Appropriate Skills and Appropriate Places course
In rural mid Wales, midwives have developed realistic ‘skills and drills’ training for home-birth emergencies with no obstetric support. Shelly Jones and Dr Marie Lewis explain how.
Powys Teaching Health Board has been running community ‘skills and drills’ training for midwives and paramedics for 15 years. Since 2007, it has offered the Appropriate Skills for Appropriate Places (ASAP) course to midwives and paramedics from across the UK.
Maternity services in Powys cover more than 200 square miles of rural mid-Wales and are wholly midwife-led. There is no district general hospital, so obstetric care is commissioned from consultant units outside the county. Women who choose to give birth in Powys can attend one of six freestanding birth centres or birth at home. The overall home-birth rate here ranges from 8% to 12%. Midwives work in the community, partnering with paramedics when necessary. Transfer times to an obstetric unit for consultant care range from half an hour to two hours, dependent on where in Powys a woman lives; it was therefore essential for the county to develop a specific skills and drills training.
Existing training tends to focus on care within the hospital setting, where most births happen (Wickham et al, 2012). Midwives in the community may be working alone, and need to respond to an emergency situation. When training has been conducted within a ‘home-like’ environment, they have been rated positively, specifically in relation to aspects such as equipment and communication (Pauley and Dale, 2016). Such training encourages the development of teamwork, and the application of practical skills in a ‘safe’ environment (Kirkham, 2018).
It was vital that the course, which has been accredited by the RCM, was robust and evidence-based. The accreditation process involved completing lesson plans, risk assessments, aide memoires and robust evaluations. The ASAP training programme has recently been awarded its second three-year accreditation.
Midwives in Powys only provide intrapartum care in freestanding midwife-led units or in a woman’s home, and their team often consists only of another midwife or a paramedic. So training needed to be developed to meet their specific needs because an obstetric skills and drills training model did not prepare them for a community-based situation. Midwifery supervisors developed a course that would meet the needs, concentrating on working in teams or in partnership with paramedics. Drills could be carried out by midwives in a setting appropriate for community care, while remaining realistic about the equipment accessible to community midwives. The setting for the training was as close to real life as possible – a remote Welsh farmhouse.
Rooted in real life
ASAP aimed to develop and deliver a realistic training programme to meet the needs of community midwives and encourage working partnerships with paramedics and health visitors (see Objectives of ASAP training, below). The two-day ‘Obstetric emergencies in the community’ course promotes the role of midwives in the community and their ability to provide up-to-date evidence-based care. It focuses on the promotion of normality, risk assessment and handling emergencies. The residential course offers opportunities for team-building and personal reflection, as well as updating knowledge. The venue allows for the set-up of real scenarios and enables midwives to practise skills in a home setting: emergencies take place in bathrooms, bedrooms, living rooms and on the stairs. Issues of transfer and support available to midwives in the community as well as risk assessment and key clinical skills are covered.
Approximately 15 delegates attend the two-day ASAP training; small numbers allow adequate time and feasibility for the practice scenarios. Midwives are required to bring with them the equipment they would normally carry in the community and use this throughout the training. Group discussion is used to evaluate and explore different approaches to dealing with difficult situations.
Between 2014 and 2017, 82 UK midwives attended the course. All attendees completed an evaluation form at the end of the course and scored each session on a Likert scale of one to five (one being poor, five excellent).
All attendees were asked to score how important they felt the training was to their practice. They all scored four or five, with an average score of 4.9, demonstrating the value of the course to community midwives. They were also asked to score how confident they felt in dealing with emergencies within the community both before and after the training. Before the training, attendees scored themselves between two and five, an average confidence score of 3.4. Following the training, scores recorded were four to five, with an average confidence score of 4.9.
All attendees said they had thoroughly enjoyed both days and valued the opportunity to practise these skills in realistic settings. Words used by the attendees to describe the course included: ‘excellent’, ‘loved it’, ‘fantastic’, ‘enjoyable’ and ‘empowering’.
Attendees described important lessons, including the promotion of normality, how to have conversations with women about birth options, taking a step back and evaluating the situation, and using what is available and thinking through the natural physiological process.
Running an obstetric emergency course in the community for midwives is valuable in the current drive to promote midwife-led care. The evaluations indicate that attendees left the course feeling more confident, empowered and better prepared to offer women a choice for place of birth.
Objectives of ASAP training
- Enable midwives to practise key emergency skills
- Encourage teamwork and communication
- Cover essential training topics
Shelly Jones is assistant HoM and Dr Marie Lewis is consultant midwife at Powys Teaching Health Board
Dr Marie Lewis is consultant midwife at Powys Teaching Health Board
Next course and how to book:
14 and 15 November, Llandrindod Wells, Powys (two-day workshop, includes accomodation) Email Zara Abberley at firstname.lastname@example.org or call 01597 828755
Kirkham LA. (2018) Exploring the use of high-fidelity simulation training to enhance clinical skills. Nursing Standard 32(24): 44-53.
Pauley T, Dale A. (2016) Train together to work together: reviewing feedback of community-based skills drills training for midwives and paramedics. British Journal of Midwifery 24(6): 428-32.
Wickham S, Nightingale L, Champion, P. (2012) Top ten tips for dealing with emergencies in the community. Essentially MIDIRS 3(9):27-33.