Team training for safer birth

Best Practice & Research Clinical Obstetrics and Gynaecology 29 (2015) 1044e1057

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Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn

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Team training for safer birth Dr Katie Cornthwaite, BA, MBBS, Academic Clinical Fellow in Obstetrics and Gynaecology, Mrs Mary Alvarez, RM, Registered Midwife, Dr Dimitrios Siassakos, MD (Research), MRCOG, MSc (Health Systems Management), PGDip.Med.Educ DLSHTM (Public Health), DFSRH, MBBS, Consultant Senior Lecturer on Obstetrics and Gynaecology * Women's Health, Chilterns, Southmead Hospital, BS10 5NB Bristol, UK

Keywords: teamwork training multi-professional situational awareness emergency communication

Effective and coordinated teamworking is key to achieving safe birth for mothers and babies. Confidential enquiries have repeatedly identified deficiencies in teamwork as factors contributing to poor maternal and neonatal outcomes. The ingredients of a successful multi-professional team are varied, but research has identified some fundamental teamwork behaviours, with good communication, proficient leadership and situational awareness at the heart. Simple, evidence-based methods in teamwork training can be seamlessly integrated into a core, mandatory obstetric emergency training. Training should be an enjoyable, inclusive and beneficial experience for members of staff. Training in teamwork can lead to improved clinical outcomes and better birth experience for women. © 2015 Elsevier Ltd. All rights reserved.

Background Birth is usually very safe in the developed world; however, it is not without risk [1]. One in six women in the UK faces a potentially life-threatening intrapartum emergency, with one in 12 labours resulting in poor maternal or neonatal outcome [2]. Obstetric emergencies can develop rapidly and unexpectedly, requiring an efficient and coordinated response from the multi-professional team. * Corresponding author. School of Clinical Sciences, University of Bristol, Women's Health, Chilterns, Southmead Hospital, BS10 5NB Bristol, UK. Fax: þ44 1179683464. E-mail address: [email protected] (D. Siassakos). http://dx.doi.org/10.1016/j.bpobgyn.2015.03.020 1521-6934/© 2015 Elsevier Ltd. All rights reserved.

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Fortunately, many of these emergencies are rare. Accordingly, combined with the mandatory reduction in working hours, it can be difficult for maternity staff to learn by experience alone. Training should provide an opportunity for members of staff to learn, refine and practise the necessary skills required to manage both the common and uncommon high-risk situations effectively. We should empower clinicians to feel confident, leading the management of obstetric emergencies; yet, evidence from research suggests otherwise. In a multicentre survey of 614 multi-professional staff in the USA, less than two-thirds of the participants replied that there was clear leadership in these situations [3]. In an Israeli study, in which 60 obstetric trainees and 84 midwives were video-recorded managing obstetric emergencies (eclampsia, shoulder dystocia, breech extraction and post-partum haemorrhage (PPH)), feedback indicated that 68% were not trained to take independent action in any of the four selected scenarios. Furthermore, 64% had never been required to lead the management of these emergencies in real life [4]. National confidential enquiries and medico-legal cases highlight the devastating consequences of suboptimal care resulting from inadequate experience, repeatedly citing poor teamwork as a factor contributing to poor outcomes [5,6]. Consequently, there has been a drive to promote effective teamwork training. In maternity, the 2004 King's Fund report ‘Safe Births: Everybody's business' advocated teamwork training for all maternity staff, highlighting the key issues of leadership and communication [7]. More recently, the Royal College of Obstetricians and Gynaecologists (RCOG) published ‘Becoming Tomorrow's Specialist’, which actively promotes teamworking and discourages clinicians from ‘working in isolation’. The report emphasises the need for effective teaching in multi-professional teamworking from the outset of training [8]. The primary recommendation in the most recent confidential enquiry, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE), is to tackle the ongoing problems with communication, clinical leadership and teamwork in maternity care. The report recognises that reduced hours and shift patterns present difficulties regarding training and continuity of care. It underlines the need for seniors to take responsibility for coordinating care, and it emphasises the importance of joint communication and agreement between midwives, obstetricians and anaesthetists when managing critically ill women [9]. The importance of teamwork training has been emphasised throughout the National Health Service (NHS). In 2008, a Patient Safety report from the House of Commons recommended that ‘those that work together should train together’, underlining skills such as teamwork, leadership and situational awareness [10]. This was echoed in the recent Keogh report, which highlighted the need for customised training in teamwork for all NHS staff [11]. This chapter summarises the most up-to-date research on how best to prepare maternity staff to deal with these high-stake emergencies, focussing on the risks involved, the core characteristics of an effective team and evidence-based training methods. Risks of poor teamwork The consequences of deficient communication and a lack of leadership are far reaching, and the stakes are high. Poor teamwork can result in huge physical, psychological and financial costs to those involved. Maternal risks Recognition of serious illness can be challenging in the obstetric population. Not only are pregnant women generally younger and fitter than the general medical population, but also the physiological adaptations of pregnancy can mask deterioration and conceal complications. Consequently, an awareness of the early warning signs is essential to improve detection of the critically ill pregnant patient and to avoid unwanted delays in effective management. Good teamwork and communication are vital. Maternal mortality Half of maternal deaths are avoidable [6]. Maternal cardiac arrest is a time-critical and rare event. Any delay in the recognition of a woman who is peri-arrest is perilous. Management requires all

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members of the multi-professional team to understand the key resuscitation steps, and to work together in a coordinated and efficient manner to avoid progression to maternal and foetal death. Knowledge of the appropriate resuscitation guidelines is essential, and clinicians need to act decisively to prevent unnecessary delays. However, these situations can be extremely stressful, and they are prone to error. A study of in-hospital cardiac arrests in the general, non-obstetric population revealed errors in 28.7% of arrests, resulting in decreased rates of survival [12]. Maternity teams not only need to provide effective resuscitation but also be trained to perform peri-mortem caesarean birth (PMCB) [13]. In the pregnant patient >20 weeks of gestation, resuscitation involves uninterrupted chest compressions (including during PMCB), left uterine displacement and PMCB started by 4 min to enable delivery by 5 min if initial resuscitation fails [14]. Time is of the essence. A review of maternal cardiac arrests showed that PMCB was performed sooner in surviving mothers and babies compared to those dying, and it recommended delivery within 10 min of arrest. Notably, PMCB was started within 4 min in only four out of 94 cases [15]. In order to achieve timely resuscitation and delivery, each member of the multi-professional team must have a defined role and communicate clearly and appropriately. However, observations from simulated maternal cardiac arrests highlight common weaknesses including poor communication, slow recognition of the warning signs and delay in initiating chest compressions [16]. The need for effective teamworking in these situations is emphasised in reviews of actual PMCB [13,15]. Confidential enquiries repeatedly recommend that all maternity staff undertake regular, documented and audited training in the management of critically unwell women to prevent progression to cardiac arrest, and maternal and foetal death [1,17,18]. However, the literature on the effect of training is conflicting. One study identified multiple deficits in team response to simulated maternal cardiac arrest despite team members having attended advanced life support [19]. Training should therefore ensure that staff understand both the underlying concepts of resuscitation and also have an opportunity to develop their teamworking skills. Maternal morbidity Effective teamworking is not only essential in resuscitation for cardiac arrest but also essential in the management of more common obstetric emergencies, such as PPH and severe sepsis [9]. Providing a prompt and effective treatment through improved teamwork and communication can prevent deterioration to hysterectomy, multiple organ dysfunction, coma, shock and admission to intensive care [1,20e22]. Birth experience Whilst the priority for maternity staff is safety for mother and baby, a woman's experience of her birth should also be a factor when delivering maternity care. Emergency situations can be frightening for women, particularly when obstetric intervention becomes necessary [23,24]. Dissatisfaction with labour and birth can lead to problems with breastfeeding and bonding, negatively impact on expectations for future births and have a detrimental effect on sexual function [25,26]. Communication between the woman and her companion, and those caring for her, is key [27,28]. Evidence shows that debriefing following the event is not beneficial, and it can even be harmful after traumatic events [29] or birth [30]. Maternity teams should therefore strive to explain the situation clearly and sensitively during the emergency, and staff should be trained accordingly [31].

Foetal risks Team training for obstetric emergencies should not only focus on the mother but also acknowledge the significant risks to babies of poor teamworking, and teach skills that can improve neonatal outcomes. Perinatal Mortality Deficiencies in communication and team training have been identified as the most common root causes for infant death in developed countries [6,7,32,33].

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Perinatal morbidity Inadequate teamwork in the management of emergencies such as shoulder dystocia or cord prolapse can have disastrous consequences including brachial plexus injury and cerebral palsy [34,35]. Although the management of shoulder dystocia typically focusses on the individual skills of the accoucheur, good teamwork and communication are crucial. The multicentre SaFE study revealed that participants training as individuals, rather than in teams, were more likely to miss critical steps to relieve the shoulder dystocia, such as McRoberts or applying suprapubic pressure [35e37]. Most cases of cerebral palsy are not associated with suboptimal care. However, misinterpretation of electronic foetal heart rate monitoring (EFM) leading to intrapartum asphyxia can result in spastic quadriplegic and athetoid cerebral palsy. Accordingly, the early recognition of deteriorating foetal monitoring and prompt involvement of the multi-professional team can prevent serious and unnecessary morbidity. Training should involve the implementation and dissemination of national guidelines that standardise the interpretation of EFM, and how to action worsening EFM [38e41]. Teamworking Teamworking is defined as the combined effective action of a group working towards a common goal [42]. Individuals with different roles should work together in a coordinated manner to achieve a successful outcome. Obstetric emergencies often develop quickly and without a warning, requiring a hasty formation of an ad hoc team. Members of the team may not have worked together before, and emergencies may occur consecutively or even simultaneously. As a result, there may be limited opportunity for teaching and debriefing. Research analysing behaviours of teams in simulated emergencies has identified key characteristics of effective teams. Knowledge, skills and attitude In order to competently manage obstetric emergencies, health-care professionals must have the underlying knowledge and skills required. However, whilst maternity staff may be inclined to report high levels of competence [43], important knowledge gaps have been identified [44]. Team training should address these deficiencies. The SaFE study demonstrated a definitive improvement in knowledge and skills following training, which was sustained at 6 and 12 months [4,45]. However, cross-sectional analysis of the pre-training data showed no correlation between conventional measures of knowledge, skills and attitude, and variation in team performance. Further analysis of both pre-training and post-training data revealed that clinical efficiency was dependent on generic teamwork scores instead [46], reflecting the need for staff to work as a team to effectively apply their knowledge and skills. Communication Clear and structured communication is essential to the functioning of an effective team. Members of the multi-professional team are typically of varying levels of seniority, necessitating unambiguous and non-threatening communication. The recent confidential enquiry, MBRRACE, identified deleterious communication deficiencies. These included disagreements and lack of communication regarding blood loss, and failure to escalate to seniors when the condition of a woman deteriorated [9]. Evidence from simulated emergencies and focus groups has shown the value of structured handover tools such as SBAR (clarify Situation and Background, make an Assessment and Recommendation) [47,48]. The use of these simple strategies can facilitate concise and informative handover between team members. MBRRACE specifically recommends the use of SBAR in situations where a prompt and decisive action is required [9]. Closed-loop communication should also be used. This ensures that information and allocation of tasks are appropriately interpreted and acted upon in emergency situations. The technique involves a team member clearly directing a message to a recipient, the recipient acknowledging and interpreting

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that message and confirming that the message has been correctly acted upon [47,48]. Team members should address recipients by their name or by establishing eye contact to avoid any ambiguity [48]. Research has shown that the use of directed and structured communication reduces error, improves team efficiency and results in better outcomes for patients [48e50]. Furthermore, transparent and comprehensible communication improves patient experience. The recent National Institute for Health and Care Excellence (NICE) intrapartum care guideline recommends that a designated team member is allocated to talk with the woman and her birth partner(s) to offer support and explain the situation throughout the emergency [51]. Done effectively, this can help to avoid undue psychological distress. Maternity staff should aim to explain the cause of the emergency, the condition of the baby and the aims of the management [28,47]. Audible and clear communication between members of staff can also facilitate this [47]. There is evidence that with clear verbalisation of tasks between team members, women and their partners might pick up what is happening; companions might even become ‘team members’ and communicate what is happening themselves to their pregnant partner [47]. Leadership Leadership is a complex skill. Leaders are expected to provide direction and structure by setting team objectives and establishing behavioural expectations [52]. Team leaders should also support and monitor the multi-professional team. Lack of leadership results in poor outcomes [53]. The recent MBRRACE report identified in maternal deaths lack of leadership, ownership and responsibility for patient care [9]. Unfortunately, until recently, there had been little evidence available to guide clinicians as to how best to establish effective leadership. However, recent research has identified some key characteristics of effective leadership. Leaders should have the knowledge and skills required to manage the situation. The leader should be the team member with the most experience of the emergency; they may not necessarily be the most senior [47]. For example, a junior doctor may have more recent and practical experience of anaphylaxis, whilst a senior midwife is likely to be more experienced in neonatal resuscitation than an obstetrician is. To aid task allocation, the leader should be aware of the roles and capabilities of the team members [47,54e56]. This can be achieved in advance at handover, or if unknown, by briefly stopping to clarify what team members can and cannot do. Leadership should be clearly declared or allocated verbally so that team members are aware of who is leading the emergency. It is vital that they communicate clearly using SBAR and allocate critical tasks using closed-loop communication. Finally, the team leader should focus on leading the emergency by avoiding performing tasks that can be done by other team members. This allows the leader to maintain a broader, ‘helicopter’ view. Situational awareness Situational awareness is a concept that was first defined in aviation. In obstetrics, it has been difficult to define and reliably measure [57,58]; however, put simply, it refers to knowing what is going on [57e59]. Multi-professional focus groups have identified three teachable components applicable to obstetric emergencies: establish the clinical situation, clarify the team abilities and remain aware of the need to communicate with the patient and partner(s) [47]. Although apparently simple, studies of simulated and real-life obstetric emergencies have revealed a paucity of situational awareness amongst maternity teams [60e63]. Shared mental methods Shared mental methods refer to the concept of a team having a shared objective and strategy to achieve it. Early and audible verbalisation of the situation or diagnosis (e.g., declaring ‘shoulder dystocia’) helps to focus the team members in order to ensure that everyone is working towards a common goal. This improves team performance, and it also helps to ensure that the woman and her partner are informed of the situation [53].

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Teamwork training e does it make a difference? Whilst these team characteristics may sound intuitive, they are often missing from teams in simulation or on the labour ward [28,47,64]. Historically, it has been difficult to assess the behavioural changes resulting from team training, with most evaluation tools relying on self-reporting and subjective assessment by observers [65]. However, more recently, clinical and social science methods have been employed to describe the specific teachable behaviours of effective teams [28,48], which can then be seamlessly incorporated into team training. It is essential that training translates into better outcomes for patients and health-care organisations. One study revealed that clinical performance prior to obstetric emergency training was worse for drills requiring multi-professional team effort, such as PPH and eclampsia, than those focussing on the skills of the individual accoucheur, such as shoulder dystocia and vaginal breech delivery. Notably, the performance improved following team-based simulation training, regardless of the scenario [4]. A retrospective observational study in a large UK maternity unit showed improved perinatal outcomes following the introduction of obstetric emergency training; brachial plexus injuries were reduced by 70% [66], whilst low Apgar scores (<7 at 5 min) and moderate, severe or total hypoxiceischaemic encephalopathy were almost halved [67]. In order to improve both patient safety and satisfaction, training should be designed to closely imitate the demands of a real-life labour ward [68]. Research has shown that ‘in-house’ training with patient actors is preferable to training at simulation centres using computerised patient mannequins, demonstrating higher safety and communication scores [68]. In simulation studies, patient actors' perception of care was significantly improved following training [69]. Moreover, obstetric lawsuits repeatedly identify communication shortages leading to patient concerns about their safety and adversely affecting patient satisfaction [70]. Team training can improve these deficiencies, thereby improving patient satisfaction [71]. Training also therefore has the potential to vastly reduce the associated litigation costs and insurance premiums [72,73]. Furthermore, clinicians enjoy multi-professional training [74]. Evidence shows that training not only improves knowledge and management of obstetric emergencies but also enhances confidence and communication skills [75]. A study using a validated tool to assess staff attitudes showed that maternity team training improves teamwork climate and fosters a positive safety culture [76]. Team training e how should it be delivered? Traditionally, lessons from the aviation industry have been applied to team training in medicine. Crew resource management (CRM) programmes have been effective in improving teamworking in emergency departments [77]. However, the same methods have failed to result in improvements in teamwork on labour wards [2]. In order to achieve better outcomes for mothers and babies, it is essential that team-training interventions are simple and relevant to the maternity care setting [78,79]. Therefore, research has focussed on the development of training tools that are specific and applicable to obstetric emergencies, typically involving ‘skills and drills’ training. However, despite the UK NHS Litigation Authority mandating annual multidisciplinary skills and drills training [73], only 51% of UK maternity units surveyed conducted such a training in 2003. Concerns about service provision and a perception of the training as threatening and stressful were predominantly to blame [80]. A multicentre study of teams in simulation, combined with inter-professional focus-group analysis, highlighted the need for teamwork training to include several methods suited to different learning styles and levels of seniority [47]. The following highlights a variety of evidence-based training interventions applicable to maternity care.

Guidelines and algorithms All members of the multi-professional team should have readily accessible, easy-to-understand and evidence-based guidelines available on the labour ward [1,33]. Training should provide an opportunity to implement and disseminate these [81]. Stickers summarising electronic foetal monitoring (EFM)

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guidance [67,82] and laminated algorithms [83] facilitate adherence, making it easy for the multidisciplinary team to be on the same page when managing an emergency. Simulation Simulation training bridges the gap between theory and real life [84]. Research has shown that simulation training translates into improvements in clinical management and communication skills in real life. Furthermore, individuals experience less anxiety when faced with real emergencies compared with their counterparts taught with lectures alone [75,85]. Simulation makes use of role-play, providing staff with an opportunity to work together and rehearse the management of a variety of obstetric emergencies. Health-care professionals are expected to actively participate and apply their teamworking skills. As new team members enter the scenario, staff can practise their handover skills, making use of techniques such as SBAR. Multi-professional teams Maternity care requires professionals with varying backgrounds, skills and knowledge to work together effectively as part of a multidisciplinary team. Traditionally, doctors and midwives attended separate training programmes serving to exacerbate inter-professional barriers. However, there has since been a move to encourage staff members who work together to train together. National bodies recommend that all members of the multi-professional team, including doctors, midwives, and allied workers such as health-care assistants and porters, attend the same training programmes [86]. This should ideally begin at the undergraduate level, when professional stereotyping may first develop [87e89]. Multi-professional training in a non-threatening environment helps to break down unnecessary and intimidating hierarchies [79,90]. Training should be enjoyable and inclusive, providing an opportunity for team bonding. In-house Local, ‘in-house’ simulation training allows members of the multi-professional team to train together in realistic settings. Delivery rooms or wards provide the best environmental fidelity for ‘skills and drills’ training, whilst a suitable seminar room can be used for lectures. The benefits of ‘in-house’ training are numerous. Not only is ‘in-house’ training potentially costeffective, but it can also result in significant improvements in real-life outcomes [91,92]. New members of staff are able to familiarise themselves with their working environment better preparing them to deal with emergencies in real life. ‘In-house’ training also allows for the identification of any local safety issues and the testing of local protocols. In one study, ‘in-house’ training highlighted that a patient bed could not pass through the doorway in two labour rooms. The door frame was subsequently widened, the decision to delivery time reduced and any potentially harmful delays avoided [92]. Although training in-house has been shown to be more successful in certain aspects than external training [71], dedicated simulation centres do afford uninterrupted training, free from the disruptions of a busy labour ward. Delivery rooms may not always be available for training use; reducing elective workload in advance can help. Another disadvantage of ‘in-house’ training is that not all units provide the same standards of training. Research is ongoing to assess what factors contribute to the variation in performance and outcomes following equivalent training programmes in different centres. Realism Simulation training should be as realistic as possible. Individuals should train within their usual professional role in which they have a better understanding of what is required and expected of them. This not only more accurately reflects real life [54], but is also potentially less daunting and stressful than training in a different role with which they may not be familiar [93]. Training should also provide an opportunity for members of the multi-professional team to develop their communication skills e using a patient actor can be invaluable [94,95]. Evidence shows that

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obstetric emergency training involving patient actors enhances communication between team members and women, when compared with those using high-technology mannequins [71]. Integrating a patient actor with a mannequin can be used to train emergencies requiring both verbal and specific manual skills such as shoulder dystocia or vaginal breech delivery [71,96]. A member of the multi-professional team with experience of the scenario can make an excellent patient. They gain an insight into the patient's perspective, and they can assist in further development by providing feedback to the team. In the PROMPT (PRactical Obstetric Multi-Professional Training) course, props are used to increase realism. These include trousers that bleed, blood-stained incontinence sheet and a perineum with a prolapsed cord [16,42]. These low-cost, low-technology props may be as effective as a more sophisticated equipment in increasing the realism of the scenario. Nonetheless, hightechnology simulators remain useful in the training of technical skills such as internal manoeuvres at shoulder dystocia [37]. Pictorial guidelines can also be used to improve the estimation of blood loss [97]. Leadership Research has helped identify particular characteristics and behaviours of effective leaders. These skills can be taught and integrated into team training: senior staff can employ them to further develop their leadership style, whilst junior staff can be given an opportunity to take on leadership roles in a simulated setting. Furthermore, training in teams allows junior doctors and midwives to learn leadership skills from their seniors. Additional research is required to further the development of evidencebased leadership training methods. Objectives and feedback Simulation scenarios should have clear and focussed learning objectives. These should be highlighted at the start of the training sessions, with any specific challenges or past errors highlighted. The primary goal of training should be safer birth for mother and baby, and objectives should reflect this. The scenarios should include the time for feedback, encouraging reflection and allowing the identification of training needs. Feedback should be constructive and linked to the outcome-based objectives. Team members observing the scenario can help provide a structured feedback by the completion of standardised checklists. Trainers can facilitate meaningful discussion and evaluation of the scenario [42], focussing on clinical outcomes. There is no need for formal, arbitrary testing of individual performance, which staff may find threatening and may discourage staff participation [76,98]. Positive actions should be emphasised and attendance encouraged [54,99]. Frequency of team training Clinical Negligence Scheme for Trusts (CNST) mandates annual multi-professional training and evidence shows that knowledge and skills are sustained for 12 months following training [45]. However, focus groups have shown that team members often do not know each other's names, roles or capabilities due to staff rotations and turnovers [47]. Although introductions at handover can minimise these issues, more frequent training on basic teamwork principles, for example, every 6 months, may help to tackle these problems more effectively. Other methods Additional training methods should be used alongside simulation training to suit different learning styles and training preferences, as identified by focus groups [47]. These can be used by all members of the multi-professional team, and not just doctors and midwives. Simulation scenarios can be videorecorded to encourage individuals to reflect and identify their own, personal learning needs. For those who feel intimidated by role-play, case-based discussions and debriefing following real-life emergencies can be particularly beneficial. Focus groups also suggested that junior doctors and midwives attend additional group teaching, without senior staff, in order to further their leadership skills.

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The goal of team training should be safer birth for mother and baby [35,67,92]. However, not all training programmes are equal. Outcomes should be continuously monitored in order to ensure that safety and quality are sustained following training [40]. Midwife's perspective Prior to the onset of annual team training, midwives were reliant on the skills they acquired as a student and experiential training from role models on the labour ward. There was no formal updating or enquiry into whether practices were research-based or indeed safe. For midwives, the introduction and implementation of team training has helped change the historically hierarchical and stereotypical culture of obstetrics, encouraging all grades of staff to contribute towards a common goal of improving maternal and neonatal outcomes. Training in teams gives midwives a safe and non-judgemental forum in which to practise the core skills required in the clinical setting [79,90]. Scenarios from both the hospital and community setting are used, and they do not allow for specific singling out of weak staff but build on existing knowledge to foster learning and development. The midwife has a crucial role to play in the early detection of abnormalities in labour. The transfer of clear, concise information between the midwife coordinator, medical staff and the woman and her labour partner is vital for a safe working environment [13,15,16]. Team training emphasises the early recognition of abnormalities. The introduction of cardiotocograph (CTG), maternal obstetric early warning score (MOEWS) and SBAR pro formas has given the midwife added perspective and clarity, which aids communication and the subsequent prompt initiation of care. Discussion using historical cases allows the midwife to reflect on poor or exemplary care. As part of effective teamworking, the midwife can use her unique relationship to prepare women for invasive procedures and to communicate any potential or actual problems [31]. In addition to disseminating knowledge and transferable skills, obstetric drills address the more subtle teamwork behaviours that would not have been considered in the basic training. The need for clarification regarding roles and responsibilities of each team member is vital for the midwife coordinator. Training in leadership and handover is also invaluable, especially when there is a delay in obstetric, anaesthetic or neonatal assistance, and she is required to instigate the initial management of an emergency. Making it evident that they are in charge and the use of closed-loop communication can facilitate the allocation of critical tasks in an emergency [47,48,100]. Situational awareness is undeniably key to effective teamwork [57,58], and it is particularly relevant to the midwife coordinator. The three components have been described as knowing your staff and their capabilities, establishing the clinical situation and background, and articulating the information for all attending the emergency to hear [47]. Midwives can implement this to facilitate appropriate allocation at handover, maintain a ‘helicopter view’ of the labour ward and clearly and concisely communicate the nature of any ensuing emergency to attending colleagues. This helps to prevent panic and disorganisation in the management of high-risk cases. The increased confidence and practical know-how gained result in greater autonomy and improved management of emergencies, with subsequent reductions in maternal and neonatal morbidity [1,20e22]. The future Recent research has shaped our understanding of the key ingredients of an effective team, and it has helped identify teachable teamwork behaviours. We no longer use generic, aviation models of training, but, instead, make use of training programmes specifically designed to improve outcomes in obstetrics. Our understanding of how best to devise and deliver team training primarily comes from simulation studies and focus-group analysis. Ongoing research using these methods will continue to advance our knowledge, whilst future studies analysing real-life obstetric emergencies may provide yet more clues. Further research is required to strengthen the evidence base with regard to leadership training. Studies investigating the key factors, which result in training working in some units but not others, will also be of great benefit. We must involve maternity service users in ongoing research so that we can learn from

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their invaluable experiences and observations. Safer birth should be the priority for all professionals working in maternity units across the UK, and we must work as a team to achieve it. Summary Obstetric emergencies can develop rapidly, requiring a swift and coordinated response from a multi-professional team. National bodies and confidential enquiries have repeatedly identified deficiencies in teamwork, communication and leadership. Maternity units across the UK are being encouraged to make concerted efforts to improve these shortages. A lack of leadership and clear communication can lead to devastating consequences including maternal and perinatal death. Simulation studies and focus-group analyses have helped identify the key ingredients of an effective maternity team. Essential knowledge and skills, transparent and concise communication, proficient leadership and shared objectives are paramount. Training in these simple teamwork behaviours can make a significant difference to the effectiveness of a team. The primary objective of training should be to improve clinical outcomes and patient experience. Training should be an enjoyable and beneficial experience for all members of staff. We should avoid unnecessary and intimidating authority gradients. Training ‘in-house’ allows members of the multi-professional team to train together, and it might also be cost-effective. Patient actors provide an opportunity for staff to practise and develop their communication skills, whilst low-cost props improve environmental fidelity. It is crucial that clinical outcomes are monitored following the implementation of training programmes, to ensure that training achieves its desired objective. Training in teams improves teamwork, but not all training is effective; both methods and contents should be evidence-based, to save mothers and babies and improve the maternity experience for all families.

Practice Points  Deficiencies in teamwork and communication continue to hinder the management of obstetric emergencies  The consequences of deficient teamwork are far reaching  Improving teamwork and leadership is a national priority  Successful teamworking is multi-factorial  Teachable teamwork behaviours have been identified  Teamwork training should be seamlessly integrated into an obstetric emergency training  In-house, inter-professional training using patient actors is cost-effective and successful  Simulation training is advocated by national bodies  Additional training methods have been identified, which can be used alongside simulation training

Research Agenda  Further analysis of teamwork and leadership behaviours using  Simulation studies  Observation of real-life obstetric emergencies (direct and video-recorded)  Maternity service user interviews  Leadership training methodology  Investigation and identification of obstacles affecting the successful implementation of teamtraining programmes  Further examination of human factors resulting in poor team performance  Application of teamwork and team-training principles to other specialties  Comprehensive and systematic evaluation of new training programmes

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Disclosure of interests (1) DS receives funding by Sands; (2) none of the authors owns stock, or hold stock options, in any obstetric emergency training company; (3) none of the authors' spouses, partners or children has any financial relationships that may be relevant to the submitted work; and (4) DS is a member of the PROMPT Maternity Foundation, a UK-based charity running training courses. He has no financial interest from this association.

Conflict of interest statement Mrs Alvarez is working on study supported by Ferring, but is paid by her hospital. Dr Siassakos is a member of PROMPT Maternity Foundation and has no financial interest from this association. He collaborates with Limbs&Things in the design of simulation models. Dr Cornthwaite has no conflict of interest to declare. References [1] Lewis G, editor. The confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. [2] Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol 2007;109(1):48e55. [3] Guise JM, Segel SY, Larison K, et al. STORC safety initiative: a multicentre survey on preparedness & confidence in obstetric emergencies. Quality & Safety in Health Care 2010;19:x-6. [4] Maslovitz S, Barkai G, Lessing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007;109(6):1295e300. [5] Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med 1999;34(3):373e83. [6] Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1e203. [7] King's Fund. Safe Births: everybody's business. An independent enquiry into the safety of maternity services in England. London: King's Fund; 2008. [8] RCOG. Becoming Tomorrow’s Specialist: Lifelong professional development for specialist in women’s health. Working Party Report; 2014. [9] on behalf of MBRRACE- UK. In: Knight M, Kenyon S, Brocklehurst P, et al., editors. Saving Lives, improving mothers’ care - lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009e12. Oxford: National Perinatal Epidemiology Unit; 2014. University of Oxford. [10] Health Committee, House of Commons. Patient safety, sixth report of session 2008-09. The Stationery Office Limited; 2009. [11] Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. NHS England 2013. [12] Ornato JP, Peberdy MA, Reid RD, et al. Impact of resuscitation system errors on survival from in-hospital cardiac arrest. Resuscitation 2012;83:63e9. [13] Smith A, Edwards S, Siassakos D. Effective team training to improve outcomes in maternal collapse and perimortem caesarean section. Resuscitation 2012;83:1183e4. [14] Soar J, Monsieurs KG, Ballance JH, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation. Resuscitation 2010;81:1434e44. [15] Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation 2012;83:1191e200. [16] Bristol Practical Obstetric Multi-Professional Training (PROMPT). 2009. [17] Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004. [18] Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305e52. [19] Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. American Journal of Obstetrics and Gynecology 2010;203. 179 e1e5. [20] Knight M. Antenatal pulmonary embolism: risk factors, management and outcomes. Bjog 2008;115:453e61. [21] Knight M. Peripartum hysterectomy in the UK: management and outcomes of the associated haemorrhage. Bjog 2007; 114:1380e7. [22] Knight M. Eclampsia in the United Kingdom 2005. BJOG 2007;114:1072e8.

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