatal  clinics for feto-maternal medicine, joint haematological and combined diabetic obstetric care and management of women with chronic or complex co-morbidities.    These are provided by three consultant obstetrician colleagues.
A one week clinical attachment to the Obstetric Unit at St Michael’s Hospital, Bristol, is included to provide experience of tertiary referral and high risk obstetric anaesthesia with clinical experience incorporating management of high-risk cardiac obstetric patients.
 A two day observership on the Neonatal Care Unit at Royal Cornwall Hospital is included to enhance learning and experience in follow-on care of the unwell or             resuscitated neonate.

Aims of the fellowship:
To develop the knowledge, skills and attitudes necessary to enable the trainee anaesthetist to provide anaesthesia and analgesia to obstetric patients safely, efficiently and to a high standard. This would enable the trainee to be considered for a consultant post with an interest in obstetric anaesthesia.

Learning outcomes:
As set out by the Royal College of Anaesthetists Advanced Obstetric Training:-
- To build on the experience of Basic, Intermediate and Higher level obstetric anaesthetic training and gain mastery in the delivery of safe and effective peri-operative anaesthetic care to patients undergoing complex obstetric procedures.
- To develop competence in the management of busy labour ward and elective and emergency obstetric theatre sessions, and in doing so demonstrating the necessary multi-disciplinary leadership, communication and team-working skills necessary to ensure the care delivered benefits both the patient and the organisation.
- To gain maturity in understanding the importance of utilising the time allocated to clinical sessions effectively, optimising throughput whilst not compromising patient safety.
- To develop the necessary maturity to guide the choice of audit cycles in developing practice and become familiar with recent developments in peri-operative anaesthetic care to this area of practice with the ability to critically evaluate these developments and to advise colleagues of useful changes in practice.
Core clinical learning outcomes:
To be capable of undertaking the peri-operative anaesthetic care for a wide variety of complex obstetric cases and list management independently; this implies an ability to:
· Provide peri-operative anaesthetic care to a wide-range of obstetric cases performed both in the labour ward and theatre, demonstrating a fundamental understanding of the problems encountered
· Show the decision making and organizational skills required of an anaesthetist to manage busy labour ward and operating sessions, ensuring that the care delivered is safe and timely, benefiting both patients and the organisation
· To assist colleagues in decisions about the suitability of surgery in difficult situations
· Provide teaching to less experienced colleagues of all members of the multi-disciplinary team.
The training is divided into:
Skills
- Proficiency in wide range of regional techniques – epidural, spinal, combined spinal epidural (CSE) and transversus abdominis plane (TAP) blocks under ultra sound guidance.
- Various approaches for regional blocks – sitting, lateral, midline, paramedian.
- Importance of strict asepsis and emphasis when teaching junior trainees.
- Competence in delivery of general anaesthesia, including direct supervision of junior trainees.
- Ability to anticipate, recognise and manage the difficult airway, both in the elective and emergency setting.
- Recognition and treatment of complications of obstetric anaesthesia and analgesia e.g. post dural puncture headache, nerve damage.
- Epidural blood patching with supervision of assisting anaesthetist.
- Management of morbidly obese patients.
- Management of obstetric emergencies.
- Management of the unwell obstetric patient requiring Level 2 Critical Care on Delivery Suite.
- Assessment, recognition and management for referral of the severely unwell obstetric patient requiring Level 3 Critical Care.
- Good communication skills and ability to perform as part of the multi-disciplinary obstetric team.
Knowledge and teaching
Knowledge of the following will be expected
- Basic, Intermediate and higher Level knowledge as described by the Royal College of Anaesthetists.
- Advance regional anaesthesia techniques such as continuous spinal catheters in management of labour and for operative delivery.
- Effect of pregnancy on normal physiology and on pathological conditions.
- A working knowledge of obstetrics, particularly intrapartum management and major pathological CTG recognition.
- Understanding of the Obstetric Unit risk management process.
- Clinical activity and acquisition of skills.
- Knowledge and teaching of anaesthetic trainees (Basic-Higher levels), midwifery staff, maternity nurses and senior midwives.
- Research and audit.
- Portfolio.

Clinical activity
The fellow will work for 4/5 sessions per week on Delivery Suite during daytime working hours, gaining valuable clinical experience in the anaesthetic management of pregnant women, both normal and high risk.  There will be 1-2 sessions of service provision each week that will constitute a variety of solo general surgical or orthopaedic lists.  The trainee will also attend the consultant led antenatal anaesthetic clinic held on Thursday afternoon.  Attendance at antenatal clinics for on at least four separate occasions is arranged in order to gain understanding of the obstetric management of various problems in pregnancy and labour.  The trainee will also shadow a neonatal consultant for two days in order to gain insight into the care of the neonate in the immediate period following delivery.  On call duties will be mainly dedicated obstetric cover and may include occasional Senior Trainee at Night duties.  It is likely that some of the complex cases will be outside the trainee’s normal working hours. Despite this, we will expect that the trainee would demonstrate their commitment by becoming involved with these cases when possible. This flexibility is necessary to achieve high level of competence in delivery of obstetric anaesthesia.
Teaching
The trainee will be expected to teach relevant aspects of obstetric anaesthesia to other anaesthetic trainees as they undertake Basic and Intermediate Level obstetric anaesthetic training. This would be primarily on a one-to-one basis on Delivery Suite.
- The fellow would be encouraged and enabled to gain experience and skills in multi-disciplinary Point-of-Care obstetric emergencies simulation training on Delivery Suite by participating as faculty in the fortnightly P-o-C simulation rolling programme. This is provided through the use of high fidelity SimMom (Laerdal) and experienced assistance from a dedicated Simulation Practitioner.
- The fellow would additionally be timetabled and encouraged to take on a role as faculty for  multi-disciplinary obstetric training for the monthly Training in Obstetric Multi-Speciality Emergencies (TOME) programme.
- Supervision of junior trainees (CT2 – ST 4) in practical aspects of obstetric anaesthetic
Management
- Providing selected topics of the Level 2 Critical Care and Recovery training programme for hospital-based midwives and maternity nurses.
 Research and Audit
- Involvement in research and audit relevant to obstetric anaesthesia.
- Presentation at Peninsula Obstetric Anaesthetic Group bi-annual meetings.
- Presentation at OAA annual meeting.
- Interesting case histories to be written up for Divisional Governance presentation or journal submission.
Portfolio
The trainee will be expected to keep a portfolio of the following:
- Logbook of obstetric analgesia and anaesthesia procedures.
- Articles and papers read and discussed.
- Attendance and presentations at local, national and international meetings.
- Publications.
- Advanced courses e.g. MOET, PROMPT, MOSES.
- Simulator training – low and high fidelity.
- Teaching experience.
- Other activities related to aspects of clinical governance in the Maternity Unit, including CNST compliance.
At the end of the block, a report will be written and submitted to the training committee.
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contact
Dr Gary Matthews FRCP FRCA MBA
Specialty Director Anaesthesia
Royal Cornwall Hospital