High Risk Pregnancy Atsm 2018

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Common competency framework competencies Medical leadership framework competencies Health inequality framework competencies
High Risk Pregnancy (2018) – approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018
Aim
To prepare the clinician for the recognition and management of high-risk pregnancy for both fetal and maternal conditions.
Prerequisites
Successful completion of an Obstetric Emergency Course, for example a MOET course or equivalent.
Key components
The ATSM comprises 5 Advanced Skills Modules (ASM). All 5 ASM are required to award the ATSM as part of CCT. Outwith CCT, individual ASM may be
recognised separately as part of continuing professional development towards your CPD programme.
ASM 1. Advanced Obstetric Ultrasound.

Identical to the ASM of the same name in the Fetal Medicine ATSM.
ASM 6. Management of Key Obstetric Medical Conditions.
Identical to the ASM of the same name in the Obstetric Medicine ATSM.
ASM 7 High-risk secondary to Environmental, Social and Lifestyle Factors.
ASM 8 High-risk secondary to Medical and Obstetric Factors.
ASM 9 Effective Communication and Clinical Governance Skills for High-Risk Pregnancy.
Educational Support
Attendance at the annual RCOG/BMFMS High Risk Course or an equivalent course prospectively approved by your Regional Preceptor is mandatory.
Attendance at the course must be after registering for the ATSM and no more than three years prior to completing the module.
TOG, STRATOG and e-portfolio support is also provided by the RCOG.
Clinical Support
The ATSM should be undertaken under the supervision of an identified Obstetric Consultant supervisor, who must be in a position to directly supervise and
assess competence as well as approve appropriate professionals to train for the wider curriculum components.
An average of least two sessions per week is required to work towards the targets.
Additional, specific, themed sessions relevant to the ATSM are listed in the module.
Work intensity
For pre-CCT trainees the ATSM has been allocated a work intensity score of 2.0.
GMC Good Medical Practice (GMP) Domains: Domain 1: Knowledge, skills and Performance Domain 2: Safety and quality Domain 3: Communication, Partnership and Teamwork. Domain 4: Maintaining Trust
Colour key:
ASM 1 Advanced Obstetric Ultrasound
Professional skills and Evidence/

Clinical competency GMP Knowledge criteria GMP GMP Training support
attitudes assessment
(1.01) Effective and safe use of 11,2 (1.01) (1.01-1.04) (1.09-1.10) (1.01-1.16)
imaging modalities Understand the risks associated with the 1,2 Appreciates the limitations of 1,2 RCOG Green top These are the
different ultrasound modalities and how to antenatal ultrasound. guideline No. 57 ultrasound
limit them. Understand mechanical index (2011) Reduced competencies for
(1.02) Optimise image for 2D 1,2 (MI) and thermal index (TI). Understands the appearances of 1,2 fetal movements. high-risk
ultrasound. artefacts and how these might be pregnancy (rather
(1.02-1.03) misinterpreted. No.31 (2013) Small than for fetal
Be familiar with the full range of 1,2 for gestational age anomaly which is
(1.03) Optimise image for Doppler 1,2 optimisation controls including, Power, Able to explain the use of 1,2,3, fetus, investigation covered in ASM2.)
ultrasound. gain, focal length, magnification, sector antenatal ultrasound and the 4 and management.
width, frame rate, pulse repetition benefits of the different Your evidence
frequency, colour and power Doppler modalities along with the (1.13) should be
(1.04) Understand benefits of and 1,2 modes. transabdominal and transvaginal Scientific impact supported by a
indications for other imaging route. paper No.33 log of sessions
modalities, 3D, 4D, and MRI. (1.04) Preterm labour, attended and
Uterine artery Doppler Be familiar with local policies for the use 1,2 (1.05-1.12) antibiotics and work-placed
and interpretation of 3D/4D ultrasound and Able to apply ultrasound finding 1,2,3 cerebral palsy. based
fetal MRI. to local and Regional guidelines, assessments
(1.05) Umbilical artery Doppler 1,2 referring as appropriate. (1.16) demonstrating
(1.05- 1.07) RCOG Green top good
Doppler ultrasound: understand when to 1,2 (1.14) guideline No. 20a communication
(1.06) Middle Cerebral artery
1,2 use Doppler ultrasound and its Able to liaise appropriately to 1,2,3 ECV to reduce skills,
Doppler, including vMax
interpretation explore option of amniodrainage breech documentation
for polyhydramnios. presentation. and recording of
(1.07) Ductus Venosus Doppler Understand how these assessments are 1,2 growth and
1,2 used to monitor growth restriction. (1.09-1.15) (1.11-1.12) anatomy.
Able to explain ultrasound 1,2,3, NICE Clinical
(1.08) Cervical length Understand how fetal anomalies may 1,2 findings and management options 4 Guideline CG 129 (1.05-1.5)
Ultrasound competency for the 1,2 influence the waveforms (for example in a manner that is non- Management of Work-placed
screening, diagnosis and cardiac arrhythmias, fetal anaemia, judgemental and easy to twin and triplet based
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management including timely 1,2 hydrops, and twin-twin transfusion understand. pregnancies in the assessments
referral of: syndrome). antenatal period. should include
Understand how MCA vMax is used to 1,2 (1.09-1.16) abnormal values
(1.09) Severe early onset fetal monitor for signs of anaemia Able to formulate a suitable RCOG Green top and explore the
growth restriction management plan, liaising where 1,2,3, guideline N0.51 antenatal
(1.08) appropriate and always 4 Monochorionic management.
(1.10) Late onset fetal growth 1,2 Cervical length: transcervical measurement 1,2 considering the individuals hopes twin pregnancy.
restriction of cervical length, the criteria for accurate and expectations for the These are
and reproducible measurement. pregnancy. STRATOG common findings
(1.11) Twin pregnancy with growth 1,2 Advanced, Clinical and should be
discordance Recognises when cervical length should be 1,2 Case Studies based upon direct
offered. eLearning: patient care.
(1.12) Twin-twin transfusion 1,2 Management of
syndrome (1.09-1.10) the SGA fetus OSAT
Management of growth restriction 1,2 (2016).
(1.13) Suspected preterm ruptured 1,2 according to National Guidelines. When to CBD
membranes refer to the Tertiary Centre.
Reflective Practice
(1.14) Polyhydramnios 1,2 (1.11-1.12)
Multiple pregnancies: able to recognise and 1,2
(1.15) Low lying placenta manage growth discordance. Understand
1,2 the influence of chorionicity.
(1.16) Ultrasound guided For monochorionicity to be able to monitor
procedures: ECV for Breech 1,2 for signs of TTTS and refer to the tertiary
centre in accordance with local guidelines.
1,2 Aware of the ultrasound features of TRAP
(Twin reverse arterial perfusion sequence)
and conjoined twins.
(1.13)
Aware of the role and limitations of 1,2
ultrasound in the management of
suspected preterm ruptured membranes.
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(1.13-1.14)
Able to accurately and reproducibly 1,2
estimate liquor volume using maximum
vertical pocket.
Understands the associations of 1,2

polyhydramnios with poor maternal
glucose control, fetal anomalies, and its
significance in monochorionic pregnancies.
(1.15)
Able to identify the lower edge of the 1,2
placenta and measure the distance from
the internal cervical os.
Recognises when there is an increased risk 1,2

of morbidly adherent uterus (such as
previous scar to uterus with overlying
placenta).
(1.16)
Practical experience of performing 1,2
successful ECV according to local guidelines.
Aware of contraindications to ECV.
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ASM 1 - Advanced Obstetric Ultrasound Part of the Fetal Medicine ATSM and the High Risk Pregnancy ATSM
Competence level Not required

Logbook
Level 1 Level 2 Level 3
ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature
Effective and safe use of imaging modalities
Optimise image for 2D ultrasound.
Optimise image for Doppler ultrasound.
Understand benefits of and indications for other imaging

modalities, 3D, 4D, and MRI.
Uterine artery Doppler
Umbilical artery Doppler
Middle Cerebral artery Doppler, including vMax
Ductus Venosus Doppler
Cervical length
Ultrasound competency for the screening, diagnosis and management including timely referral of:
Severe early onset fetal growth restriction
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Logbook
ASM 1. Advanced Obstetric Ultrasound Date Signature Date Signature Date Signature
Late onset fetal growth restriction
Twin pregnancy with growth discordance
Twin-twin transfusion syndrome
Suspected preterm ruptured membranes
Polyhydramnios
Low lying placenta
Ultrasound guided procedures:
ECV for Breech
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Training Courses or sessions
Date
Title Signature of educational supervisor
Authorisation of signatures (to be completed by the clinical trainers)
Name of clinical trainer (please print) Signature of clinical trainer
Completion of ASM 1: Advanced Obstetric Ultrasound Date Signature
Comprising the safe and effective use of imaging modalities, the screening, diagnosis and
management of the at risk fetus. Level 3 is to the level expected within Secondary Care and includes
timely liaison with the MDT and Tertiary Centre when appropriate.
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ASM 6 Management of Key Obstetrical Medical Conditions

Hypertension (6.01-6.12) (6.01-6.12) (6.01) These represent

(6.01) Chronic hypertension 1,2 Detailed knowledge of the aetiology, 1,2 Able to make a thorough 1,2 NICE (2011) the core medical
incidence, recurrence risks, obstetric, assessment of a presenting Hypertension in conditions with
Renal medical & neonatal complications of these problem with appropriate Pregnancy which you should
(6.02) Hydronephrosis 1,2 key medical problems in pregnancy investigation and consideration of diagnosis and have a thorough
differential diagnoses management knowledge based
Gastrointestinal 1,2 Take an appropriate history and conduct an 1,2,3, (CG07). upon direct
(6.03) Obstetric cholestasis examination in a woman presenting with 4 Consider effects on fetus or 1,2 clinical
(6.04) Hyperemesis gravidarum the symptom / sign / abnormality. neonate when prescribing drugs (6.06) experience.
for mother Scientific impact
Endocrinology 1,2 Arrange appropriate investigations counsel 1,2,3, paper No. 23 The evidence
(6.05) Pre-existing diabetes without re maternal and fetal risks plan pregnancy, 4 Liaise with midwives and other 1,2,3 Diagnosis and should support
complications delivery and postnatal care health professionals to optimise treatment of this and may
patient management Gestational include the full
(6.06) Gestational diabetes 1,2 Understand the pathophysiology, 1,2 Diabetes. range of work
presentation and implications for maternal Use appropriate referral pathways 1,2 placed based
Respiratory 1,2 &/or fetal health of common late and local protocols NICE Guideline assessments
(6.07) Asthma pregnancy complication. NG3 (2015) along with a
Diabetes in record of any
Dermatology 1,2 Know the aetiology, incidence, 1,2 Pregnancy: relevant clinics
(6.08) Eczema pathophysiology, diagnosis, management, management from courses or
obstetric, medical & neonatal preconception to meetings
Neurological 1,2 complications, and recurrence risks of each the postnatal attended.
(6.09) Headache condition. period.
(6.10) Epilepsy (6.13- 6.15) RCOG Clinical

Understand the interpretation of each of 1,2 Green Top
Haematological 1,2 these investigations and how they are Guidelines:
(6.11) Thrombocytopenia influenced by pregnancy. 10A (Management
of preeclampsia/
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(6.12) Previous thromboembolic eclampsia)
disease
20a (External
Investigations 1,2 cephalic version
(6.13) ECG interpretation and reducing the
incidence of
(6.14) CXR interpretation breech
presentation)
(6.15) Blood gas interpretation
No. 20 (Breech
presentation,
management)
No.27 (Placenta
Praevia and
Placenta Praevia
Accreta: Diagnosis
and Management)
No. 43 (Obstetric
cholestasis)
RCOG Clinical
Green Top
Guideline 31 (Small
for gestational age:
fetus: investigation
and management)
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ASM 6. Management of Key Obstetric Medical Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM
Conditions.

Logbook
ASM 6. Management of key obstetric medical Date Signature Date Signature Date Signature
conditions
Hypertension
Chronic hypertension
Renal
Hydronephrosis
Gastrointestinal
Obstetric cholestasis
Gastrointestinal
Hyperemesis gravidarum
Endocrinology
Pre-existing diabetes without complications
Endocrinology
Gestational diabetes
Respiratory
Asthma
Dermatology
Eczema
Neurological
Headache
Neurological
Epilepsy
Haematological
Thrombocytopenia
10
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Logbook
ASM 6. Management of key obstetric medical Date Signature Date Signature Date Signature
conditions
Haematological
Previous thromboembolic disease
ECG interpretation
CXR interpretation
Blood gas interpretation
11
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Date
Completion of ASM 6: Management of Key Obstetric Medical Conditions Date Signature
Appropriate management of the key obstetric medical conditions in each trimester to the level
expected within secondary care and liaison with the tertiary centre when appropriate.
12
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ASM 7 High Risk Secondary to Environmental, Social and Lifestyle Factors
13
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Substance misuse 1,2 (7.01-7.03) (7.01-7.03) (7.01-7.04) (7.01-7.04)

(7.01) Current alcohol misuse Know the incidence, pharmacology, 1,2 Provide sympathetic support. 1,2,3, RCOG Statement 5 Record of
obstetric, medical & neonatal complications 4 (Alcohol attendance at drug
(7.02) Obstetric management for and legal consequences for the abuse of: Respect confidentiality. 1,2,3, consumption and / alcohol abuse
current opiate misuse alcohol, cannabis, opiates, cocaine and 4 the outcomes of clinic or relevant
crack cocaine, heroin, benzodiazepines, Recognise if there are issues 1,2,3 pregnancy). psychiatry clinic.
(7.03) Obstetric management for amphetamines, LSD, phencyclidine (angel relating to child protection and
current stimulant misuse. dust), solvent misuse and not forgetting where to seek advice. Work alongside
cigarette smoking. drug liaison
(7.04) MDT assisted conversion to Achieve harm minimisation in 1,2,3, midwife or
an opiate replacement programme Know their interactions with prescribed 1,2 partnership with women. 4 community team.
drugs and analgesia during labour.
Take an appropriate history and 1,2,3, OSAT
Understand the organization of dependency 1,2 examination. 4
services and links with psychiatric and CBD
social services; the theories of addiction Plan pregnancy, delivery and 1,2,3
and self-harming behaviours prevalence of postnatal care within a multi- Reflective Practice
psychiatric co-morbidity and its detection. disciplinary team.
(7.01-7.04) Talk to the drug dependency 1,2,3

Manage cases of alcohol or substance team, psychiatrists, social
abuse in pregnancy; arrange and interpret 1,2,3 services, pharmacists, midwives
appropriate maternal & fetal investigations and neonatologists understand
refer, where appropriate, for further their services and your role in
assessment. supporting the care they deliver.
(7.02-7.03) Counsel appropriately about: 1,2,3,

Knowledge of the law regarding class A and drinking / drug cessation 4
class B drugs. 1,2 maternal, fetal and neonatal risks:
long-term health implications,
Knowledge of the local and national viral and other infections breast-
strategies for reduction in drug and alcohol 1.2 feeding / contraception, effects of
misuse.
14
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risk taking behaviour.
(7.04)
Knowledge of neonatal management and (7.02)
outcome (incl. management of withdrawal Be able to explain the features of 1,2,3,
and long term effects). 1,2 neonatal withdrawal. 4
Teach the parents how to 1,2,3,

recognise signs of neonatal 4
withdrawal.
15
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Care of the Pregnant Teenager 1,2 (7.05 - 7.06) (7.05) (7.06)
(7.05) Mother <18 years Know the incidence, associated obstetric, 1,2 Ability to effectively 1,2,3, NICE guideline
medical & neonatal complications and legal communicate and respond to 4 CG110. (2010)
Social vulnerability 1,2 consequences of social disadvantage with the hopes and concerns of Pregnancy and
(7.06) Care plan for recent arrival to respect to: domestic violence, teenage pregnant teenagers. complex social
the UK pregnancy and asylum seekers. factors
(7.06) Understand when and 1,2,3
Understand the influence of ethnic & 1,2 how to use the different
religious background on obstetric agencies involved in processing
expectations and outcome. claims for asylum status and
meeting their practical needs
Knowledge of the law in relation to seeking 1,2 (Police, Home Office, Social
asylum. Services).
Be sensitive to the potential for 1,2,3

psychological and emotional
traumas previously experienced
by many asylum seekers.
Reflect upon the consequences 1,2,3

of being displaced from home,
community and country.
Obesity (BMI >40) 1,2

(7.07) Assessment of maternal risks (7.07 -7.09) (7.07-7.09) (7.07-7.09)
and counselling at booking. Know the incidence, associated obstetric, 1,2 Liaise with midwives and other 1,2,3 CMACE/RCOG Joint
medical & neonatal complications of the health professionals to optimise Guideline (2010)
(7.08) Fetal assessment. pregnant obese patient. patient management. Management of
women with
(7.09) Intrapartum obstetric and Understand the endocrinology of obesity 1,2 Provide care with sensitivity and 1,2,3, obesity in
anaesthetic care plan. empathy. 4 pregnancy.
Understand the place of weight reduction 1,2
strategies and appropriate nutrition in Provide specific practical advice to 1,2,3, Scientific impact
16
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managing the pregnant obese patient. reduce the maternal and fetal 4 paper No.18
risks of obesity during pregnancy Nutrition in
Understand the management of obesity 1,2 and birth. pregnancy.
and its complications during pregnancy.
Use appropriate referral pathways 1,2 NICE Guideline
Conduct a booking risk assessment and 1,2 and local protocols. Intrapartum Care
plan follow up visits and care. for High Risk
Women (in
Undertake antenatal (fetal and maternal) 1,2,3 development
assessment of the obese patient. 2017).
Arrange and interpret appropriate 1,2,3

investigations including screening for
gestational diabetes.
Recognise and manage health risks 1,2,3

associated with maternal obesity; the place
of weight reduction strategies and nutrition
17
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Domestic violence 1,2,3, (7.10) (7.10) (7.10)

(7.10) History taking and MDT care 4 Knowledge of the role of different agencies 1,2 Recognise the impact of domestic 1,2 STRATOG Core
plan (Social Services, Police, Voluntary groups) in violence on the physical, training: (2016)
the investigation of suspected domestic psychological and emotional Domestic abuse
violence and the protection of vulnerable health of women and their and substance
women and children. families. misuse.
Knowledge of the law in relation to physical 1,2 Be able to describe the role of 1,2,3,
and sexual assault, bodily harm and rape. support agencies and encourage 4
engagement if appropriate.
Women who decline blood 1,2 (7.11) (7.11) (7.11)

products Understand those Religious beliefs and 1,2 Assist in the construction of an 1,2,3, www.noblood.org
(7.11) Care-plan specific to customs that may affect healthcare or advanced directive detailing the 4 (No blood: blood
individual circumstances, for consent for medical interventions. acceptability or not of blood and management and
example Jehovah’s Witness. blood products and their use in avoidance)
Knowledge of the alternatives to blood 1,2 acute circumstances.
transfusion. RCOG Green top
guideline No. 47
Be familiar with the set up and use of cell- 1,2 Blood transfusion
salvage during surgery. in Obstetrics.
18
Colour key:
ASM 7 High Risk Secondary to Environmental, Social Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM
and Lifestyle Factors

Logbook
ASM 7 High Risk Secondary to Environmental, Social Date Signature Date Signature Date Signature
Substance misuse
Current alcohol misuse
Substance misuse
Obstetric management for current opiate misuse
Substance misuse
Obstetric management for current stimulant misuse
Substance misuse
MDT assisted conversion to an opiate replacement
programme
19
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Logbook
ASM 7 High Risk Secondary to Environmental, Social Date Signature Date Signature Date Signature
Care of the Pregnant Teenager
Mother <18 years
Social vulnerability
Care plan for recent arrival to the UK
Obesity (BMI >40)
Assessment of maternal risks and counselling at booking
Obesity (BMI >40)
Fetal assessment.
Obesity (BMI >40)
Intrapartum obstetric and anaesthetic care plan.
Domestic violence
History taking and MDT care plan
Women who decline blood products
Care plan specific to individual circumstances, for example
Jehovah’s Witness.
20
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Date
Completion of ASM 7: High Risk Secondary to Environmental, Social and Lifestyle Factors Date Signature
Appropriate management and liaison with the MDT for those pregnancies where environment,
social or lifestyle factors present significant risks. Experience supplemented by sessions outwith
Obstetrics and Gynaecology in high-risk clinics specialising in the treatment of substance misuse.
21
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ASM 8 High Risk Secondary to Medical and Obstetric Factors

(8.01-8.04)
Psychiatric Disorders 1,2 (8.01-8.04) (8.01-8.04) (8.01-8.04) Evidence of
(8.01) Chronic psychotic illness Know the prevalence, effects of pregnancy, 1,2 Take an appropriate history from 1,2,3, Mental Health Act attendance at:
management strategies and prognosis of a woman with psychiatric illness. 4 (1983) obstetric
(8.02) Mood disorder: chronic these psychiatric conditions. psychiatry or adult
depression / anxiety Be able to construct a differential 1,2,3, RCOG Good psychiatry clinics
Know the pharmacology, maternal, fetal, 1,2 diagnosis and advise on the 4 Practice Guideline and perinatal
(8.03) Bipolar illness neonatal and long-term effects of tricyclics, influence of the illness on No 14. psychiatry services
SSRIs, phenothiazines, butyrophenones pregnancy and pregnancy on the Management of where available.
(8.04) Postpartum psychosis (e.g. haloperidol), benzodiazepines, lithium illness. Women with
and carbamazepine. Mental Health (8.06-8.07)
Understand the concept of 1,2 issues during OSAT Cervical
Understand the legal issues (incl. Mental mental capacity, and how it is pregnancy and the cerclage.
Health Act and consent, child protection) 1,2 evaluated. postnatal period.
(8.01-8.16)
Know the risk factors, diagnostic features, Be able to advice on breast- 1,2,3, NICE guideline
natural history and prognosis (incl. 1,2 feeding. 4 CG192 (2015) Reflective practice
recurrence risks) of pregnancy- induced / Antenatal and
related psychiatric disease Be able to discuss the role of local 1,2,3, Postnatal Mental OSAT
specialty teams in the community 4 Health: clinical
Neonatal management (incl. withdrawal and hospital setting. management and CBD
and long term risks of drugs), legal issues 1,2 service guidance.
(incl. Mental Health Act and consent, child Understand the process for liaison 1,2,3 Evidence of
protection). and the criteria for referral to eLearning
specialist mother and baby units.
(8.05) These are
Recognise the potential for haemolytic Understand the role of primary relatively
disease of the new-born, the antenatal 1,2 care and liaise appropriately with 1,2,3 common
monitoring required and investigations the General Practitioner. scenarios and
needed after delivery. your evidence
(8.06- 8.11) Be aware of the variety of should wherever
22
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The ability to weight the evidence as it treatment options: supportive, 1,2 possible be based
relates to the patient’s previous obstetric 1,2 pharmacological, psychotherapy, on your direct
history for these common late pregnancy ECT. clinical
complications. experience.
Be able to discuss recurrence risks
(8.12-8.16) and how best to prepare for 1,2,3,
Know the incidence, risk factors, future pregnancies. 4
transmission risks, neonatal consequences, 1,2
long-term prognosis and management
strategies to reduce vertical transmission
of: Herpes Simplex (HSV), HIV, Hepatitis B &
C (HBV, HCV), Group B Streptococcus (GBS).
Detailed knowledge about bacterial and

viral infections with the potential for 1,2
vertical transmission (HIV, HBV, HCV, HSV,
GBS) and the strategies available to reduce
maternal, fetal and neonatal harm.
Know when and how to refer for further

assessment or treatment (especially HIV, 1,2,3
HBV HCV)
(8.13)
Give appropriate advice to an HIV positive
woman about interventions available to 1,2,3,
reduce vertical HIV transmission in 4
pregnancy
Advise on the use of acyclovir for

symptomatic treatment of genital HSV or 1,2,3,
for prophylaxis against recurrent attacks in 4
late pregnancy
23
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(8.14-8.15)
Assess risk for HBV or HCV infections and
arrange HBV vaccination ± 1,2,3
immunoglobulin appropriately for at risk
groups according to local protocol.
(8.16)
Understand how to construct a
management plan for pregnancy and 1,2
delivery in a woman found to be a carrier
of GBS.
Haematological 1,2 (8.05) (8.05) RCOG Green top

(8.05) Red cell alloimmunisation Recognise the potential for haemolytic 1,2,3 Able to liaise with paediatric 1,2,3 guideline
with normal fetal surveillance disease of the new-born, the antenatal colleagues to ensure timely No.22 Use of anti-
monitoring required and investigations delivery and assessment of HDN D.
needed after delivery. following delivery. No.65
Management of
red cell antibodies
in pregnancy.
Obstetric History 1,2 (8.06- 8.11) Liaise with midwives and other 1,2,3 RCOG Green top
The ability to weight the evidence as it 1,2 health professionals to optimise guidelines:
(8.06) Previous preterm delivery relates to the patient’s previous obstetric patient management. (8.06-8.07)
(<34 weeks) history for these common late pregnancy No. 7. Antenatal
complications. Use appropriate referral pathways 1,2,3 steroids.
(8.07) Previous recurrent second and local protocols.
trimester loss (8.08) No. 60
Cervical cerclage.
(8.08) Previous or suspected Explain correctly and put into the
cervical incompetence clinical context the ultrasound & (8.06-8.09) NICE
24
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Doppler findings. 1,2,3, Guideline NG25
(8.09) Suspected preterm rupture 4 (2015) Preterm
of the membranes labour and birth.
Use other fetal tests (e.g. CTG)
(8.10) Previous shoulder dystocia and maternal tests (e.g. blood (8.07-8.09)
investigations) in an appropriate 1,2,3 No 1b Preterm
(8.11) Recurrent antepartum fashion and be able to recognise labour and
haemorrhage deteriorating trends, which tocolytic drugs.
mandate action such as the need No.44 Preterm
for delivery. prelabour rupture
of membranes.
RCOG Scientific
impact paper
No.33 Preterm
labour antibiotics
and cerebral palsy.
(8.10)
Green top
guideline No.42
Shoulder dystocia
(8.11)
Green top
guideline No. 63.
Antepartum
haemorrhage.
25
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Infection 1,2 (8.12-8.16) (8.12-8.16) (8.12 -8.17)

(8.12) Genital Herpes diagnosed Know the incidence, risk factors, 1,2 Formulate, implement and where 1,2,3
before or during pregnancy transmission risks, neonatal appropriate modify a RCOG Green Top
consequences, long-term prognosis and multidisciplinary management Clinical Guidelines:
(8.13) HIV diagnosed before or management strategies to reduce vertical plan for HIV, HSV or Hepatitis No.30:
during pregnancy transmission of: Herpes Simplex (HSV), positive women. Management of
HIV, Hepatitis B & C (HBV, HCV), Group B genital herpes
(8.14) Hepatitis B diagnosed before Streptococcus (GBS). Counsel women and their 1,2,3, during pregnancy.
or during pregnancy partners om their management 4
Detailed knowledge about bacterial and 1,2 options including: No. 36: Prevention
(8.15) Hepatitis C diagnosed before viral infections with the potential for of Early Onset
or during pregnancy vertical transmission (HIV, HBV, HCV, HSV, - Risks / benefits of anti- retroviral Neonatal Group B
GBS) and the strategies available to therapy for HIV Streptococcal
(8.16) New diagnosis of Group B reduce maternal, fetal and neonatal harm. Disease.
Haemolytic Strep. - Risks/benefits of acyclovir
Know when and how to refer for further 1,2,3 treatment for HSV No. 39:
(8.17) New infection of varicella assessment or treatment (especially HIV, Management of
zoster in pregnancy HBV HCV) - Neonatal treatment and/or HIV in pregnancy.
vaccination
(8.13) No. 13 (2015)
Give appropriate advice to an HIV positive 1,2,3, - Long term outcome for mother Chicken Pox in
woman about interventions available to 4 and infant Pregnancy.
reduce vertical HIV transmission in
pregnancy Respect confidentiality. 4 RCOG Patient
information (2013)
Advise on the use of acyclovir for 1,2,3, HIV in pregnancy.
symptomatic treatment of genital HSV or 4
for prophylaxis against recurrent attacks in No 64a Sepsis in
late pregnancy pregnancy and
No64b. Sepsis
(8.14-8.15) following
Assess risk for HBV or HCV infections and 1,2 pregnancy.
26
Colour key:

arrange HBV vaccination ±
immunoglobulin appropriately for at risk Scientific Advisory
groups according to local protocol. Committee
Opinion paper 3
(8.16) (Intrauterine
Understand how to construct a 1,2 infection &
management plan for pregnancy and perinatal brain
delivery in a woman found to be a carrier injury)
of GBS.
(8.17) Give appropriate advice to women 1,2,3, NICE Guidelines
exposed to varicella zoster and instigate 4 (Antenatal Care,
the appropriate management for those Caesarean Section)
with confirmed infection.
27
Colour key:
ASM 8. High Risk Secondary to Medical and Obstetric Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM
Factors

Logbook
ASM 8. High Risk Secondary to Medical and Obstetric Date Signature Date Signature Date Signature
Factors
Psychiatric Disorders
Chronic psychotic illness
Mood disorder: chronic depression / anxiety
Bipolar illness
Postpartum psychosis
Haematological
Red cell alloimmunisation with normal fetal surveillance
Obstetric History
Previous preterm delivery (<34 weeks)
Obstetric History
Previous recurrent second trimester loss
Obstetric History
Previous or suspected cervical incompetence
Obstetric History
Suspected preterm rupture of the membranes
Obstetric History
Previous shoulder dystocia
28
Colour key:

Logbook
ASM 8. High Risk Secondary to Medical and Obstetric Date Signature Date Signature Date Signature
Factors
Obstetric History
Recurrent antepartum haemorrhage
Infection
Genital Herpes diagnosed before or during pregnancy
Infection
HIV diagnosed before or during pregnancy
Infection
Hepatitis B diagnosed before or during pregnancy
Infection
Hepatitis C diagnosed before or during pregnancy
Infection
New diagnosis of Group B Haemolytic Strep.
Infection
New infection of varicella zoster in pregnancy
29
Colour key:
Date
Completion of ASM 8: High Risk Secondary to Medical and Obstetric Factors Date Signature
Appropriate management and liaison with the MDT for those pregnancies where obstetric medical
problems present significant risks. Experience has been supplemented by sessions outwith
Obstetrics and Gynaecology in high-risk perinatal psychiatric clinics, Mother and Baby Unit,
haematology, infectious diseases and Genitourinary clinics.
30
Colour key:
ASM 9 Effective Communication and Clinical Governance Skills for High-Risk Pregnancy

Effective Communication (9.01-9.04) (9.02) (9.01) (9.01-9.0)

How to conduct an interview with a patient 1,2,3, Be able to explain the UK law as it 1,2,3, www.noblood.org/
(9.01) Explain any implications for 1,2,3, to identify their prior beliefs, expectations, 4 relates to female genital 4 (No blood: blood These are
the pregnancy and childbirth for 4 comprehension, priorities and fears. mutilation. management and communication
strongly held parental beliefs. avoidance) skills and the
How to lead a non-directive discussion of 1,2,3, (9.03-9.04) evidence should
(9.02) High risk for Fetal Genital 1,2,3, medical facts and explore the patient’s 4 Respect confidentiality. 4 (9.02) demonstrate this.
Mutilation. 4 responses and feelings to achieve joint RCOG Statement 3 Suitable evidence
decision-making. Liaise effectively with the MDT. 1,2,3 (Female Genital is:
(9.03) Early or pre-pregnancy 1,2,3, Mutilation)
counselling for on-going substance 4 How to break bad news and discuss difficult 1,3,4 Be able to discuss risk taking 1,2,3, Reflective practice
misuse. issues or uncertainty. behaviour and harm minimisation 4 RCOG Green top
in an informative, helpful but guideline N0.53 OSATS
(9.04) Early or pre-pregnancy 1,2,3, Bereavement processes and behaviour. 1,3,4 non-judgemental manner. (2015) FGM and its
counselling for on-going maternal 4 management. CBD
alcohol misuse. (9.02)
Knowledge of the UK and international laws 1,2 Department of Evidence of
and directives regarding Female Genital Health factsheet: eLearning
Mutilation (FGM). Understanding of the FGM in the serious
various FGM procedures and their crime Act 2015.
consequences, including for pregnancy and These are
delivery. (9.04) relatively
NICE Guideline common
(2011) CG115. scenarios and
Alcohol use your evidence
disorders, should be based
diagnosis on your direct
assessment and clinical
management of experience.
harmful drinking
31
Colour key:

and alcohol
dependence.
(9.05) Communication of the risks 1,2,3, (9.05) (9.05) (9.05)

of morbid obesity during pregnancy 4 Knowledge of the risks associated with 1,2 Ability to quantify the risks during 1,2,3, CMACE/RCOG
and childbirth. increased BMI in pregnancy and the pregnancy and minimise risks 4 Joint Guideline
postpartum and how these may be through use of (2010)
minimised. thromboprophylaxis and support Management of
services. women with
Knowledge of the steps that can be taken 1,2 obesity in
pre-pregnancy to reduce the risks of Able to discuss harm 1,2,3, pregnancy.
morbid obesity during pregnancy. minimisation constructively and 4
provide accurate and accessible RCOG Patient
information. information (2011)
Why your weight
Construct an individualised care 1,2,3, matters during
pathway for labour and delivery. 4 pregnancy and
after birth.
STRATOG
Advanced, Generic
Skills Case Studies
eLearning: Female
obesity in
obstetrics and
gynaecology a
primary care
perspective
(2015).
32
Colour key:

(9.06) Care plan for previous 1,2 (9.06-9.07) (9.07) (9.06-9.07)

stillbirth or adverse neonatal Construct a suitable care plan through an 1,2,3 Be able to communicate 1,2,3, RCOG Clinical
outcome. understanding of the aetiology of stillbirth effectively and sensitively with 4 Green Top
and the future monitoring and colleagues, patients and relatives. Guideline No.31
(9.07) Debrief after stillbirth or 1,2,3, management of such high-risk pregnancies. Small for
adverse neonatal outcome. 4 Be able to break bad news 1,3,4 gestational age:
appropriately and support fetus: investigation
distress. and management.
No. 55 (2010) Late

intrauterine 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.
33
Colour key:

(9.08) Discuss child protection 1,2,3 (9.08) (9.08) (9.08) (9.08)

concerns within MDT. Liaise with midwives and other health 1,2,3 Make relevant referral as a result 1,2,3 NICE Clinical Achieve a
professionals to optimise patient of domestic violence. guideline CG.89 minimum of level
management. (2009) When to 1 child protection
Use interpreting services 1,2,3 suspect child competence.
Empower and inform women to make 1,2,3, appropriately. maltreatment.
appropriate choices for herself and her 4 Reflective practice
family in pregnancy and childbirth. Conduct booking and follow up 1,2,3, within ePortfolio.
visits. 4
Achieve minimization of harm in 1,2,3,
partnership with women. 4 Arrange and interpret appropriate 1,2
investigations.
Identify and deal appropriately with 1,2,3
domestic violence and child protection Recognise health risks arising 1,2,3
issues. from previous / current social
problems.
Use appropriate referral pathways and 1,2,3
local protocols. Engage in organisation & running 1,2,3
of multidisciplinary pregnancy
(9.08) services to encompass the needs
Knowledge of the law relating to 1,2 of socially disadvantaged groups.
protection of children.
Act as local obstetric liaison for 1,2,3,
Knowledge of the role of different 1,2 groups with particular needs and 4
agencies in the care of children and social requirements.
investigation of concerns for their welfare
(Social Services, Health Visitors, Police, Engage in organisation & running 1,2,3
GPs, Community Paediatricians, of child protection procedures.
Community Psychiatric practitioners).
34
Colour key:

Governance
(9.09) (9.09) (9.09-9.14) (9.09-9.14)
(9.09) Demonstrate effective 1,2,3 Understand the definition of reflective 1,2 Ability to use reflective practice to 1,2,3, RCOG Clinical Reflective
reflective practice across a range of practice, and those models that may be demonstrate positive changes 4 Governance Advice practice.
scenarios (attach supporting used to support reflection learnt as a consequence of No.1c Producing a
evidence). challenging clinic encounters. clinical practice Relevant Audit or
(9.11-9.14) guideline. other Quality
(9.10) Produce a relevant Audit, 1,2 Knowledge of team working: Team 1,2,3 Improvement
Guideline or other Quality dynamics, with different roles and No.2 Improving Project.
Improvement Project (attach responsibilities for individual members. patient safety. Risk
supporting evidence). management for Log of risk
Influences, both positive and negative, on 1,2,3 maternity and management
(9.11) Lead Risk Management case 1,2,3 team development. gynaecology. cases.
review.
Understand the principles of delivering 1,2,3, No.5
(9.12) Work effectively within the 1,2,3 effective support, mentoring and 4 Understanding
MDT. motivation. Audit.
(9.13) Know when and how to refer 1,2,3 Implementing changes and progressing as 1,2,3 No.6 Obtaining
to support services (such as a team. valid consent.
psychiatric, medical, social services,
counselling) Leadership styles and behaviours. 1,3 GMC Leadership
and Management
(9.14) Demonstrate awareness of 1,2,3 for all doctors
own limitations, when to refer and (2012)
how best to share care and
monitoring. GMC Good
Medical Practice
(2013).
35
Colour key:
ASM 9. Effective Communication and Clinical Part of the High Risk Obstetrics ATSM and the Obstetric Medicine ATSM
Governance Skills for High-Risk Pregnancy

Logbook
ASM 9. Effective Communication and Clinical Governance Date Signature Date Signature Date Signature
Skills for High-Risk Pregnancy
Explain any implications for the pregnancy and childbirth for
strongly held parental beliefs.
High risk for Fetal Genital Mutilation.
Early or pre-pregnancy counselling for on-going substance

misuse.
Early or pre-pregnancy counselling for on-going maternal
alcohol misuse.
Communication of the risks of morbid obesity during
pregnancy and childbirth.
Care plan for previous stillbirth or adverse neonatal outcome.
Debrief after stillbirth or adverse neonatal outcome.
Discuss child protection concerns within MDT.
Governance
Demonstrate effective reflective practice across a range of scenarios (attach supporting evidence).
Produce a relevant Audit, Guideline or other Quality Improvement Project (attach supporting evidence).
Lead Risk Management case review.
36
Colour key:

Logbook
ASM 9. Effective Communication and Clinical Governance Date Signature Date Signature Date Signature
Skills for High-Risk Pregnancy
Work effectively within the MDT.
Know when and how to refer to support services (such as psychiatric, medical, social services, counselling)
Demonstrate awareness of own limitations, when to refer and how best to share care and monitoring.
37
Colour key:
Date
Completion of ASM 9: Effective Communication and Clinical Governance Skills for High- Date Signature
Risk Pregnancy
The full range of communication, professionalism and governance skills have been demonstrated
within the context of high-risk pregnancy.
38
Colour key:
39

High Risk Pregnancy Atsm 2018

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Colour key:

ASM 1. Advanced Obstetric Ultrasound.

ASM 1 Advanced Obstetric Ultrasound

Professional skills and Evidence/

Professional skills and Evidence/

Professional skills and Evidence/

Understands the associations of 1,2

Recognises when there is an increased risk 1,2

Competence level Not required

Optimise image for 2D ultrasound.

Optimise image for Doppler ultrasound.

Understand benefits of and indications for other imaging

Umbilical artery Doppler

Middle Cerebral artery Doppler, including vMax

Ductus Venosus Doppler

Severe early onset fetal growth restriction

Competence level Not required

Twin pregnancy with growth discordance

Twin-twin transfusion syndrome

Suspected preterm ruptured membranes

Low lying placenta

Ultrasound guided procedures:

ECV for Breech

Training Courses or sessions

Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

Completion of ASM 1: Advanced Obstetric Ultrasound Date Signature

ASM 6 Management of Key Obstetrical Medical Conditions

Professional skills and Evidence/

Hypertension (6.01-6.12) (6.01-6.12) (6.01) These represent

(6.10) Epilepsy (6.13- 6.15) RCOG Clinical

Professional skills and Evidence/

Competence level Not required

Competence level Not required

Blood gas interpretation

Training Courses or sessions

Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

Completion of ASM 6: Management of Key Obstetric Medical Conditions Date Signature

ASM 7 High Risk Secondary to Environmental, Social and Lifestyle Factors

Professional skills and Evidence/

Substance misuse 1,2 (7.01-7.03) (7.01-7.03) (7.01-7.04) (7.01-7.04)

(7.01-7.04) Talk to the drug dependency 1,2,3

(7.02-7.03) Counsel appropriately about: 1,2,3,

Professional skills and Evidence/

Teach the parents how to 1,2,3,

Professional skills and Evidence/

Be sensitive to the potential for 1,2,3

Reflect upon the consequences 1,2,3

Obesity (BMI >40) 1,2

Professional skills and Evidence/

Arrange and interpret appropriate 1,2,3

Recognise and manage health risks 1,2,3

Professional skills and Evidence/

Domestic violence 1,2,3, (7.10) (7.10) (7.10)

Women who decline blood 1,2 (7.11) (7.11) (7.11)

Competence level Not required

Competence level Not required

Training Courses or sessions

Authorisation of signatures (to be completed by the clinical trainers)

Name of clinical trainer (please print) Signature of clinical trainer

ASM 8 High Risk Secondary to Medical and Obstetric Factors

Professional skills and Evidence/

Professional skills and Evidence/