CHHS14/043

Canberra Hospital and Health ServicesOperational Guideline Eligibility for Birth Centre and Canberra Midwifery Program CareContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Background............................................................................................................................... 2

Inclusion Criteria.......................................................................................................................2

Booking Procedure....................................................................................................................3

Exclusion Criteria...................................................................................................................... 3

Booking Procedure....................................................................................................................8

Implementation........................................................................................................................ 8

Evaluation................................................................................................................................. 8

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Definition of Terms...................................................................................................................9

Search Terms.......................................................................................................................... 10

Consultation............................................................................................................................10

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Purpose

To optimise outcomes for women and their babies by ensuring that the place of birth within the Centenary Hospital for Women and Children(CHW&C) (birthing or birth centre) and model of care is appropriate to the woman’s needs. This document provides a framework to guide clinical decisions regarding the suitability of women wishing to give birth in the Birth Centre.

Scope

This document applies to: Medical Officers Midwives who are working within their scope of practice (Refer to Scope of Practice for

Nurses and Midwives Policy) Student Midwives, Medical Students under direct supervision.

Background

The Birth Centre provides an environment that promotes physiological birth. It is suitable for women planning an active birth who do not require ongoing obstetric surveillance in labour or continuous Cardiotograph (CTG) monitoring.

Women planning to give birth in the birth centre with the Canberra Midwifery Program (CMP) should also be suitable for midwifery led care through antenatal, labour, birth and the postnatal period. However, in order to promote continuity of care between pregnancies, women who have been a previous client of the CMP program, who do not meet the inclusion criteria for the birth centre in their current pregnancy and request care by a CMP midwife, may be cared for by a CMP midwife with regular obstetric review and a plan to give birth in the birth suite.

Inclusion Criteria

A woman with a normal (low) risk pregnancy and for whom an uncomplicated labour and birth can be anticipated is eligible to give birth in the Birth Centre.Normal risk includes; Absence of medical or obstetric risk factors that would require obstetric surveillance of

labour and birth (see exclusion criteria below) Singleton pregnancy Cephalic presentation Term pregnancy (37-42weeks)

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Booking Procedure

Women seeking a place in the Canberra Midwifery Program will be advised that their suitability for this model of care can only be confirmed following assessment by a health practitioner.

A midwife will conduct an initial screening assessment based on clinical history, by phone prior to scheduling a booking visit. If the woman meets the inclusion criteria and has no conditions listed in columns A or B in the attached table, she may be offered a place in the CMP and plan to give birth in the Birth Centre.

All women with conditions listed in column A must be assessed for suitability for this model of care following their booking in visit and after a collaborative meeting involving midwifery and obstetric input. Following a booking in visit where detailed clinical history and assessment has been conducted the case notes will be reviewed by a senior midwife, member of the CMP team and a designated obstetrician. These meetings will be schedule weekly. Booking with the CMP can only be confirmed for these women following agreement by the collaborative team and the aim will be to complete this process before 16 weeks gestation.

Low risk women who develop conditions in the exclusion criteria after 24 weeks gestation, can remain in the care of CMP but will need to deliver in Birthing not the Birth Centre.

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Exclusion Criteria

A. Conditions requiring individual assessment and consultation

B. Agreed Exclusions at commencement of care

Anaesthetic DifficultiesMalignant hyperthermia or neuromuscular disease or family history of the same

Previous anaesthetic complications (e.g. difficult intubation (decision to be informed by anaesthetic consultation early in pregnancy)

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Auto immune disorder/Connective tissue disorderInactive SLE without renal involvement or with skin/joint problems only

Active Systemic Lupus Erythematosis (SLE) or with major organ involvement or on Anti-phospholipid syndrome

Other autoimmune disease SclerodermaRheumatoid arthritisPeriartiritis nodosa,Marfan’s syndrome

Raynaud’s diseaseOther systemic rare conditions

Body Mass IndexPre pregnancy BMI of > 35(Advise woman of recommendation for repeat BMI at 36 weeks and if >40 plan for birth in BS with CEFM)

Pre pregnancy BMI of <18 or BMI >40

Cardiovascular disease:Benign heart murmurs Palpitations

Arrhythmia, murmurs:recurrent, persistent or associated with other symptomsOther cardiac disease Cardiac valve diseaseCardiac valve replacementCardiomyopathyCongenital cardiac diseaseChronic HypertensionIschaemic heart diseasePulmonary hypertension

Drug dependence or misuseRecent history of alcohol or other drug misuse Alcohol or other drug misuse – SUPS programme

care

A. Conditions requiring individual assessment and consultation

B. Agreed Exclusions at commencement of care

EndocrineAddison’s Disease, Cushing’sdisease or other endocrine disorder requiring treatment

Pre existing Type‐ I and Type II diabetesStable hypothyroidism hyperthyroidism or unstable hypothyroidism

Gastro-intestinalStable Inflammatory bowel disease including Crohn’s disease and ulcerative colitis

Liver disease with abnormal LFT’s

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HaematologicalCoagulation disorders including Von Willebrand’s Decline blood products (JW)Haemolytic anaemiaHemoglobinopathies including sickle cell disease, Thalassemia majorImmune thrombocytopenia or other platelet disordersAtypical antibodies, which carry the risk of

hemolytic disease of the newborn (decision to

informed by 1st Trimester assessment in FMU)

Rhesus antibodies

History of Thromboembolic disordersHistory of Thrombophilia with previous obstetric complications or Anti-phospholipid antibodies and hereditary thrombophilia other than MTHFR mutation

Infectious diseasesHIV- infection

High risk carriers of Hepatitis-B and Hepatitis-C Hepatitis B with positive serologyTuberculosis under treatment

Maternal ageAge: Primiparous women >40yrs (Advise woman of recommendation for IOL with CEFM at 39 weeks)

Age <16yrs

Multiparous women > 40yrs with other risk factors and previous obstetric complications (Advise woman of recommendation for IOL with CEFM at 39 weeks)

NeurologicalOther epilepsy Epilepsy with medication or seizure within last 12

monthsMyasthenia gravisPrevious cerebro vascular accidentAV malformationsSub-arachnoid hemorrhage, aneurysmsMuscular dystrophy or Myotonic dystrophy Multiple Spinal cord lesion (paraplegia or quadriplegia)

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A. Conditions requiring individual assessment and consultation

B. Agreed Exclusions at commencement of care

Organ transplantsAny organ transplant

Perinatal Mental Health ProblemsPuerperal PsychosisHistory of psychosis or other severe mental health issue requiring admission in the last

Renal diseaseAbnormal renal functionPrevious Kidney Surgery with potential to impair kidney function during pregnancy like removal of a KidneyRecurrent UTI’s with previous history of

pyelonephritisGlomerulonephritis

Any renal disease requiring consultation with a renal specialistnewborn

Respiratory diseaseCystic fibrosisSevere lung function disorder

Mild to moderate asthma Severe asthma on oral steroidsSarcoidosis

Skeletal problemsPelvic deformities due to (trauma, Symphysis rupture, rachitis)

Scheuermann’s disease

Spinal abnormalities Severe Kyphosis and Scoliosis with rodsHistory of developmental skeletal disorders Spondylolisthesis

Osteogenesis imperfectaPre-existing Gynecological disorders

Female genital mutilationFibroidsInfertility treatment Cervical amputation

Myomectomy and HysterotomyUterine Anomalies: Bicornuate uterus/Unicornuate uterus, Uterine Septum, Uterus didelphus, vaginal septum, or other Pelvic floor reconstruction surgery/ continence procedures/ Fistula repair

IUCD in situSingle LLETZ Cervical surgery like Cone biopsy /Multiple

LLETZ in a primiparous women or without a subsequent term delivery newborn

Abnormal pap smear results requiring regular follow up during pregnancy

Trophoblastic disease last 12 months

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A. Conditions requiring individual assessment and consultation

B. Agreed Exclusions at commencement of care

Previous Obstetrics History newbornPrevious Caesarean sectionPrevious PPH of >1000mlsPrevious pre eclampsia or eclampsia or HELLP Autoimmune thrombocytapaeniaPrevious ABO incompatability and Rh iso immunization Active blood incompatibilityIso-immunisation (ant-red cell antibodies and ant-platelet antibodies)Previous cervical suturing / cervical weaknessPrevious perinatal deathPrevious neonatal encephalopathyUterine rupture

Previous shoulder dystociaPrevious obstetric cholestasis

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Grand multiparity > 5Previous placental abruptionCongenital and /or hereditary disorder of a previous child

Previous history of placenta accretaPrevious third degree tear Fourth degree perineal tear in previous

pregnancy Persistent pelvic floor Previous preterm delivery / PPROM@<34weeksPrevious manual removal of placentaPrevious cervical tear

History of previous baby >4.5kg (Advise woman of recommendation for Ultrasound scan assessment of estimated fetal weight at 36 weeks and review of plan for place / timing / monitoring in labour History of previous intra-uterine growth restricted baby(IUGR) baby <10 percentilePrevious 3 x first trimester miscarriages without a term antecedent pregnancyPrevious 1 X Second trimester miscarriage in the antecedent pregnancy

OtherHistory of any malignancy within the last 2 yrs newborn Current malignancy

Indications in Present PregnancyLow PAPP-A of < 0.2

Thalassemia minor with significant anaemia at commencement of care (Hb <90)

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Booking Procedure

Women seeking a place in the Canberra Midwifery Program will be advised that their suitability for this model of care can only be confirmed following assessment by a health practitioner.

A midwife will conduct an initial screening assessment based on clinical history, by phone prior to scheduling a booking visit. If the woman meets the inclusion criteria and has no conditions listed in columns A or B in the attached table, she may be offered a place in the CMP and plan to give birth in the Birth Centre.

All women with conditions listed in column A must be assessed for suitability for this model of care following their booking in visit and after a collaborative meeting involving midwifery and obstetric input. Following a booking in visit where detailed clinical history and assessment has been conducted the case notes will be reviewed by a senior midwife, member of the CMP team and a designated obstetrician. These meetings will be

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CHHS14/043

schedule weekly. Booking with the CMP can only be confirmed for these women following agreement by the collaborative team and the aim will be to complete this process before 16 weeks gestation.

Low risk women who develop conditions in the exclusion criteria after 24 weeks gestation, can remain in the care of CMP but will need to deliver in Birthing not the Birth Centre.

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Implementation

This operational guideline will be discussed at the fortnightly Canberra Midwifery Program staff meeting and distributed to all staff via email. Copies will be displayed on notice boards and placed in tea rooms.

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Evaluation

Outcome MeasuresAll women planning birth in the Birth Centre will be managed according to this operational guideline clinical procedure. Where a deviation occurs the alternative management plan will be recorded in the Clinical notes in consultation with the Senior Registrar/consultants.

MethodCompliance with this operational guideline will be measured by Birthing Outcomes System audit.

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Related Policies, Procedures, Guidelines and Legislation

Maternity: Birth Centre eligibility criteria, Royal Darwin Hospital

National Midwifery Guidelines for Consultation and Referral, Australian College of Midwives,

3rd edition May 2013.

1.1.2.3 Exclusion Criteria to Low Risk Midwives Clinic, Section B, King Edward Memorial Hospital

Family Birth centre services, King Edward Memorial Hospital

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References

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CHHS14/043

Northern Territory Government, Royal Darwin Hospital (undated) Maternity: Birth Centre eligibility criteria

Australian College of Midwives (2013) National Midwifery Guidelines for Consultation and

Referral, 3rd edition

King Edward Memorial Hospital (2014) Exclusion Criteria to Low Risk Midwives Clinic, Section B, p 1-7

National Institute for Health and Care Excellence (NICE) ( 2007) Intrapartum care guideline, http://www.nice.org.uk/guidance/cg055

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) (2012) College Statement C-Obs 30. Maternal Suitability for Models of Care, and Indications for Referral within and Between Models of Care.

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Definition of Terms

Primiparous: woman who has not given birthMultiparous: woman who has given birth to a baby previous to this current pregnancyPlacenta accreta: a placenta which is morbidly adhered to the uterine wallGrand multiparity: a woman who has given birth to more than 6 babiesCardiotocograph (CTG): an electronic method of monitoring the fetal heart rate and maternal uterine contractions continuously

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Search Terms

Canberra Midwifery Program eligibility, CMP eligibity, continuity eligibility

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Consultation

NAME/POSITION/LOCATION (of person/s; groups consulted)

DATE FEEDBACK RECEIVED

FEEDBACK ACTION COMMENTS

Melissa Pearce 13/5/14 Incorporate changes

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Toby Angstmann 2/5/14 Unable to change CMP model to an all risk model.

Adair, StevenAlder, Wendy Bateman, KristiBates, LucyBergmann, TrudyClark, MadelineDavis, Deborah Dobson, JackyEling, JenniferFinlay, AnnFowler, Christine Hamilton, Emmalee Hindmarsh, SharonKnight, DavidMaher, Penny

May 2014 No feedback, happy with document

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

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