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Time to introduce resident consultants overnight in Obstetrics and Gynaecology

Lessons learnt from confidential enquiries into maternal deaths have been published since 1954 in the UK and we have significantly improved our obstetric practices and have made childbirth safer over the years in the country.

The Royal College of Obstetricians and Gynaecologists even published a document in 2010 to summarize the minimal standards of organisation and delivery of care on labour ward. Also the RCOG document “The Future Role of Consultant”, emphasised the importance of obstetricians to be present at the delivery suite and defined the number of consultant obstetric cover required for a unit depending on the number of deliveries.

Obstetric emergency drills, mandatory CTG training package, maternity risk management strategies and maternity dash boards are few of the other advanced obstetric activities to improve maternal and foetal outcomes.

However, the European Working Time Directives was introduced in 2007 limiting the number of junior doctor hours at work on the delivery suite shift. Along with this PMETB introduced reduction in the training time period for obstetric and gynaecology trainees. With reduction in the junior doctor working hours and reduction in their training, we ended up with junior doctors being trained in less time period with less number of training hours and hence less experienced trainees on delivery suite.

We are also faced with increasing maternal morbidity due to rising caesarean section rates along with high maternal BMI and increasing maternal age.

There are implications for a shortage of experienced staff in the delivery suite especially at night. The activity of the delivery suite is the same 24/7. We do not have experienced Registrars 24/7 as in the past to cover night shifts. Moreover, it has been reported by the “Hospital at Night” project 2009, NPSA and BMA that maternal and neonatal morbidity is higher if a woman delivers out of hours.

Moreover, the cost to the NHS of litigation in maternity services over a 10 year period from 2000 to 2010 was £3.1 billion resulting in 1 in 1000 births ending in litigation.

In addition, the NHS Hospitals are paying out a significant amount of money to cover locum doctor shifts on the Delivery Suite. With all these factors affecting the speciality, the Royal College of Obstetricians and Gynaecologist are now recommending 24/7 delivery suite cover by obstetrician consultants for safe maternal and foetal outcome.

At night, a resident consultant obstetrician provides the right advice and service to a labouring woman, at the time during labour when they need it. The resident consultant also avoids unnecessary admissions of patients when they present in acute gynaecology with acute gynae complaints. Hence improving not only obstetric but also acute gynaecology services in out of hours time.

This has an impact also on continuity of care during the day for patients. Moreover resident obstetricians and gynaecologists are better able to supervise and train juniors and complete their work based assessments including OSATS even on the night shift. The consultants will have more hands on experience and more time off work during the day time which could be used for their professional development and could also be beneficial for consultants with young families.

One of the challenges or arguments against resident consultant posts is the expense. But it is wrong to believe that resident consultants are expensive for the NHS trust. If we look at the wider picture, resident consultants during the day time will be an asset to the Unit doing all other clinical activities for example, gynae clinics, antenatal clinics, day unit and main theatres, helping the trust to achieve targets.

Another argument against resident consultants is the introduction of a two tier consultant level. To avoid this, colleagues should treat their resident colleagues as equal and help them to integrate in the unit. There are examples of where this has worked. Tiredness is also a questionable argument as consultants are off during the day and the following day after a night shift.

I worked as a resident consultant for over three years alongside day time gynaecological sessions in York. York Hospital has resident consultant Obstetrician and Gynaecologists since 2010 and has demonstrated a decrease in caesarean sections at night and more successful trials in the presence of resident consultants. The advantages of resident consultants have been presented by the unit at national conferences.

It’s time now to seriously think of introducing resident consultants across the country to improve mother and baby outcome. It should be seen as a progression as it will provide better quality of care to patients.

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