MATERNITY SERVICES
Level 5 Service Aligned to Department of Health (Vic) Capability Framework 2010.
South West Health Care Warrnamboolhas operated and maintained a maternity service for many years. The maternity service at Warrnambool is supported by Specialist Obstetricians, Paediatricians and GPs.
South West Healthcare is the primary referral centre for smaller rural services in the SW region. Portland, Terang, Camperdown & Timboon operating low risk services refer women with identified risk to consultants & specialists in Warrnambool. Neonates born at Western District Healthcare Hamilton, who require ongoing Paediatric Consultant care in the Special Care Nursery are transferred to SWHC Warrnambool.
Currently Warrnambool manages approximately 590 births annually. South West Healthcare (Warrnambool) provides medium – high risk maternity care to women throughout pregnancy and birthing continuum. Direct consultation & referral with level 6 Tertiary services located in Melbourne for women deemed ‘high risk’ with additional complexity.
This document, outlining the framework for the continuing provision of maternity care, must be read in conjunction with current policies, clinical practice guidelines\credentialing and performance indicators.
1BACKGROUND
While it is not possible to eliminate all potential adverse outcomes from a pregnancy and/or birth, it is possible to predict and minimise preventable adverse outcomes and reduce the likelihood of other adverse events occurring. This can be achieved by providing appropriate management and care of the pregnant woman from conception through to the postpartum period. Good management means that care is provided by the most appropriately qualified health professional or team of professionals, and in the most appropriate setting.
Whilst grouping women according to their associated risks is necessary to assist health care services develop and institute protocols and guidelines for admission and safe clinical practice, it is also critical that each pregnancy is considered and managed individually. Continued consideration of potential risks and ongoing review by health care professionals throughout each pregnancy is essential, given that adverse events can emerge unexpectedly even in low-risk pregnancies.
2. DEFINITIONS
1. Low Risk Admission Criteria– Suitable to birth at level 2 / 3 servcie
For the purposes of this framework, low risk pregnancies are those described in Table 1.1
2. Intermediate Risk Admission Criteria–Obstetric Consultation & Referral required
South West Healthcare Warrnambool
For the purposes of this framework, intermediate risk pregnancies are those described in Table 1.2.
Women may be suitable for care and \ or birth at their local community service (2 /3) or they may require transfer to a facility with the capacity and services to provide a higher level of care (Level 4 / 5)
Antenatal care should be provided in consultation with an obstetrician and / or other appropriate specialist.
It is highly likely women identified as having intermediate risk receives intrapartum care at SWHC Warrnambool.
3. High Risk Admission Criteria– for the purposes of this framework, high-risk pregnancies are those described in Table 1.3 and are not suitable to be booked to birth at a low level service (level 2 / 3).
Women in this category must have specialist Obstetrician care antenatally and for birth at South West Healthcare Warrnambool or level 6 Tertiary Centre.
4. Women and Babies who may to require Tertiary (Level 6) Care. – Established formal communication procedures with level 6 services.
- Discussion & negotiation with NETS / PERS.
- Discussion & negotiation with Specialist Consultants at SWHC Warrnambool
- Discussion & negotiation with Midwifery Manager / Nursing Supervisor (workforce availability).
Clinical Risk Management Assessment
- Experienced workforce availability (Specialist consultants, Anaesthetics, Midwifery)
For the purposes of this framework, high risk ‘complex’ women who may require tertiary care could include;
- Assessed ‘high risk complex’ by specialist anaesthetic team.
- Assessed ‘high risk complex’ Morbid Obesity
- Equipment not adequate to provide safe monitoring & care. (Ultrasound / fetal monitoring)
- Assessed ‘high risk complex’ no ICU or SCN beds available at SWHC Warrnambool
- Pre term labour < 32 weeks
- Skilled neonatal workforce availability
- Consultation, referral and transfer as directed by NETS.
- Pre existing complex medical conditions (e.g. Renal disease)
- Rare fetal disorder
- Haematological disorders
Capability framework – South West Healthcare Warrnambool Maternity Services
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ADMISSION GUIDELINES FOR PREGNANCY, BIRTHING AND POST PARTUM CARe
1.1 Low Risk Admission Criteria - Birthing atSOUTHWEST hEALTHCARE wARRNAMBOOL
(Level 2 / 3)
Low Risk Admission Criteria / Rationale & risk management strategiesAge between 18 – 40 years
At term – 37 – 42 weeks
Cephalic presentation
Singleton pregnancy
Longitudinal lie
Regular antenatal attendance
Multiparous with history of uneventful pregnancy
Maternal age less than 18
Maternal age greater than 40
Grand Multiparous
Late presentation for antenatal care
Group B Strep colonisation
Capability Framework for Victorian maternity and newborn services. Department of Health Victoria; August 2010
Capability framework – South West Healthcare Warrnambool Maternity Services
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1.2Intermediate Risk - Birthing at SOUTHWEST HEALTHCARE WARRNAMBOOL
Women identified in this category require consultation with Specialist Obstetrician
Highlighted = women who may require level 6 tertiary management +/- neonates at risk.
Intermediate Risk Admission Criteria: / Rationale & risk management strategiesMaternal Factors
Maternal Age Less than 18 years / Consultant Specialist Obstetrician
Maternal Age Greater than 40 years / Consultant Specialist Obstetrician
Obesity where BMI > 35 and <40 at 24 to 28 weeks gestation who is assessed as suitable for anaesthetic by independent GP anaesthetist / Consultant Specialist Obstetrician
Anaesthetic consultation – may require level 6 management if morbid obesity with complex medical problems / or monitoring equipment not sufficient for accurate monitoring.
Chronic illness – renal disease, cardiac disease, NIDDM / Consultant Specialist Obstetrician
Collaboration with treating Physician
May require level 6 tertiary management
Gestational Diabetic not on insulin / Consultant Specialist Obstetrician
Diabetic educator
Epilepsy / Consultant Specialist Obstetrician
Collaboration with treating Physician
Intermediate Risk Admission Criteria: / Rationale & risk management strategies
Maternal Factors (cont)
Hypertension (essential): a pre existing diagnosis of hypertension pre conception or before 20 weeks of pregnancy without apparent underlying cause
Systolic >= 135 mmHg
Diastolic >= 85 mmHg / Consultant Specialist Obstetrician
Collaboration with treating Physician
Uterine abnormality: where the lie of the foetus may be compromised / Consultant Specialist Obstetrician
Recent or recurrent drug abuse:
- Heroin
- Cocaine
- Methadone
- Stimulants
- Volatile agents (paint, glue, petrol)
Consultation with Paediatrician
Consultation with Women’s Alcohol & Drug Service (WADS)
- Cannabis
- Alcohol
- Bezodiazepam
Consultation with Women’s Alcohol & Drug Service (WADS
Injury to bony pelvis / Consultant Specialist Obstetrician
Current psychiatric disturbances / Consultant Specialist Obstetrician
Consultation with primary mental health team
Auto immune disease / Consultant Specialist Obstetrician
Collaboration with treating physician
May require level 6 consultation / management
Maternal Pyrexia (38 degrees) / Consultant Specialist Obstetrician / Registrar
Late presentation for A/N care / Consultant Specialist Obstetrician
Capability framework – South West Healthcare Warrnambool Maternity Services
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Intermediate Risk Admission Criteria: / Rationale & risk management strategiesObstetric Factors
Active genital herpes / Consultant Specialist Obstetrician
Grand Multiparous / Consultant Specialist Obstetrician
Previous Premature birth
< 34 weeks / Consultant Specialist Obstetrician
Previous difficult birth (difficult forceps, shoulder dystocia) / Consultant Specialist Obstetrician
Previous Post Partum Haemorrhage / Consultant Specialist Obstetrician
Previous Caesarean section (even when the woman has laboured successfully post caesarean section) / Consultant Specialist Obstetrician
Antepartum Haemorrhage,
‘time critical’ / Consultant Specialist Obstetrician
Cervical Incompetence/Cone biopsy / Consultant Specialist Obstetrician
Capability framework – South West Healthcare Warrnambool Maternity Services
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Intermediate Risk Admission Criteria: / Rationale & risk management strategiesObstetric Factors (cont)
More than 3 spontaneous or induced abortions / Consultant Specialist Obstetrician
Previous Severe Pre-eclampsia
- BP >= 170 / 110 during previous pregnancy associated with SGA
- Abnormal renal function tests
- Abnormal liver function tests
- Required parenteral antihypertensive during management of pre-eclampsia
- Required magnesium sulphate during management of pre-eclampsia
Pre-eclampsia - de novo hypertension after 20 weeks / Consultant Specialist Obstetrician
Investigate underlying causes – may include Level 6 (tertiary) management
Previous history of 3rd trimester IUGR or SGA / Consultant Specialist Obstetrician
Oligohydramnios / Consultant Specialist Obstetrician
Polyhydramnious / Consultant Specialist Obstetrician
Intrapartum Haemorrhage
‘time critical’ / Consultant Specialist Obstetrician
Prolonged rupture of membranes / Consultant Specialist Obstetrician
Group B Strep Colonisation / Consultant Specialist Obstetrician
Consultant Paediatrician
Intermediate Risk Admission Criteria: / Rationale & risk management strategies
Fetal Factors
Malpresentation/ Unstable lie persisting after 37 weeks / Consultant Specialist Obstetrician
Breech Presentation / Consultant Specialist Obstetrician
Known foetal abnormality / Consultant Specialist Obstetrician
Consultant Specialist Paediatrician – may require level 6 management
Suspected / confirmed FDIU / Consultant Specialist Obstetrician
Blood stained liquor on rupture of membranes
/ Consultant Specialist Obstetrician / registrar1.3 HIGH Risk Criteria – Suitable to Birth at SWHC Warrnambool.
High Risk Criteria – not permitted to birth at PDH nor eligible for admission or ongoing management. / Rationale & risk management strategiesHigher level care required
Consultant Obstetrician Management
Obstetric Factors
Premature labour < 37 weeks / Consultant Specialist Obstetrician
Multiple Pregnancy / Consultant Specialist Obstetrician
Post maturity beyond 42 weeks / Consultant Specialist Obstetrician
Suspected / confirmed IUGR / Consultant Specialist Paediatrician
Adequate equipment / workforce available / SCN cot
Significant macrosomia (Greater than 95 percentile) Large for dates (Primigravida) / Consultant Specialist Obstetrician
Pre-term Premature Rupture of Membranes (membranes rupture prior to 37 weeks) / Consultant Specialist Paediatrician
Placenta praevia Grade II, III and IV / Consultant Specialist Obstetrician
Capability framework – South West Healthcare Warrnambool Maternity Services
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High Risk CriteriaMaternal Factors / Rationale & risk management strategies
Higher level Care required
Insulin Dependent Diabetic / Consultant Specialist Physician
Severe anaemia / Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Obesity
where Booking BMI > 40 / Consultant Specialist Obstetrician
May require level 6 (tertiary) care
No antenatal care presents late in Pregnancy or in labour / Consultant Specialist Obstetrician
High Risk Criteria
Fetal Factors / Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Evidence of suspected foetal compromise at any gestation / Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Antenatal non-reassuring foetal status / foetal distress / Consultant Specialist Paediatrician
Rhesus iso-immunisation that develops during pregnancy / Consultant Specialist Obstetrician
Consultant Specialist Paediatrician
May require level 6 (tertiary) care
High Risk Criteria
Post partum Factors / Consultant Specialist Obstetrician
Post –partum eclampsia / Consultant Specialist Obstetrician
Uterine prolapsed / Consultant Specialist Obstetrician
Serious psychological problem / Consultant Specialist Obstetrician
Consultant Specialist Psychiatrist
Uterine rupture / Consultant Specialist Obstetrician
Capability framework – South West Healthcare Warrnambool Maternity Services
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Level 2 High Dependency SCN - Uncomplicated 32 weeks gestation or more, or birth weight at least 1300gms
High Risk CriteriaNeonatalConsultant Paediatrician on call 24 /7. Paediatric registrar or HMO on site 24 /7.
As per Neonatal Services Guidelines – Level 2 High Dependency / Rationale & risk management strategies
(Neonatal Handbook- )
Paediatric Consultation / Management. → Consultation with NETS → Transfer to level 6 tertiary hospital as discussed.
Any infant requiring 1:1 care > 4 hours post birth / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants with Perinatal / birth asphyxia / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants requiring > than 40% Oxygen to maintain O2 saturation >92% / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants with suspected congenital heart disease / Paediatric Consultation
May require transfer / birth at tertiary level 6 centre
Infants with significant or multiple congenital anomalies / Paediatric Consultation → Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
‘Unwell’ infants, manifested by lethargy, poor feeding, weak cry, cyanosis, vomiting, biliary vomiting / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Periods of apnoea and / or bradycardia / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Suspected sepsis / Paediatric Consultation / management
Level 2 SCN care
Infants with seizures / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants bleeding from any site / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Significant meconium aspiration / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Persistent hypothermia / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Jaundice / Paediatric Consultation
Level 2 SCN care
Infants <2000gms / Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants <2500gms / Paediatric Consultation
Level 2 SCN care
Hypoglycaemia (BSL < 2.0) not responding to oral feeds / Paediatric Consultation
Level 2 SCN care
Capability framework – South West Healthcare Warrnambool Maternity Services
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Level 5; Complexity of care, Infrastructure, Workforce, diagnostic services, Support Services,
Clinical Governance, Service Links, Education & Research.
(Ref; Capability Framework for Victorian Maternity & Newborn Services, 2010) pp 21 – 23.
Midwifery/ Nursing Staff
All nursing staff must have current registration with the Nurses Board of Victoria with midwifery endorsement
Midwives rostered 24hrs per day.
Designated midwife in charge with neonatal experience / managerial responsibility
Designated midwifery educator PPT or FT.
A neonatal / paediatric qualified nurse / midwife in charge of the SCN each shift it is occupied.
3.7 Continuing education & competency (DoH framework pp 4)
For the maintenance of competencies all health services should provide access to educational support for health professionals involved in pregnant and birthing women and their babies, in at least the following areas
- Antenatal & postnatal care
- Normal progress of labour
- CTG Interpretation
- Identification and management of maternity emergency situations
- Neonatal Resuscitation
- Basic / advanced adult Life support
Capacity to provide advanced Obstetric care 24/ 7 includes Caesarean Section.
Medical Staff
- 24hr / 7 day Specialist Obstetrician available for consultation
- Designated Obstetric registrar 24 / 7 or HMO
- Shared care program (GPs) available for low risk women from local area
- Consultant Anaesthetist Available 24 / 7
- Anaesthetic Registrar on site 24 /7
- Consultant Paediatrician on call / available as required.
- Paediatric registrar and / or HMO on site 24 / 7.
Capability framework – South West Healthcare Warrnambool Maternity Services
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