Download maternity services

MATERNITY SERVICES
Level 2 / 3 Service Aligned to Department of Health (Vic) Capability Framework 2010.
Camperdown hospital has operated and maintained a maternity service for many years. The maternity service at
Camperdown is supported by GP proceduralists located in Camperdown and Terang, and consultant Obstetricians
located at South West Healthcare Warrnambool.
Currently Camperdown manages approximately 70 births annually. In conjunction with local General Practitioners
and Consultant Obstetricians, the health service provides low – risk maternity care to women throughout the birthing
continuum.
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.
1 BACKGROUND
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.
It is difficult to determine a definition of a low risk pregnancy. Women within the low-risk group have the potential to
become high-risk at any stage of the pregnancy or birth process, and women in the high-risk group can have a
perfectly normal birth, despite increased levels of surveillance and medical intervention.
Therefore, regular risk assessment for women expecting to have a normal pregnancy and birth is necessary. This is
important to assist health professionals identify and prevent the onset of various complications, and guide decisions
that determine the most appropriate care. This would include an articulation of where and by whom that care is
provided.
Camperdown Capability Framework – Maternity Services 2010
2. DEFINITIONS
Low Risk Admission Criteria – Suitable to birth at Camperdown
For the purposes of this framework, low risk pregnancies are those described in Table 1.1
Intermediate Risk Admission Criteria – Obstetric Consultation & Referral required
Transfer to 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 Camperdown or they may require transfer to a facility with the
capacity and services to provide a higher level of care.
Antenatal care should be provided in consultation with an obstetrician and / or other appropriate specialists. A
management plan for individual cases should be made at 34-36 weeks.
It is highly likely women identified as having intermediate risk with receive intrapartum care at SWHC Warrnambool.
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 Camperdown.
Women in this category must have specialist care antenatally and for birth.
For those women who present or rapidly progress to high-risk cases, emergency management protocols
must be followed and transfer\retrieval organised as soon as possible.
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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ADMISSION GUIDELINES FOR PREGNANCY, BIRTHING AND POST PARTUM CARE
1.1 LOW RISK ADMISSION CRITERIA FOR MATERNITY CARE & BIRTHING AT CAMPERDOWN HOSPITAL
Low Risk Admission Criteria
Age 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
Rationale & risk management strategies
Must be induced and birthed before 42 weeks or transferred
Para 5 or more requires further consideration – see grand multiparous
Consultation with Obstetrician required
Consultation with Obstetrician required
Consultation with Obstetrician required
Consultation with Obstetrician required
Variance (1) no regular AN care received (2) regular AN care elsewhere.
As per clinical practice guideline
12/08/2017 Authorised by Dr Chris Beaton; Consultant Obstetrician SWHC
Capability Framework for Victorian maternity and newborn services. Department of Health Victoria; August 2010
www.health.vic.gov.au/maternitycare>
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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1.2 INTERMEDIATE RISK ADMISSION CRITERIA FOR BIRTHING AT CAMPERDOWN HOSPITAL
Intermediate Risk Admission Criteria:
Maternal Factors
Maternal Age Less than 18 years
Maternal Age Greater than 40 years
Rationale & risk management strategies
Consultation with Obstetrician
Increasing maternal age is proportionate to increase in maternal morbidity and mortality.
Obstetrician consultation is required to assess suitability of birthing at Camperdown
Consideration to birth at Camperdown after consultation if no other compounding risk factors.
Obesity where BMI > 35 and <40 at 24 Determine other risk factors
to 28 weeks gestation who is assessed May need ultrasound late in pregnancy to determine approximate size and lie of baby.
as suitable for anaesthetic by Consult obstetrician as to suitability for birth at Camperdown
independent GP anaesthetist
Chronic illness – renal disease, cardiac Requires care of a physician and obstetrician during pregnancy as close monitoring of the pregnancy required with possible
induction of labour prior to term.
disease, NIDDM
Not suitable to birth at Camperdown
Gestational Diabetic not on insulin
Epilepsy
Antenatal Consultation with Obstetric Consultant.
May birth at Camperdown if:
 Has Regular antenatal care
 Has consultation and education with Diabetes Educator
 BSL are consistently well controlled within normal limits throughout the pregnancy
 Postnatal neonatal management is able to be met within staffing levels at the time
Requires detailed morphology scan
Consultation and close monitoring with obstetrician and neurologist / physician antenatally
Intrapartum care at higher level service
Not suitable to birth at Camperdown
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Maternal Factors (cont)
Hypertension (essential): a pre existing
Consultation with obstetrician required antenatal.
diagnosis of hypertension pre conception or Consideration to birth at Camperdown per Obstetrician consultation & direction
before 20 weeks of pregnancy without
apparent underlying cause
Systolic >= 135 mmHg
Diastolic >= 85 mmHg
Uterine abnormality: where the lie of the
foetus may be compromised
Recent or recurrent drug abuse:
 Heroin
 Cocaine
 Methadone
 Stimulants
 Volatile agents (paint, glue, petrol)



Cannabis
Alcohol
Bezodiazepam
Injury to bony pelvis
Current psychiatric disturbances
Auto immune disease
Maternal Pyrexia (38 degrees)
Late presentation for A/N care
Consultation with obstetrician required antenatal.
Some women will require LUSCS or transfer depending upon type and degree of abnormality.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Not for birth at Camperdown
Antenatal consultation with obstetrician
Individual cases at the discretion of the whole maternity team with an individual plan allowing for postnatal monitoring of the
baby.
Consideration to birth at Camperdown per Obstetrician consultation & direction
If mother wishes vaginal birth, pelvic adequacy must be assessed
Mother must be informed of increased risk of need for analgesia (epidural) in labour.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Need for psychiatric/mental health review early in pregnancy as may need to change or cease current medication.
If stable,
Consideration to birth at Camperdown per Obstetrician consultation & direction
Involve Community Mental Health Services in Discharge Planning.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Consideration to birth at Camperdown per Obstetrician consultation & direction
Requires consultation and assessment by obstetrician. (as per table 1.1)
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Obstetric Factors
Active genital herpes
May require caesarean section if vesicles present at time of presentation. May require acyclovir prophylaxis from
36 weeks. If recurrent and no vesicles, or if has vesicles but membranes ruptured for more than 4 hrs, no benefit to
LUSCS.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Grand Multiparous
Increased risk of postpartum haemorrhage, incoordinate labour, unstable lie.
If lie unstable monitor foetus
IV access during labour.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous Premature birth
Increased incidence of re-occurrence requiring availability of neonatal and paediatric services
< 34 weeks
Monitor carefully antenatally
AN consultation with obstetrician (progestogens not used)
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous difficult birth (difficult forceps, May require elective caesarean or induction of labour at or pre term.
shoulder dystocia)
Potential for reoccurrence and possible benefit vs. risk of LUSCS to be clearly documented in antenatal record.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous Post Partum Haemorrhage
Must have blood X-matched and available & established IV (16G or 18G) access during labour.
Active Third Stage (Use Ergometrine 250mcg 500mcg IM, given with antiemetic)
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous Caesarean section (even
VBAC is not available at Camperdown unless there is not 24 hour C/S capability.
when the woman has laboured
Refer to capacity framework flowchart.
successfully post caesarean section)
Consideration to birth at Camperdown per Obstetrician consultation & direction
Antepartum Haemorrhage,
Significant APH transfer if time permits.
‘time critical’
Increased risk of re-occurrence and SGA requires close monitoring.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Cervical Incompetence/Cone biopsy
If stitch in situ will require removal of suture at approximately 36 – 37 weeks by Consultant Obstetrician
Birth may then proceed at Camperdown if not additional risk factors or complications indicating care in larger facility
Consideration to birth at Camperdown per Obstetrician consultation & direction
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Obstetric Factors (cont)
More than 3 spontaneous or induced Providing there are no other medical or obstetric indications for continued care in larger facility.
abortions
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous Severe Pre-eclampsia
Increased risk of developing Pre eclampsia in next pregnancy (20% chance of re-occurrence overall)
 BP >= 170 / 110 during previous
Increased frequency of visits required
pregnancy associated with SGA
Close monitoring of pregnancy
 Abnormal renal function tests
Increased risk of need for induction of labour preterm if it recurs.

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Abnormal liver function tests
Required parenteral antihypertensive
during management of pre-eclampsia
Required magnesium sulphate during
management of pre-eclampsia
Consideration to birth at Camperdown per Obstetrician consultation & direction
Pre-eclampsia - de novo hypertension
after 20 weeks
Obstetric care may require ongoing investigation and induction of labour or caesarean section, risk of placental
insufficiency and intra uterine growth restriction.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Previous history of 3rd trimester IUGR Increased chance of re-occurrence.
or SGA
May require detailed scan to eliminate reoccurrence- then able to be cared for at Camperdown according to the
mother’s wishes, providing there are no other medical or obstetric indications for continued care in larger facility.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Oligohydramnios
Antenatal consultation with Obstetrician
Not suitable to birth at Camperdown
Polyhydramnious
Antenatal consultation with obstetrician
Assess degree of polyhydramnious. GTT recommended
Foetal abnormalities can be the cause, increased risk of cord prolapse, premature labour and abruption placenta.
Discussion with obstetrician required.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Intrapartum Haemorrhage
Requires immediate assisted delivery if able or LUSCS or transfer if birth is not imminent.
‘time critical’
Consultation with Obstetrician / PERS / NETS
Prolonged rupture of membranes
Increased risk of infection, requires continuous CTG monitoring in labour, commence IV therapy if greater than
18hrs.
Speculum Examination Minimal vaginal digital examination.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Group B Strep Colonisation
Refer to clinical practice guideline
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Fetal Factors
Malpresentation/ Unstable lie persisting Dependant upon position/lie at onset of labour and if persistent, elective LUSCS or transfer out.
after 37 weeks
Consideration to birth at Camperdown per Obstetrician consultation & direction
Breech Presentation
Known foetal abnormality
Suspected / confirmed FDIU
Blood stained liquor on rupture of
membranes
Consultation with Obstetrician to discuss options.
i.e. ECV
Intrapartum care at higher level facility.
Consideration to birth at Camperdown per Obstetrician consultation & direction
Refer to PSANZ guidelines
May require induction of labour and epidural, risk of disseminating intravascular coagulation,
Facility should offer choice of post mortem and detailed investigations
Consideration to birth at Camperdown per Obstetrician consultation & direction
Blood stained liquor is usually foetal blood from vasa praevia and needs urgent birth.
Ongoing management should be discussed with Obstetrician at secondary facility.
Transfer if the birth is not imminent. (SWHC)
Transfer guidelines level 2 / 3 services

Established links with surrounding level 1 and 2 health services regarding consultation, referral and patient transfer

Established links with geographically appropriate health services with higher levels of care regarding consultation, referral and patient
transfer.

Formal transfer guidelines need to be established
Communication guidelines to other services
 Established communication links with surrounding level 1 & 2 health services and practitioners
 Established formal communication procedures with higher level units to facilitate the links described above.
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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1.3 HIGH Risk Criteria – Not suitable to Birth at Camperdown hospital Nor Eligible for Admission for Ongoing Management
High Risk Criteria – not permitted to Rationale & risk management strategies
birth at PDH nor eligible for admission or
ongoing management.
Higher level care required
Obstetric Factors
Premature labour < 37 weeks
NOT SUITABLE TO BIRTH AT CAMPERDOWN
Multiple Pregnancy
Post maturity beyond 42 weeks
Suspected / confirmed IUGR
Significant macrosomia (Greater than
95 percentile) Large for dates
(Primigravida)
Pre-term Premature Rupture of
Membranes (membranes rupture prior
to 37 weeks)
Placenta praevia Grade II, III and IV
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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High Risk Criteria
Maternal Factors
Insulin Dependent Diabetic
Severe anaemia
Obesity
where Booking BMI > 40
No antenatal care presents late in
Pregnancy or in labour
Rationale & risk management strategies
Higher level Care required
NOT SUITABLE TO BIRTH AT CAMPERDOWN
High Risk Criteria
Rationale & risk management strategies
Fetal Factors
Higher level Care required
Evidence of suspected foetal
NOT SUITABLE TO BIRTH AT CAMPERDOWN
compromise at any gestation
Antenatal non-reassuring foetal status /
foetal distress
Rhesus iso-immunisation that develops
during pregnancy
NOTE: High Risk Presentations with Imminent Delivery are special circumstances where even high risk deliveries will need to be
managed locally.
Those women presenting with conditions that would normally exclude them from delivery at Camperdown, that present in established
labour and where transfer would be unsafe will require local intrapartum management, in consultation with specialist obstetricians and
paediatricians as required.
ALERT: Intrapartum Transfer
 Whilst it is ideal that likely complications requiring specialist obstetric services are identified so that transfer can occur prior to established labour
 If complications do arise, OBGYN at SWHC is notified, consider LUSCS (if available) and where there is foetal compromise it is recommended to have
PERS and NETS involved.
 If considering intrapartum transfer, the risks of transfer must be weighed against the risks that optimal care may not be able to be provided at
Camperdown. Therefore, it is important that transfer is considered as early as possible.
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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High Risk Criteria
Post partum Factors
Post –partum eclampsia
Uterine prolapsed
Serious psychological problem
Uterine rupture
Rationale & risk management strategies
High Risk Criteria
Neonatal Factors–transfer out
Any infant requiring 1:1 care > 4 hours post birth
Infants with Perinatal / birth asphyxia
Infants requiring > than 40% Oxygen to maintain O2 saturation
>92%
Infants with suspected congenital heart disease
Infants with significant or multiple congenital anomalies
‘Unwell’ infants, manifested by lethargy, poor feeding, weak cry,
cyanosis, vomiting, biliary vomiting
Periods of apnoea and / or bradycardia
Suspected sepsis
Infants with seizures
Infants bleeding from any site
Significant meconium aspiration
Persistent hypothermia
Jaundice
Rationale & risk management strategies
(Neonatal Handbook- http://www.rch.org.au)
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Specialist Obstetrician management in higher level facility
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Infants <2000gms
Infants <2500gms
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
If early onset or increasing jaundice of unknown origin medical consultation &
investigation.
Consult with Paediatrician or NETS prepare to transport to a higher level care facility
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Hypoglycaemia (BSL < 2.0) not responding to oral feeds
Paediatric Consultation & referral SWHC / NETS → Transfer out as advised
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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MINIMUM EDUCATION REQUIREMENTS FOR STAFF
Midwifery Staff
All nursing staff must have current registration with the Nurses Board of Victoria with midwifery
endorsement
Midwifery skill / knowledge requirements (CPD) – Currency of practice
 Neonatal resuscitation

Adult BLS / includes resuscitation of the pregnant woman

Perineal suturing

IV cannulation

Obstetric Emergencies
o Breech
o APH / PPH
o Shoulder Dystocia
o Cord Prolapse
o Retained placenta / Snapped cord

Electronic Foetal Surveillance

Breastfeeding
Medical Staff
Reciprocal Arrangements proceduralists GPs Terang / Camperdown. Shared Obstetric consultation and
direction & support SWHC Warrnambool
Medical roster forecast denoting on call / medical availability (level 2 / 3 capability framework requirement).
MINIMUM STAFF REQUIREMENTS
1 midwife with second back up midwife or GP for birth.
These minimum staffing levels are to be used as a guide. Good clinical judgement should prevail when it
comes to deciding whether the situation requires greater numbers of staff. If in doubt more staff should be
called in at the discretion of the lead midwife or senior midwife on duty, or transfer to a larger facility should
be arranged
Labour
Once a woman is in established labour, the ratio of midwife to mother is 1:1. The midwife should not have
any other patient load
Induction of Labour
The ratio of midwife to mother is 1:1
Birthing
For the purposes of this category it is assumed that no women are admitted who fall into the high risk
criteria
All Vaginal Births
1 midwife for first stage with medical consultation as needed.
1 GP or 1 midwife, plus 2nd midwife present for second stage.
Progressive handover / update to Obstetrician on call at SWHC as required
Careful consideration if no C/S team available in case of failed instrumental delivery.
Capability framework – Camperdown Maternity Services
Authorised by Dr. Chris Beaton; Consultant Obstetrician;
December 2010
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Safe Practice Framework – guidelines