Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence / assessment (10.01) Severe preeclampsia (10.02) Eclampsia (10.03) HELLP syndrome 1,2 1,2 1,2 (10.01-10.3) Understand best practice for the management of severe pre-eclampsia. Including its definition, diagnosis, acute management and associated complications. Understand the pathophysiology and pharmacology for the condition. Be able to interpret investigations Understand the acute and long-term maternal and fetal risks associated with the condition. 1,2,3 1,2 1,2 (10.01) Take an appropriate medical history and examination of a woman with symptoms of severe disease. Be able to interpret and act appropriately upon investigations. Be able to construct a differential diagnosis and recognise symptom and signs of co-existing maternal disease (HELLP, chronic hypertension, pre-existing renal damage.) (10.01-10.02) Manage cases of complex severe pre-eclampsia with: (a) HELLP (b) eclampsia (c) pulmonary oedema (d) acute renal failure (10.01-10.02) Institute / modify drug therapies, plan delivery and postnatal care refer, where appropriate, for further assessment / treatment. Be able to give accurate advice for future pregnancies. 1,2,3 1,2 1,2,3 1,2,3 (10.01-10.03) RCOG Green to guideline N0.10a Pre-eclampsia /eclampsia management. RCOG Patient information (2012) (10.01-10.12) Each condition within ASM.10 is core to the understanding of medical problems during labour. For each of the 12 conditions your supporting evidence must be based upon more than one case in which you have been directly involved. Suitable evidence includes, Reflective Practice, log of cases, OSATs, MiniCEX and CBD.
Know how to manage hypoglycaemia and ketoacidosis in pregnancy. Know how to appropriately monitor the fetal condition at all stages of pregnancy. (10.05) Understand how GDM is identified in pregnancy, its impact and how to mitigate its effects. Understand its short and long term implications. 1,2 1,2 (10.04-10.05) Liaise with diabetologists, diabetic nurse specialists, dieticians, and other specialists where appropriate, counsel, maternal and fetal risks, importance of good glycaemic control (including use of insulin in GDM) Discuss long-term risks, contraception options and the management future pregnancies. Gestational diabetes. Attendance at Obstetric Medical clinics / adult diabetes clinics. STRATOG Advanced, Maternal Medicine eLearning: Gestational diabetes mellitus (2016). STRATOG Advanced, Maternal Medicine eLearning: diabetes without complications (2015). (10.06) Known haemoglobinopathy 1,2 (10.06) Understand how haemoglobinopathy impacts upon the antenatal and intrapartum care of the woman. Understand the risks to the fetus and how these may be monitored. 1,2 10.06) Manage thalassaemia or other haemoglobinopathy. Counsel on fetal and maternal risks, arrange and interpret appropriate investigations (10.06) Green top guideline No.66 Thalassemia in pregnancy.
Understand the genetic basis for the common haemoglobinopathies and what prenatal testing is available. 1,2 liaise regarding therapy, plan delivery and postnatal care. Be able to explain the option of prenatal diagnosis. RCOG patient information (2015). Beta Thalassemia and pregnancy. (10.07) High risk for venous thromboembolism (10.08) Prior thromboembolism 1,2 1,2 (10.07-10.08) Understand how to quantify thromboembolism risk and how best to mitigate that risk. 1,2 (10.07-10.08) Manage a case of thrombophilia and / or previous VTE in pregnancy, arrange and interpret appropriate investigations. Be able to accurately risk score for thromboembolism, and to communicate that risk effectively. Discuss and plan treatment accordingly. Institute/modify VTE prophylaxis where appropriate. 1,2,3 (10.07-10.08) RCOG Patient information (2015). Diagnosis and treatment of venous thrombosis in pregnancy and after birth. STRATOG Advanced, Maternal Medicine eLearning: Previous venous (2016). (10.09) Renal disease in labour 1,2 (10.09) Have an understanding of the effects of labour and the immediate postpartum period on chronic renal disease. 1,2 (10.09) Perform, under supervision, appropriate assessment and management of a labouring woman with renal disease. Arrange and interpret appropriate investigations, 1,2,3 (10.09) STRATOG Advanced, Maternal Medicine eLearning: Kidney Disease in Pregnancy. 1,2,3
formulate, implement and where appropriate modify a multi-disciplinary management plan with appropriate liaison where necessary. (10.10) HIV including MDT approach to minimising potential sequelae. 1.2 (10.10) Understand how HIV impacts upon the antenatal, intrapartum and postpartum care of the woman. Understand the risks to the fetus and how these may be reduced. Understand the transmission of HIV and how viral load may be monitored and the treatments available. 1,2 1,2 (10.10) Manage a case of HIV in labour: plan mode of delivery and suitable treatment to minimise neonatal transmission. (10.10) RCOG Patient information (2013) HIV in pregnancy. (10.11) Intrapartum pyrexia 1,2 (10.11) Understand the causes of pyrexia in labour, their investigation and treatment as well the potential impact upon mother and baby. 1,2 (10.11) Manage intrapartum pyrexia, coordinating midwifery, neonatal and microbiology assistance as required. 1,2,3 (10.11) RCOG Green top guideline No.64 Sepsis in pregnancy. No.64b Sepsis following pregnancy. (10.12) Increased risk to from Group B Haemolytic Streptococcus 1,2 (10.12) Understand which groups are at increased risk of GBS and how to mitigate this increased risk. Understand the features of early and late onset neonatal GBS infection. 1,2 (10.12) Explain risks and implement local policy to reduce risks of GBS in the new-born. Liaise appropriately with neonatal team. 1,2,3 (10.02) RCOG Patient information (2013). Group B streptococcus infection in babies.
Completion of ASM 10: Key Intrapartum Obstetric Medical Disorders Date Signature Safe and effective management of these maternal medical conditions has been achieved through direct exposure and decision making for a range of clinical cases including timely liaison with the MDT and tertiary services if appropriate. ASM 14: Key intrapartum scenarios: non-technical and technical skills Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/ assessment Safely manage non-cephalic presentation. (14.01) Non-technical: Recognition and informed counselling for breech presentation. (14.02) Technical: Competency for the recognition of presentation. (14.03) Delivery of vaginal breech (may use Other Methodology). (14.04) Delivery at caesarean section for breech and transverse lie. 1,2 1,2 1,2 (14.01- 14.04) Understand the appropriateness of the different modes of delivery for breech, transverse and oblique lie presentations. Understand how management might differ for multiple pregnancy. Understand the manoeuvres to minimise the risks for both assisted breech delivery and breech extraction for singleton and multiple pregnancies during vaginal delivery and also at caesarean section. 1,2 1,2 1,2 1,2 (14.01-14.04) Be able to communicate effectively in a manner that can easily be understood the risks accompanying all non-cephalic presentations and the options available. Be able to construct a safe birth plan and where appropriate modify this according to the clinical findings as they evolve. Effectively liaise where appropriate, with anaesthetists, 1,2,3 1,2,3 (14.01-14.04) RCOG Green top guideline No. 20a (2006) ECV reducing the risk of breech presentation. No.20b (2006) Management of Breech Presentation. For this ASM each intrapartum scenario listed is core to the safe practice on the delivery suite. For each of the scenarios your supporting evidence must be based upon more than one case in which you have been cephalic
In addition to direct exposure, CBD with your supervisor are particularly useful for those areas in which your exposure to cases has not been sufficient to cover the breadth of the condition. Safely manage preterm labour. (14.05) Non-technical: Demonstrate expertise when balancing delivery with aiming to prolong pregnancy. Good communication with the family and wider MDT including paediatric team. (14.06) Technical: Proficiency in intrapartum care for preterm vaginal delivery. (14.07) Technical: Proficiency in preterm (<32 week) caesarean section. 1,2 3,4 1,2 1,2 (14.05-14.07) Understand the pathophysiology, investigations and management of preterm labour and preterm premature rupture of membranes (PPROM). Understand the symptoms, signs and range of presentations for acute chorioamnionitis. Understand when and how to use tocolytics. Understand the maternal risks associated with preterm delivery and the options that are available to minimise these risks. 1,2 1,2 1,2 1,2 1,2 (14.05-14.07) Ability to liaise effectively with neonatologists / microbiologists; to arrange transfer if appropriate. Counsel women and their partners accordingly on the maternal, fetal and neonatal risks in a manner that is easy to understand. Debrief and formulate a suitable management plan for future pregnancies. 1,2,3 (14.05) RCOG Green top guideline No.7 (2010) Antenatal steroids to reduce preterm morbidity. Green top guideline No. 1b Preterm labour and tocolytic drugs. Scientific impact paper No.41 (2014) Perinatal management of the pregnant
14.08) Non-technical: Formulate clear intrapartum care plans based on clear communication of all issues. (14.09) Technical: Competency for the delivery of preterm multiple pregnancy. (14.10) Technical: Competency for delivery by term caesarean section and term vaginal delivery. 1,2 1,2 Understand the influence of fetal growth restriction, discordant growth, prematurity, chorionicity and malpresentation on the recommendation and successful conduct for all modes of delivery for multiple pregnancies. Understand the role of intrapartum ultrasound and CTG monitoring for multiple pregnancies. 1,2 Be able to construct a suitable intrapartum care plan, liaising appropriately. Be able to explain the delivery options and any associated maternal and fetal risks in a manner that is easy to understand. risks Be able to run a multiple pregnancy skills drill that could include: Malpresentation of twin 1 Malpresentation of twin 2 after vaginal delivery of twin 1. CTG concerns Preterm labour ECV in labour Internal podalic version 1,2,3 NICE Clinical Guideline CG 129 Management of twin and triplet pregnancies in the antenatal period. RCOG Green top guideline N0.51 Monochorionic twin pregnancy. RCOG Consent Advice No.7 (2009) Caesarean Section Safe rotational vaginal delivery. (14.11) Non-technical: Provide appropriate information to support informed choice for all method of delivery options. (14.12) Technical: Competency in at least 2 of the following 3 methods to rotate to the position: manual 1,2 1,2 (14.11-14.12) Understand the indications and for each form of instrumental delivery: Neville Barnes forceps Kiellands forceps Kiwi cup ventouse Soft cup ventouse Metal cup ventouse including the posterior cup. 1,2 (14.11-14.12) Be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained. Understand your own limitations for each method and 1,2,3 (14.11-14.12) RCOG Green top guideline No.26 (2011) Operative vaginal delivery. STRATOG eLearning and simulation for
Safely manage PPH. (14.15) Non-technical: Demonstrate good communication skills and the use of MDT. (14.16) Technical: Acute resuscitation and medication for PPH (14.17) Technique: Uterine balloon tamponade. (14.18) Technical: B Lynch suture technique. 1,2 1,2 1,2 (14.15-14.18) Understand the factors that predispose to PPH and how these risks may be minimised. Understand the consequences of massive acute PPH and how the situation may be investigated and monitored. Understand the role of the MDT for massive PPH. Understand the surgical management of PPH: intrauterine balloon, brace suture internal iliac ligation hysterectomy and interventional radiology (vascular balloons and coils). Understand the medical management of PPH: oxytocin, ergometrine, 15 F2, misoprostol, and recombinant factor VIIa. 1,2 1,2 1,2 1,2 1,2 (14.15-14.18) Be able to rapidly assess the extent of haemorrhage and institute appropriate resuscitative measures. Ability to lead the team for all aspects of PPH including the acute maternal resuscitation, investigation and subsequent management. Be able to run skills drill for primary PPH incorporating: - uterine atony - inverted uterus - adherent placenta - uterine rupture Be able to debrief all involved and communicate effectively in a manner that can be easily understood. 1,2 1,2,3 (14.15-14.18) NICE Clinical Guideline CG190 (2014) Intrapartum Care. RCOG Green top guideline No.52 (2009) Prevention and management PPH. RCOG Good Practice Guideline No.6 (2007) The role of emergency and elective interventional radiology in PPH. Observation of and discussion with senior medical staff Appropriate postgraduate courses (Management of the Labour Ward 1,2,3
MOET or equivalent). Sessions in Obstetric Anaesthesia, ITU/HDU. STRATOG Safely manage maternal sepsis (14.19) Technical: timely recognition, investigation and treatment. (14.20) Non-technical: Demonstrate good communication skills with patient, relatives and MDT liaison. 1,2 (14.19-14.20) Understand the various causations and presentations of sepsis the maternal and fetal risks, how to investigate and manage suspected and confirmed sepsis. Understand antibiotics pharmacology and which are most suitable for use in pregnancy and postpartum. 1,2 1,2 (14.19-14.20) If delivery is indicated be able to advise on the most appropriate mode of delivery and to explain your reasoning in a way that is easy to understand so that valid consent may be obtained. Be able to liaise effectively within the MDT to optimise the outcome for mother and baby. Be aware of your own limitations and know when to seek further advice. (14.19-14.20) RCOG Green top guideline No.44 (2010) Preterm prelabour rupture of membranes. RCOG Green top guideline 64a (2012) Sepsis in Pregnancy and 64b (2012) Bacterial sepsis following pregnancy Safely manage antepartum stillbirth (14.21) Technical: Competency in the conduct of all stages of labour for stillbirth. 1,2 (14.21) Understand the options available to effect safe delivery. Be able to explain the risks in terms of both short term and potential long-term complications. (14.22) Be able to communicate effectively and sensitively with colleagues, patients and relative. 1,2,3 (14.21-14.22) RCOG Green top guideline No.55 (2010) Late intrauterine fetal 1,2,3 1,2,3 1,2,3
(14.22) Non-technical: Demonstrate good communication skills; explain diagnosis, management options appropriate investigations and follow up. Understand treatments available to reduce associated risks. Be familiar with the investigations that may determine causation of antepartum stillbirth including the option of examination and karyotyping. 1,2 1,2 Construct an individualised care pathway for labour and delivery. Be able to take informed consent for post-mortem based upon a thorough understanding of the process and the value of the procedure. Be able to liaise effectively and organise suitable support and follow up. death and stillbirth. RCOG Good Practice Guidelines No.4 Registration of stillbirth before 24 weeks and No.5 Disposal following pregnancy loss before 24 weeks. SANDS Information for Professionals. Guide for consent takers. SANDS (2016) Pregnancy loss and the Death of a Baby: guidelines for professionals. 1,2,3 1,2,3 1,2,3
Authorisation of signatures (to be completed by the clinical trainers) Name of clinical trainer (please print) Signature of clinical trainer Completion of ASM 14: Key intrapartum scenarios: non-technical and technical skills Date Signature Safe and effective communication and management of intrapartum conditions has been achieved to level 3 through direct exposure to the required range of clinical cases including timely liaison with the MDT and tertiary services if appropriate. ASM 15: Intrapartum Ultrasound Skills Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/ assessment (15.01) Identify the presenting part prior to induction of labour. 1,2 1,2 (15.01-15.03) Be able to identify the following: -Fetal lie 1,2 (15/01-15.03) Be able to use and set up the ultrasound machine correctly. Be able to clearly record your findings. 1,2 These skills build upon those undertaken during the RCOG Basic obstetric (15.01- 15.08) These skills are designed to be used on the delivery suite but
(15.02) Determine each presentation and lie for twin pregnancy at term. (15.03) Determine the presenting part in preterm or suspected preterm labour. 1,2 -Presenting part (cephalic, breech flexed, extended and footling as well as shoulder presentation), - Identify the landmarks of the fetal head - Determine the position of the fetal spine, placental location and amniotic fluid volume. Be able to advice on the intrapartum care based upon your ultrasound findings. ultrasound module. Direct supervision on the delivery suite wherever possible. (15.01-15.07) These skills may also be acquired through ultrasound assessments in non-labouring women during the third trimester. may also be acquired in women in the third trimester. OSAT (15.04) Locate fetal heart beat intrapartum 1,2 (15.04) Be able to confirm and appropriately record intrapartum fetal viability. 1,2 (15.04) Be able to explain the findings in a manner that is easy to understand. (15.05) Confirmation of intrauterine fetal demise. 1,2 (15.05) Be able to rapidly and accurately determine the activity of the fetal heart within the fetal chest and whether a fetal heartbeat is present. Recognise the ultrasound features of intrauterine demise and record 1,2 (15.05) On confirmation of the diagnosis be able to explain the findings in a sympathetic manner and advise on a suitable and safe management plan. (15.06) Intrapartum Identification of occipital-anterior presentation. (15.07) Intrapartum identification of occipito-posterior presentation. 1,2 1,2 (15.06 -15.07) Understand how ultrasound may be used to augment and confirm the clinical findings of abdominal palpation and vaginal examination. Recognise the necessary landmarks: intracranial (midline echo, thalami, head shape) and extracranial (position of the ears, eyes, nose and fetal spine) so that the attitude of the fetal head and the position of the occiput may be determined. 1,2 1,2 (15.06-15.07) Be able to correctly orientate the probe so that the intrapartum orientation of the fetal occiput can be correctly determined. 1,2 1,2,3 1,2,3 1,2,3
(15.08) Recognise the normal appearances of the postpartum uterus. 1,2 (15.08) Understand the physiological changes that occur postpartum and the typical intrauterine appearances. Recognise the ultrasound features that suggest retained products of conception. 1,2 (15.08) Where there is a high index of suspicion for retained products, be able to construct a suitable management plan. ASM 15. Ultrasound Skills to support intrapartum care. Part of the Advanced Labour Ward Practice ATSM
Recognise the common forms of epilepsy and their distinguishing features. Consider the overlap in presentation with eclampsia and how to investigate and manage each in the intra partum setting. RCOG Green Top Guidelines: 10A (Management of preeclampsia/ eclampsia). No.68 Epilepsy in pregnancy. These are relatively rare conditions Evidence may include a suitable simulation manikin based obstetric emergency course. Supplement any clinical exposure with CBD undertaken with an experienced supervisor. Suitable evidence may include evidence of eLearning, MDT meetings as well as direct clinical exposure. OSAT CBD Reflective Practice. (16.02) Herpes Simples Virus (16.03) Hepatitis B, Hepatitis C 1,2 1,2 Note: These competencies are also found in ASM.8 High risk secondary to medical and obstetric factors Here the focus is on their intrapartum management. (16.02-16.03) Know the transmission risks, neonatal consequences, long term prognosis and management strategies to reduce vertical transmission of: Herpes Simplex (HSV) and Hepatitis B & C. 1,2 (16.02-16.03) Counsel women and their partners on intrapartum and postpartum risk reduction for each viral infection. Respect confidentiality and liaise appropriately. 1,3,4 (16.02) RCOG Green Top Clinical Guidelines: 30: Management of genital herpes during pregnancy. (16.04) Sickle cell crisis 1,2 (16.04) Note: These competencies are also found in ASM.11 (11.13) and ASM 12 (12.09). Here the focus is on their intrapartum management. Review the genetics, presentation and management of sickle cell disease in pregnancy with particular emphasis on 1,2 (16.04) With appropriate liaison manage women with sickle cell disease demonstrating an understanding of how risks may be minimised intrapartum. Be able to explain these risks in a manner that is easy to understand. (16.04) RCOG Patient information (2014) Sickle cell disease in pregnancy. 1,2,3
(16.07) Amniotic fluid embolism. (16.08) Massive pulmonary embolism. (16.09) Cerebrovascular accident. (16.10) Cardiac event. 1,2 1,2 1,2 1,2 (16.07) Understand the principles of maternal resuscitation and how these relate to pregnancy collapse and massive postpartum haemorrhage. For each condition review its aetiology and differential diagnosis. Consider how pregnancy may influence the presentation and lead to specific challenges for effective treatment. 1,2 1,2 (16.07) Be able to rapidly assess the urgency of the clinical situation obtain help and provide rapid resuscitative measures. Liaise appropriately with the MDT. Be able to debrief all involved and communicate effectively in a manner that can be easily understood. (16.08-16.09) RCOG Green top guideline 37 a & b (2015) reducing the risk and acute management of VTE. STRATOG Core training. Stroke in pregnancy. Core training Venous thromboembolic disease. (16.11) Management of the morbidly adherent placenta 1,2 (16.11) Review the knowledge base and skills under ASM14.15-14.16 for the safe management of PPH. Understand the aetiology of morbidly adherent placenta, its diagnosis on ultrasound and on MRI. Understand the risks versus the benefits of leaving the placenta in situ. The role of interventional radiology. 1,2 1,2 (16.11) Be able to select the most appropriate place, timing and ultimately the best uterine incision for delivery of the baby. Have preparations made to activate the local major haemorrhage protocol for massive obstetric haemorrhage. Rapidly assess the extent of haemorrhage and institute 1,2 1,2 1,2 (16.11) RCOG Green top guideline No. 27 (2011) Placenta praevia, placenta praevia accreta, vasa praevia: Diagnosis and management. RCOG Good Practice Guideline No.6 (2007) The role of emergency and elective interventional
appropriate resuscitative measures. Ability to lead the team for all aspects of PPH including the acute maternal resuscitation, investigation and subsequent management. Be able to debrief and plan for future pregnancies. radiology in PPH. (16.12) Correction of uterine inversion 1,2 (16.12) Review the hydrostatic technique, the manual and surgical technics for correction of uterine inversion. Understand the pharmacological support available both uterine relaxants and the role of anaesthesia. 1,2 (16.11 -16.12) Be able to quickly recognise and assess the clinical situation. Through effective minimise the risks of maternal collapse, haemorrhage. 1,2 (16.13) Management of perineal or abdominal wound breakdown 1,2 (16.13) Understand the principles of wound care, how to minimise breakdown and infection. Review the basis for choosing late versus early repair of perineal breakdown and healing by secondary intention versus suturing (Cochrane review 2013). 1,2 1,2 (16.13) Communicate effectively all of the options available in order to obtain valid consent. Construct suitable follow up with the involvement of primary care. (16.13) NICE Clinical Guideline No.74 (2008) Prevention and treatment of surgical site infection
STRATOG – technical skills eLearning: Perineal assessment and repair (2015). Cochrane Database of Systematic Reviews (2013) Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. (16.14) Surgical Management of intra-abdominal haemorrhage (1615) Classical caesarean section (16.16) Caesarean hysterectomy 1,2 1,2 1,2 (16.14-16.16) Understand how to apply the radiological and pharmacological available to supplement the surgical approaches to minimise bleeding. Be able to plan effectively if a classical caesarean section is likely or when hysterectomy is necessary. 1,2 1,2 (16.14-16.16) Know your own limitations for these rare conditions. Use the MDT effectively to plan the intervention and support the surgical management to minimise risks. (16.14) RCOG Green top guideline No.63 (2011) Antepartum haemorrhage. No.52 Postpartum haemorrhage. (16.15-16.16) RCOG Safety alert No.1 (2011) Out of hours cover for
Clinical competency GMP Knowledge criteria GMP Professional skills and attitudes GMP Training support Evidence/ assessment (17.01) Explain the risks and benefits of the different forms of analgesia and anaesthesia for labour. (17.02) Explain the risks and benefits of the different forms of analgesia and anaesthesia for assisted delivery and caesarean section. (17.01-17.02) Review all forms of analgesia for use in labour with the focus on how best to explain them. Understand the inherent risks and benefits of each and how best to balance these risks for the common intrapartum clinical situations. 1,2 (17.01-17.02) Be able to explain complex information including all forms of risk in a way that is easy to understand. (17.01-17.02) NICE Clinical Guideline CG.190 (2014) Intrapartum care. Royal College of Anaesthetists (2013) Pregnancy Guidelines. RCOG Clinical Governance Advice No.7 (2008) Presenting information on risk. (17.01 -17.07) These are largely skills and the supporting evidence should reflect this. Evidence of a short attachment to obstetric anaesthesia, HDU/ITU. Feedback should be multisource wherever possible and include obstetric anaesthetists. OSAT CBD Supporting evidence in ePortfolio of reflective practice. (17.03) Agree intrapartum care plan for previous traumatic delivery. 1,2 (17.03) Understand shared decision making and best practice for constructing care plans in labour. (17.03) Be able to provide honest, informative and balanced clinical information in a way that is easy to understand. (17.03) STRATOG Non-technical skills eLearning: Communication skills and Communicating with patients. 1,3,4 (17.04-17.06) 1,3 (17.04-17.06) 1,3,4 (17.04-17.06) STRATOG
(17.08) Relevant Audit or other Quality Improvement Project. (17.10) Log of risk management cases. (17.04) Demonstrate good communication skills following stillbirth. (17.05) Debrief family after adverse intrapartum outcome. (17.06) Debrief staff after adverse intrapartum outcome. 1,3,4 1,2,4 Understand the bereavement reaction, how people react often to bad news and how best to approach difficult and challenging consultations. Be familiar with the investigations that may determine causation of antepartum stillbirth including the option of examination and karyotyping. 1 Be able to break bad news appropriately and support distress. Be able to advise upon the local support available and the options for further discussion. Know when to ask for assistance and how to offer a second opinion if required. 1,3,4 1,3,4 Core training (2016) Communication skills. RCOG Green top guideline No.55 (2010) Late intrauterine fetal death and stillbirth. (17.07) Co-ordinate the clinical running of Labour Ward: triage and staffing. (17.07) Understand how to triage clinical cases according to local guidelines. Understand the labour ward staffing structure and the minimum staffing number safety standards. 1,2 1,2 (17.07) Ability to co-ordinate the LW appropriately and communicate effectively all plans and decisions to team members. (17.07) Direct supervision by senior staff and indirect support as confidence develops. Feedback from NOTTS. (17.08) Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence). 1,2 RCOG Clinical Governance Advice No.1c Producing a clinical practice guideline. No.2 Improving patient safety. Risk