Maternity and Newborn Services - WA Health · · 2012-04-19meet both health and family needs so that the health outcomes for mothers and ... Maternity and Newborn Services Services

WA Country Health Service

Maternity and Newborn Services

This information is available in alternative formats upon request

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Effective: 10 September 2011

TITLE: MATERNITY AND NEWBORN SERVICES

1. PREFACE The WA Country Health Service is the largest country health system in Australia and one of the biggest in the world. It covers an area of 2.5 million square kilometres servicing a regional population of 454,000 people. WA Country Health Service hospitals handle per year as many emergency department presentations as those in the metropolitan area and nearly as many births as the State’s major maternity hospital, King Edward Memorial Hospital. The WA Country Health Service is committed to:

ensuring service safety and quality are a priority, while providing access to maternity and newborn services as close as possible to where people live

supporting communities, mothers and families to be fully informed about service availability, the evidence for decision-making, and the benefits and risks associated with service access options, and

working with Aboriginal communities and families to develop services that better meet both health and family needs so that the health outcomes for mothers and newborns improve

working with other service providers to improve service capacity and access. Balancing Safety and Preferred Service Access Getting the balance right between safety, maximum service access and sustaining services is the commitment the WA Country Health Service makes to country communities and consumers.

The availability of a skilled medical, midwifery, nursing, allied health and Aboriginal health workforce as well as the ability to maximise safety underpins every service decision.

Healthy questioning about the balance between service safety and greater access by policy makers, service providers, clinicians, communities and consumers prompt consideration of both:

clinical evidence about service safety and

the service access needs of mothers, families and communities. Families and communities are keen to have maternity services available locally, including birthing services. Being away from family, homelands and their community during pregnancy and birthing is not what a family wants. Equally, when complications arise it is an expectation of consumers and families, that the required care and services are available and that these services are safe. Clinicians and health services are given the responsibility of care for the mother and newborn and they seek to reduce risk and make the delivery and outcome as safe as possible.

These are the service needs and views that

inform this document.


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In the process of compiling this document, clinical evidence has been reviewed to ensure the standards are up to date and relevant. Consumers’ views were heard in consultations, particularly across the Pilbara and Wheatbelt, where health related consultations were occurring.

The Importance of Ante Natal, Post Natal and Early Childhood Care Understandably, there is strong focus on the birthing event. To have a safe and satisfying birth, effective antenatal care is essential. Effective post natal care must follow to support the wellbeing of the mother and child. It is important that maternity and newborn services are seen as a continuum of care including pre-pregnancy, antenatal, intrapartum, birthing and post natal, moving to early childhood development. The social determinants of health such as education, income and environment all influence the level of poverty, nutrition, education and health awareness of communities and individuals. To achieve healthy mothers and babies requires all services to advocate, lobby and actively work to improve the wellbeing of communities in the spirit of “It takes a community to raise a child”. The WA Country Health Service is one of many maternity and newborn service providers. General practitioners, Aboriginal Community Controlled Health Organisations, medical and allied health specialists, community midwives, tertiary and private hospitals are also significant service providers. It is vital that this network of services partners communicates effectively to achieve the best care for families, mothers and babies.

Enquiries about the WACHS Maternity and Newborn Services document can be directed to WACHS Regional Medical and Nursing Directors or to:

Melissa Vernon: [email protected] or Terri Barrett: [email protected] or Dr Diane Mohen: [email protected]

The Maternity and Newborn Services Working Group

Extensive consultation has been undertaken with the WACHS Medical and Nurse Directors and the WACHS Obstetric and Gynaecology Clinical Advisory and Patient Safety Group.

Melissa Vernon. WACHS Executive Director Primary Health and Engagement - Convenor Maternity and Newborn Services.

Dr Diane Mohen. Clinical Expert. WACHS Obstetrics and Gynaecology Clinical Lead, Obstetric Director (Rural) Statewide Obstetric Support Unit.

Terri Barrett. Clinical Expert. Drafting Maternity Standards and Guidelines. Midwifery Director Statewide Obstetric Support Unit.

Kate Reynolds. Regional Clinical Expert. Nurse Unit Manager. Maternity and Paediatrics Bunbury Regional Hospital. WACHS South West.

Marianne Slattery. Regional Clinical Expert/ Regional Nurse Director Representative. Regional Nurse Director WACHS South West.

This WACHS Maternity and Newborn Services document informs clinicians, service managers and communities about where services can be

delivered and the standards that apply to these services.

It also identifies that seasonal and skilled workforce shortages occurring in certain areas may necessitate temporary downgrading of local service

levels until such time as safe staffing and services can be resumed.

mailto:[email protected]�




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2. INDEX

Maternity and Newborn Services Services – Introduction ................................ 5

Maternity and Newborn Services Area and Regional Planning Guide ..................9

Strategic and Background Documents – A Quick Summary ........................... 11

WA Country Health Service Regional Resource Centres, Integrated District Health Services and Smaller Hospitals ................................. 13

WA Country Health Service Maternity and Newborn Service Guidelines Levels 1-5 Based on WA Health Clinical Service Framework

WACHS Maternity Service Guidelines Levels 1 -5 ...................................... 18

WACHS Newborn Service Guidelines Levels 1 - 5 ...................................... 28

Minimum Maternal and Newborn Equipment and Medication List..................... 37

WACHS Maternity & Newborn Services Governance Structure ...................... 41

APPENDICES ........................................................................................................43

APPENDIX 1: Strategic Background Documents, Models of Care Descriptions and Clinical Safety & Quality ............................................. 44

APPENDIX 2: WA Health Clinical Service Framework – Designated Levels for Obstetrics and Neonates .................................................. 51

APPENDIX 3: Maternity and Neonatal Services by Level ............................. 56

APPENDIX 4: WACHS Maternity and Neonatal Referral Guideline Summary for Service Levels .............................................................. 57

APPENDIX 5: Client Information Sheet - Sample ....................................... 62

APPENDIX 6: Clinician Fact Sheet related to Client Information Sheet ............. 66

APPENDIX 7: Post Natal Care Decision Making Tree ................................. 69

APPENDIX 8: Maternal and Newborns Models of Care Implementation Principles................................................. 70

ABBREVIATIONS AND GLOSSARY ...................................................... 79

Relevant Reading............................................................................. 80


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WACHS Maternity and Newborn Services

Introduction The WA Country Health Service is geographically the largest Western Australian area health service and the largest country health system in Australia with 70 hospitals, 39 remote area nursing posts and community and child health services in 221 locations. The WA Country Health Service is committed to improving health outcomes for all women and newborns in country areas by:

ensuring service safety and quality are a priority while providing access to maternity and newborn services as close as possible to where people live

enabling communities, mothers and families to be fully informed about service availability, the evidence for decision-making, and the benefits and risks associated with service access options

working with Aboriginal communities and families to develop services that better meet both health and family needs, so that the health outcomes for mothers and newborns improve

working with other service providers to improve service capacity and access.

This document guides the availability of maternity and neonatal services within the WA Country Health Service.

WACHS directly employs around 8,500 staff (approximately 5,700 full time equivalent [FTE] staff). Nurses and midwives comprise 2451 FTE of this total. In the Northwest of the state, a salaried generalist medical workforce, supported by resident and visiting specialists, provide the bulk of hospital-based medical acute and primary care services. A mix of salaried generalists, local and visiting specialists, visiting medical officers and sub-specialists provide medical services across the rest of country WA.

Workforce shortages in specific areas at particular times may necessitate temporary reduction of local service levels until such time as safe staffing can be resumed.

Women in rural and remote areas of WA, especially those outside of regional centres, face specific challenges in accessing maternal and infant health services due to the distance, isolation, lack of suitable transport and accommodation, and in some cases, social and health disadvantage. 1

Women residing in country areas generally represent one quarter of the total number of women who give birth in WA.2

Around one quarter of all deliveries in WA public hospitals are in WACHS hospitals, highlighting the significance of WACHS as a provider of maternity and newborn services.

1 Gee V & Ernstzen AN. 2008. Perinatal, Infant and Maternal Mortality in Western Australia, 2002-2006.

Department of Health: Perth, WA. 2 Gee V. (2010). Perinatal, Infant and Maternal Mortality in Western Australia, 2004-2008. Department of

Health, Perth, WA.

Pregnancy, birthing and parenting are significant, meaningful life events and consumers of maternity and neonatal

services have the right to receive accessible and safe quality services.1

WACHS aims to provide maternity and newborn services as close to home as

possible, where the services can be safe and sustained.


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Each year, approximately one quarter of country residents birth in the metropolitan area for a variety of reasons including:

at risk pregnancies requiring specialist services

personal choice (family, supports, provider) and

limited access to maternity services close to home. Aboriginal women experience poorer maternal health outcomes, higher rates of perinatal and infant mortality and deliver babies with lower average birth weights when compared to non-Aboriginal women.3

Reductions in infant mortality rates

Source: ABS (2010) Deaths Australia, 2009. Cat No. 3302.0. Canberra: ABS.

(Excerpt from Director General Presentation) The WA Aboriginal infant mortality rate declined from 20.6 in 1996, to 7.7 in 2009. In 2007, WA reported the lowest perinatal and infant mortality rates in Australia. The Kimberley region has the highest infant mortality rates compared to the other regions in WA. While the infant mortality rate in the state almost halved over the 15 years from 1994 to 2008 (from 6.2 per 1,000 to 3.3 in 2008), the infant mortality rate of the Kimberley region remains nearly three times that of the state (10.0 per 1,000 compared with 3.5) from 2004 to 2008.3 In WA, almost a quarter (24%) of Aboriginal women who gave birth between 2004-2008 were teenage women (less than 20 years of age), in contrast with non-Aboriginal women of whom 4.1% were teenagers.3

3 Gee V. (2010). Perinatal, Infant and Maternal Mortality in Western Australia, 2004-2008. Department of

Health, Perth, WA.

http://intranet.health.wa.gov.au/news/attachments/110406_Kim_Snowball_Delivering_Success.pdf�


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Area and Regional Planning Process Flowchart for Maternity and Newborn Services The following flow chart outlines a process to assist regions and health services to assess and plan Maternity and Newborn Services using the Clinical Services Framework. The flowchart is a guide and is to be modified and adapted to suit health needs within the local and regional context.

In view of these outcomes for Aboriginal mothers and babies, and that around two-thirds of all births to Aboriginal women in WA are to Aboriginal women

residing in WACHS areas, improvement of these health outcomes is a key goal for WACHS, working in partnership with Aboriginal Community Controlled

Health Organisations and Aboriginal communities throughout the state.


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MATERNITY AND NEWBORN SERVICES

AREA AND REGIONAL PLANNING

- FLOWCHART -


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Maternity and Newborn Services Area and Regional Planning Guide

Identify WA Clinical Services Framework determined level. See pages 35 - 37

Review WACHS Maternity and Newborn Services using the following to determine capacity to provide the service at the CSF determined level (see link above):

Workforce capacity, skill and availability including access to consultant or GP obstetrician, paediatrician, anaesthetist, allied health and midwifery services, Aboriginal health workers and support services.

Facilities including access to physical facilities, surgical, allied health, pathology, radiology and pharmacy.

Proximity to safe caesarean section capability.

Access to blood replacement products. Demand including birth numbers.

Determine the Model(s) of Care that best meet health and community need within the demographic context and resource capacity.

This includes funding, facility, infrastructure, equipment, workforce availability, sustainability, skills, capacity and willingness.

Include consultation with WACHS clinicians and relevant staff, other service providers and consumers in this assessment.

Determine Inclusion and Exclusion Criteria (Referral Guidelines) for both maternal and neonatal services specific to each site.

(See Appendix 4)

Continuous Improvement Develop and implement systems to ensure: continuous learning to prevent errors and achieve ongoing improvement monitoring of maternity care service provision and outcomes by applying the dissemination, review and feedback process of the WACHS Obstetric [Maternal and Newborn Indicators] Dashboard. (See Appendix 1)

http://www.health.wa.gov.au/HRIT/docs/clinicalframework.pdf�

http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Improving_Maternity_Services_Framework.pdf�


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MATERNITY AND NEWBORN

STRATEGIC AND BACKGROUND

DOCUMENTS

- A QUICK SUMMARY -


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Strategic and Background Documents - A Quick Summary -

There are a number of planning and strategic documents that inform WACHS Maternity and Newborn Services. They include: Policy Framework, Improving Maternity Services: Working Together Across WA The Policy Framework: Improving Maternity Services: Working Together Across WA 2007 underpins the development of this Maternity and Newborn Services guideline. This policy framework outlines the goals for maternity service provision, information about current service provision and definitions of possible models of care for the future. Maternity Models of Care Developing and implementing new or modified models of maternity care is a key element in meeting the health care needs of rural and remote communities and informing regional clinical service and workforce planning. WA Country Health Service does not advocate one particular model of maternity care over another, and supports safe, sustainable, evidence based practice and models that align with the health priorities and service needs of the specific communities. When referring to researched models of care it is important to take into consideration that research settings for models of care usually have much higher work volume than experienced in WACHS maternity care units. Changing models of care in Country areas requires local agreement that should be informed by both quantitative and qualitative data including clinical outcomes, relative costs and commitment to monitor the impact of changes in clinical care. Refer to Implementation Principles - Maternity Models of Care (WACHS, 2009, Appendix 8). WA Strategic Plan for Safety & Quality in Health Care 2008-2013 Safety and quality in all WA Health services is of paramount importance. WA Health has adopted the four pillars of clinical governance to ensure that safety and quality are embedded in all services (Office of Safety & Quality, 2001). WA Health Clinical Services Framework 2010-2020 The WA Health Clinical Services Framework 2010-20204 details the level of obstetric and neonatal service to be provided at each health service within WACHS (refer to page 14). It should be noted that although sites may be designated a specific level of clinical service delineation, the availability of clinicians and other staff, plus resources within the local area does influence service provision capability. Therefore the clinical service delineation (levels) will be adjusted accordingly. The WA Country Health Service Obstetric and Neonatal Service Levels 1 – 5 are based on the WA Health Clinical Services Framework 2010 - 2020 (Refer Appendix 2) with reference to the Standards for Maternal and Neonatal Services in South Australia 20105. WA Country Health Service Obstetric and Neonatal Clinical Service Levels 1-5 The WA Country Health Service Obstetric and Neonatal Clinical Service Levels 1-5 are listed in the following tables with expanded descriptions for Maternity and Newborn Care outlined in the WA Country Health Maternity and Newborn Service Guidelines Levels 1 – 5 in pages 17-35 of this document.

4 WA Health Clinical Services Framework 2010-2020. Western Australia Department of Health.

5 Standards for Maternal and Neonatal Services in South Australia, 2010 South Australia. Department of Health

http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Improving_Matenrity_Services_Framework.pdf�

http://www.safetyandquality.health.wa.gov.au/docs/WA_strategic_plan_for_safety_and_quality_in_health_care_2008-2013.pdf�


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OBSTETRIC AND NEONATAL CLINICAL SERVICE LEVELS

FOR

WA COUNTRY HEALTH SERVICE

REGIONAL RESOURCE CENTRES, INTEGRATED DISTRICT HEALTH SERVICES

AND SMALLER HOSPITALS


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WA Country Health Service Regional Resource Centres,

Integrated District Health Services and Smaller Hospitals

Clinical Service Levels 1-5 The Clinical Service (role delineation) levels (1 to 5) for WACHS Regional Resource Centres, Integrated District Health Services and Smaller Hospitals listed in the following table are based on the WA Health Clinical Services Framework, 2010 – 2020 4 (CSF) which is a guide to services planning. Expanded descriptions follow the table. WACHS small hospitals and community health services are not included in the CSF, but also provide some antenatal, perinatal and postnatal services depending on service need, clinical workforce skill and availability. Smaller hospitals have been included in the role delineation table overleaf based on the role delineation definitions within the CSF and the service capability of the hospitals.

http://www.health.wa.gov.au/publications/documents/CLINICAL_SERVICES_FRAMEWORK_WEB.pdf�


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Clinical Service Levels of Obstetric and Neonatal Care

[as per WA Health Clinical Services Framework, 2010 – 2020]

REGION HOSPITAL OBSTETRICS

2011/12 OBSTETRICS

2014/15 NEONATES

2011/12 NEONATES

2014/15

KALGOORLIE 4 4 *4/5 *4/5

ESPERANCE 3 3 3 3

LAVERTON 1 1 1 1

LEONORA 1 1 1 1

NORSEMAN 1 1 1 1 GO

LD

FIE

LD

S

RAVENSTHORPE 1 1 1 1

BROOME *3/4 *4 *3/4 *4

DERBY *3 *3 *3 *3

KUNUNURRA *3 *3 *3 *3

FITZROY CROSSING

1 1 1 1

HALLS CREEK 1 1 1 1

KIM

BE

RL

EY

WYNDHAM 1 1 1 1

PORT HEDLAND 4 4 4 4

NICKOL BAY *3/4 *3/4 *3/4 *3/4

NEWMAN 1 1 1 1

ONSLOW Not available Not available Not available Not available

PARABURDOO 1 1 Not available Not available

ROEBOURNE Not available Not available Not available Not available

PIL

BA

RA

TOM PRICE 1 1 1 1



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2011/12 OBSTETRICS

2014/15 NEONATES

2011/12 NEONATES

2014/15

ALBANY 4 4 3 4

KATANNING 3 3 3 3

DENMARK 1 1 1 1

GNOWANGERUP 1 1 1 1

KOJONUP 1 1 1 1

GR

EA

T

SO

UT

HE

RN

PLANTAGENET 1 1 1 1

GERALDTON 4 4 4 4

CARNARVON 3 3 2 2

DONGARA 1 1 1 1

EXMOUTH 1 1 1 1

KALBARRI 1 1 1 1

MEEKATHARRA 1 1 1 1

MORAWA 1 1 1 1

MID

WE

ST

NORTH MIDLANDS

1 1 1 1

BUNBURY 4 4/5 4 4

BUSSELTON 3 3/4 3 3

MARGARET RIVER

2 2 2 2

COLLIE 3 3 2 2

WARREN 2/3 2/3 2 2

BRIDGETOWN 2 2 2 2

AUGUSTA 1 1 1 1

BOYUP BROOK 1 1 1 1

DONNYBROOK 1 1 1 1

HARVEY 1 1 1 1

SO

UT

HW

ES

T

PEMBERTON 1 1 1 1


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2011/12 OBSTETRICS

2014/15 NEONATES

2011/12 NEONATES

2014/15

NARROGIN 3 3 3 3

NORTHAM *2/3 *2/3 *2/3 *2/3

MERREDIN 1 1 1 1

MOORA 1 1 *1 *1

BEVERLEY 1 1 1 1

BRUCE ROCK 1 1 1 1

CORRIGIN 1 1 1 1

DALWALLINU 1 1 1 1

GOOMALING 1 1 1 1

KELLERBERIN 1 1 1 1

KONDININ 1 1 1 1

KUNUNOPPIN 1 1 1 1

LAKE GRACE 1 1 1 1

NARAMBEEN 1 1 1 1

QUAIRADING 1 1 1 1

SOUTHERN CROSS

1 1 1 1

WAGIN 1 1 1 1

WONGAN HILLS 1 1 1 1

WYALKATCHEM 1 1 1 1

WH

EA

TB

EL

T

YORK 1 1 1 1

* Some levels differ from the WA CSF and are based on hospital service capability and

workforce capacity in the town or region.


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WA COUNTRY HEALTH SERVICE

MATERNITY AND NEWBORN SERVICE GUIDELINES

LEVELS 1-5

BASED ON WA HEALTH CLINICAL SERVICE FRAMEWORK


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WACHS Maternity Service Guidelines Levels 1-5

The WA Country Health Service uses the WA Health Clinical Service Framework (CSF) levels as the basis for planning services. The following tables contain expanded information for each CSF level, describing services, facilities, clinical workforce, service links and support services that have been developed with reference to the Standards for Maternal and Neonatal Services in South Australia 20105. The level of services provided by the WA Country Health Service in country communities is determined using these guidelines.

The WACHS Maternity and Newborn Service guidelines informs clinicians, service managers, stakeholders and communities about where services can be delivered and the standards that apply to these services. This includes summarising for Level 1 to 5 sites, the type of:

service available

facilities and clinical workforce required to safely provide the service

service links and support services required to sustain the service.

The WA Country Health Service seeks to maintain the determined service levels or to upgrade these, where there is a demonstrated need and safe and sustainable capacity.

In some towns, at particular times, there may occur temporary service changes

or reductions when the service level cannot be maintained safely.

For example: Services supported at a Level 3 service need to be modified during times when there is an absence of the clinical workforce required to support

emergency caesarean section capability. Similarly, services offered at a Level 4 site would revert to Level 3 in the absence of a consultant obstetrician.

The WA Country Health Service is to seek to maintain the service at the

designated level. Service safety is to drive the decision for changes in service level and this is to include safe work practices including safe working hours.

Safe working hours along with effective communication and clear systems of

accountability and escalation, are identified as important in minimising the risk of clinical errors. Services requiring 24/7 on call cover are to aim for not less than one in four first on call (minimum one in three) and not less than one in three (minimum one in two) second on call.


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WA Country Health Service: Maternity Service Guidelines Level 1 (based on Clinical Service Framework)

Complexity of

Care/Service Description Facilities Clinical Workforce Service Links Support Services

LE

VE

L O

NE

No planned births

Emergency births as per Remote Area Nursing Emergency Guidelines.6 Transfer of mother and infant(s) to Level 2 service or higher.

Antenatal, postnatal care is carried out by visiting medical officers, private GPs, ACCHO GPs or RFDS GPs, with or without the assistance of AHWs or RNs/RMs depending on the type of patient care needed.

Emergency care.

Patient support until the retrieval team arrives.

Emergency resuscitation equipment available 24/7.

Protocols guiding staff in:

managing emergency presentations until the retrieval team arrives

organising the retrieval team.

Generalist hospital staff.

Nursing and medical (may or may not include trained midwife).

Nursing and medical officers competent in adult and neonatal basic life support and resuscitation.

May have access to a:

community midwife/child health nurse providing care related to antenatal and postnatal period.

May have access to a:

general practitioner who may provide shared obstetric care.

Ambulance and RFDS emergency transport services.

Established telecommunication link with allied and community services, regional and/or tertiary obstetric service and retrieval service.

Established telecommunication links between general practitioner, shared care providers and hospitals providing intrapartum care.

Limited local services with no on call for pathology, pharmacy and diagnostic imaging. 24/7 pharmacy advice available.

No emergency transfusion supplies.

Access to ANMC midwifery education.

Access to emergency and resuscitation care education for adult and neonates, including regular drills.

Access to WA Health ’Remote Area Nursing Emergency Guidelines’ 4th Edition, 2005.6

Access to NETS Handbook.

Access to RFDS Guidelines.

6 Remote Area Nursing Guidelines


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Complexity of

Care/Service Description Facilities Clinical Workforce Service Links Support Services

LE

VE

L T

WO

Normal low-risk pregnancies and births and management of newborns > 37+0 weeks gestation and an estimated birth weight > 2500 grams with minimal complications. No onsite Caesarean section availability. Ambulance transfer required to access emergency caesarean section. Access to 24 hr telephone support from specialist obstetricians. Access to e-health or telehealth.

A range of antenatal, birthing and postnatal care in a designated birthing room(s).

CTG monitor.

Portable ultrasound scan.

A nursery for the transitional care and stabilisation of the unexpected sick neonate equipped with radiant heater, convection warmed incubator, oxygen analyser, pulse oximeter and phototherapy.

Emergency resuscitation equipment available for adult and neonate 24/7.

Midwives rostered and available 24/7.

May have access to a community midwife/child health nurse providing care related to antenatal and postnatal period.

GP Obstetric proceduralist available 24/7.

Nursing/midwifery and medical officers competent in adult and neonatal basic life support resuscitation.

May have health professional trainees providing services whilst under supervision.


Established telecommunication link for consultation and advice with higher level obstetric and neonatal/paediatric service, including a range of surgical and medical specialties, mental health, child protection and families and communities services and the state wide retrieval service.

Established communication links between the GP obstetric proceduralist admitting, the health service providing the intrapartum care and consultant obstetricians and social workers.

Referral arrangements with allied and community health services, including dieticians, physiotherapists and social workers.

Limited local service with no on call for pathology, pharmacy and diagnostic imaging. 24/7 pharmacy advice available.

Limited emergency transfusion supplies. (access to four units of 0 neg blood onsite).


Access to emergency and resuscitation care education for adult and neonates.

Access to obstetric emergency training including regular multidisciplinary drills.

Access to intrapartum monitoring (*including CTG) education and competency assessment.


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Complexity of Care /Service Description

Facilities Clinical Workforce Service Links Support Services

LE

VE

L T

HR

EE

As for Level 2 plus:

Elective and emergency caesarean* capability.

24 hr anaesthetic service available (versus on call).

Visiting specialist obstetrician or ready availability of regional resident specialist obstetric review.

Where gestation and/or birth weight are borderline for transfer it maybe reasonable to consider managing the woman on-site where all aspects of her care are assessed as favourable. This requires consultation with the regional or tertiary consultant obstetrician regarding clinical care and the local clinical manager regarding site workforce skill and capacity.

A range of antenatal, birthing and postnatal care in a designated birthing room(s).

CTG monitoring. Portable ultrasound

scan. A nursery for the

transitional care and stabilisation of the unexpected sick neonate equipped with radiant heater, convection warmed incubator, oxygen analyser, pulse oximeter and phototherapy.

Emergency resuscitation equipment available for adult and neonate 24 hours per day, 7 days a week.

Access to operating rooms able to perform emergency Caesarean section*


Access to a community midwifery service.

Specialist obstetrician or GP obstetric proceduralist available 24/7.

Medical officers with appropriate credentials available 24/7 i.e. one for anaesthetic, one for surgical procedure and one for resuscitation of the neonate.

Nursing/midwifery and medical officers competent in adult and neonatal basic life support and resuscitation. In some instances it may be appropriate to have a nurse/midwife credentialed in neonatal resuscitation as the primary attendant for the newborn e.g. elective caesarean section under regional anaesthesia.

May have health professional trainees providing services while under supervision.


Established telecommunication links for consultation and advice with higher-level obstetric services, including a range of surgical and medical specialties, mental health, child protection and family and community services and the state wide retrieval services.


Access to mental health team for the management of mental health emergencies.

Limited local service with possibly no on call for pathology, pharmacy and diagnostic imaging. Pharmacy advice available 24/7.

Limited emergency transfusion supplies (access to four units of O neg blood on site).

Access to operating room and anaesthetic services with on call staff available.


Access to emergency and resuscitation education, for adults and neonates, including regular multi -disciplinary drills in all obstetric emergencies

Access to intrapartum monitoring (including CTG) education and competency assessment.


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Complexity of Care Facilities Clinical Workforce Service Links Support Services

LE

VE

L F

OU

R

As for Level 3 *plus:

Planned births of low and moderate risk mothers / babies (> 34 weeks gestation singleton pregnancy or uncomplicated twin pregnancy that delivers > 35 weeks with an estimated birth weight > 2000grams).


Specialist obstetrician first or second on call 24/7.

Cont'd over…

A range of antenatal, birthing and postnatal care in a designated birthing suite.

CTG monitoring available for antenatal and intrapartum care with ‘scalp’ pH or lactate measurement and ultrasound machine located in birthing unit.


A registered midwife with appropriate post registration qualifications, for example ≥ SRN 3 in public sector as per the WA ANF Award 2007, designated to manage the maternity/birthing unit in conjunction with a designated lead specialist obstetrician.

Access to paediatric support for supervision of clinical care within a timeframe responsive to clinical need.

Qualified operating room staff available 24/7.

General practitioner and/or appropriately accredited medical officers with perinatal services credentials available 24/7 including assist with a caesarean section (one for anaesthetic, one surgical procedure and one for resuscitation of the neonate).


Established telecommunication links for consultation and advice with higher-level obstetric services, including a range of surgical and medical specialties, mental health, child protection and families and community’s services and the state-wide retrieval services.

Local pathology service with on call 24/7 for specimen analysis.

Limited blood and blood product services with on call available 24/7.

Pharmacy advice available 24/7.

Local diagnostic imaging services with on call service 24/7 for perinatal diagnosis.

Local access to operating room and anaesthetic services with on call staff available to respond 24/7.


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Continued… Complexity

of Care Facilities Clinical Workforce Service Links Support Services

LE

VE

L F

OU

R C

ON

T’D

Access to paediatricians and specialist anaesthetists.

On-call roster for obstetricians and anaesthetists.

Some allied health undergraduate education. [Onsite Commonwealth Level 2 Nursery Neonatal Facilities].

Special care nursery for

the transitional care and stabilisation of the unexpectedly sick neonate and for the care of uncomplicated convalescent preterm and term infants equipped with radiant heater, convection-warmed incubator humidified head box, oxygen therapy < 40% for ≤ 4 hours, oxygen analyser, pulse oximeter photo therapy lamp, infusion pump.

Operating facilities able to perform an emergency caesarean section.*


Medical officers

accredited in anaesthetics and available 24/7.

Community midwifery service providing care related to but not restricted to the postnatal period.

Access to mental health team.



Referral

arrangements with allied and community health services, including dieticians, physiotherapists and social workers.

Access to mental health team for the management of mental health emergencies.

Access to ANMC

midwifery education.

Access to emergency adult and neonatal resuscitation, including regular multidisciplinary drills in all obstetric emergencies.

Access to CTG education and competency assessment.


Page 24 of 80



LE

VE

L F

IVE

As for Level 4 *plus:

Births of low, moderate and high-risk mothers/babies (singleton infants greater than 32 weeks gestational age or twins at a gestational age of > 34 weeks and estimated birth weight > 1500 grams.

Service provided to high risk mothers/babies by specialist obstetricians, neonatal paediatricians and anaesthetists.

Cont'd over…

A range of antenatal, birthing and postnatal care in a designated birthing maternity /birthing suite supporting women and baby centred care.

CTG monitoring available for antenatal and intrapartum care with ‘scalp’ pH or lactate measurement and ultrasound machine located in birthing unit.

An appointed / nominated specialist obstetrician as head of obstetric services.

An appointed/ nominated anaesthetist as head of obstetric anaesthetic services.

A designated specialist obstetrician and paediatrician available for consultation 24/7.

An obstetric medical officer onsite 24/7 at least Registrar level.

A neonatal/paediatric medical officer with a designated role in neonate services available onsite 24/7.

A registered midwife with appropriate post registration qualifications designated to manage the birthing unit.

Established links with Level 6 obstetric and neonatal services which provide consultation and advice from a full range of:

sub specialist paediatric medial and surgical services.

paediatric allied health including dieticians, physiotherapists, social welfare, occupational therapy, speech pathology, audiology, dietetics and child protection services.

Full range of pathology, pharmacy and diagnostic imaging services on call 24/7.

Neonatal special care unit and adult high dependency units and access to an adult intensive care unit.

Operating Room capacity available 24/7 with onsite or on call staff.

Anaesthetic available 24/7 with additional on with onsite or on call staff.

Full range of blood and blood product services 24/7.


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Continued…


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Onsite 24 hr medical officer obstetric cover by registrar or above.

24 hr cover by specialist obstetricians, paediatricians and anaesthetists.


Access to HDU/ICU facility.

Regional referral role.

Cont'd over…

Operating facilities able to perform emergency Caesarean section.

A designated neonatal special unit able to provide: phototherapy, gavage feeding, administration inspired oxygen analysis and pulse oximetry, regulatory care via radiant heater or incubator, administration IV therapies through infusion pumps, cardio-respiratory monitoring, immediate access to blood gas machine for measurement of blood gas, plasma glucose and electrolytes.

A registered midwife / nurse with appropriate post registration qualification, designated to manage each specific maternity area.

Midwives rostered 24/7.

A Community Midwifery Service available usually providing care related to but not restricted to the postnatal period.

A registered midwife / nurse with appropriate post registration qualification, for example ≥ SRN 3 public sector as per the WA ANF Agreement 2007 designated to manage neonatal special care unit.

An appointed/nominated paediatrician or Neonatologist as head of neonatal services.

adult medical, surgical psychiatry and allied health services.

adult mental health, drug and alcohol services.

adult intensive care services.

laboratory services.

genetic counselling services.

fetal and maternal medicine services.

dentistry services.


Access to emergency adult and neonatal resuscitation education, including regular multidisciplinary drills in all obstetric emergencies.

Access to CTG education and competency assessment.


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Continued…

6 Thomas, J., Paranjothy, S., & James, D. (2004). National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section. BMJ, 328, 665-668.


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allied health services

Onsite Level 5 Neonatal Facilities


At least 20% of neonatal nurses have appropriate post registration qualifications.

Qualified operating room staff available 24/7.

Specialist anaesthetist accredited and available for consultation.

Health professional trainees providing services whilst under supervision of their accredited consultant.


Established communication links with the state-wide retrieval services

Access to a range of mental health services

Ambulance and RFDS emergency transport services


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Not available in country WA. Available metropolitan tertiary centres only.


Tertiary obstetric services.

Specialist obstetric services including subspecialty maternal fetal medicine, obstetric medicine, genetic services.

Dedicated HDU facilities.

Onsite access to ICU.

Has facilities to undertake obstetric and fetal research.

Coordinates training of specialist obstetricians and specialist midwives.

Onsite Level 6 NICU.


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WACHS Newborn Service Guidelines

Levels 1-5 The WA Country Health has used the WA Health Clinical Service Framework (CSF) and Framework for the Care of Neonates in Western Australia 2009 levels, as the basis for planning neonatal services. The following tables contain expanded information for each CSF level, describing services, facilities, clinical workforce, service links and support services with reference to the Standards for Maternal and Neonatal Services in South Australia 20105. The level of services provided by the WA Country Health Service in country communities is determined using these guidelines. The WA Country Health Service Maternity and Newborn Service guidelines provide information for clinicians, service managers and communities about where services can be delivered and the standards that apply to these services. The WA Country Health Service seeks to maintain the determined service levels or to upgrade these where there is a demonstrated need and capacity. In some towns at particular times, temporary service reductions may occur when the service level cannot be maintained, mostly due to workforce or skill shortages.


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WA Country Health Service: Newborn Service Guidelines Level 1 (based on Clinical Service Framework)

Complexity of Care /Service Description Facilities Clinical Workforce Service Links Support Services

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May include care of well babies with emphasis on parenting, bonding and support for feeding and lactation.

24-hour on-site access to a health professional skilled in initiating neonatal resuscitation and accredited in neonatal resuscitation.

Patient support until the retrieval team arrives.

Emergency resuscitation equipment available 24/7.

Protocols guiding staff in:

emergency presentations.

organising retrieval team.

care required until retrieval team arrives.

Generalist hospital staff.

Nursing and medical (may or may not include trained midwife).

Nursing and Medical Officers competent in neonatal basic life support and resuscitation.


Local general practitioner proceduralist with access to specialist obstetrician for advice.

Established telecommunication link with allied and community services, higher level obstetric and paediatric service and retrieval service.

Established telecommunication links between general practitioner, shared care providers and hospitals providing intrapartum care.

Limited local services with no on call for pathology, pharmacy and diagnostic imaging.


No emergency transfusion supplies.


Access to NETS WA guidelines.


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Onsite Level 1 neonatal facilities.

Care of well babies of >37 weeks gestation and birth weight >2500g with minimal complications (e.g. hypoglycaemia, minor infections not requiring parenteral treatment, physiological jaundice).

Refer to attached neonatal inclusion/exclusion criteria for each level (Appendix 4).

24 hr onsite access to a health professional skilled in initiating neonatal resuscitation and accredited in neonatal resuscitation.

Telephone access to emergency care and transport.



Midwives or neonatal trained nurses rostered and available 24/7.

GP with neonatal care procedural skills available 24/7.




Established telecommunication link for consultation and advice with higher level neonatal / paediatric service, including a range of surgical and medical specialties, mental health, child protection and families and communities services and the state-wide retrieval service.

Established communication links between the admitting GP and a consultant paediatrician.


Limited local service with no on call for pathology, pharmacy and diagnostic imaging.


Limited emergency transfusion supplies.





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Where gestation and /or birth weight are borderline for transfer it maybe reasonable to consider managing the woman on-site where all aspects of her care are assessed as favourable following consultation with the regional or tertiary consultant obstetrician regarding clinical care and the local clinical manager regarding site workforce skill and capacity.

Refer to attached neonatal inclusion/exclusion criteria for each level.







Established telecommunication link for consultation and advice with higher level neonatal/paediatric service, including a range of surgical and medical specialties, mental health, child protection and families and communities services and the state-wide retrieval service.

Established communication links between the admitting GP and a consultant paediatrician.


Limited local service with possibly no on call for pathology, pharmacy and diagnostic imaging.


Limited emergency transfusion supplies.




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Complexity of Care Facilities Clinical Workforce Service Links Support Services L

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As for Level 3 plus: Onsite neonatal facilities with low dependency patients and apnoea monitoring, low-level Oxygen therapy (including monitoring) and nasal/oral-gastric feeding (as defined by Commonwealth Level 2 Nursery). Paediatrician on-call 24 hours. Management of newborns > 34+0 weeks gestation with some complications that can be managed locally (see inclusion /exclusion criteria for each level). Short term intravenous therapy available. All patients requiring nursery care are referred for management by attending paediatrician. Access to designated allied health services Some allied health undergraduate education.

Special care nursery for the transitional care and stabilisation of the unexpected sick neonate and for the care of uncomplicated convalescent preterm and term infants equipped with radiant heater, convection-warmed incubator humidified head box, oxygen therapy < 40% for ≤ 4 hours, oxygen analyser, pulse oximeter photo therapy lamp, infusion pump.


Staffing as per Commonwealth DoHA requirements.


Access to paediatrician for supervision of clinical care 24/7.

Access to mental health team.




Established telecommunication links for consultation and advice with higher level paediatric services, including a range of surgical and medical specialties, mental health, child protection and families and community’s services and the state wide retrieval services.


Access to mental health team for the management of maternal mental health emergencies.

Local pathology service with on call 24/7 for specimen analysis.

Local pharmacy service with on call services 24/7 for urgent requests. Pharmacy advice available 24/7.

Local diagnostic imaging services with on call service 24/7 for neonatal diagnosis.

Limited blood and blood product services with on call available 24/7.

Access to neonatal resuscitation education.



Page 33 of 80



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Onsite neonatal facilities with high dependency patients and provision of short-term mechanical ventilation (< 6 hours) pending transfer, nasal CPAP with facilities for arterial blood gas monitoring.

Management of newborns > 32+0 weeks gestation with minimal complications.

Non invasive BP monitoring.

Cont'd over…

A designated neonatal special unit able to provide: phototherapy, gavage feeding, administration inspired oxygen analysis and pulse oximetry, regulatory care via radiant heater or incubator, administration IV- therapies through infusion pumps, cardio-respiratory monitoring, immediate access to blood gas machine for measurement of blood gas, plasma glucose and electrolytes.

An appointed / nominated paediatrician or neonatologist as head of neonatal services.

A designated specialist obstetrician and paediatricians available for consultation 24/7.

A medical officer onsite 24/7.

A neonatal/paediatric medical officer with a designated role in neonate services available onsite 24/7.

Paediatricians on-call 24 hours.

Paediatric registrar or above on site 24 hours.

A registered midwife / nurse with appropriate post registration qualification, for example ≥ SRN 3 public sector as per the WA ANF Agreement 2007 designated to manage the neonatal special care nursery.


Established links with Level 6 obstetric and neonatal services which provide consultation and advice from a full range of:

sub specialist paediatric medical and surgical services paediatric allied health including dieticians, physiotherapists, social welfare, occupational therapy, speech pathology, audiology, dietetics and child protection services, genetic counselling services.

Full range of pathology, pharmacy and diagnostic imaging services with on call 24/7.

Full range of blood and blood product services 24/7.

Access to emergency and resuscitation education and competency assessment.


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Continued…


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Has access to clinical and diagnostic paediatric subspecialties.

Service led by neonatal paediatricians.

Access to specialist SRN.

Role in post graduate medical and nursing education.

Careful consideration to receiving transfers from L1 neonatal facilities (Level 2 or Level 3 hospital).

Access to specialised allied health services.


Staffing as per Commonwealth DoHA requirements.

At least 20% of neonatal nurses have appropriate post registration qualifications.

A Community Midwife service available usually providing care related to but not restricted to the postnatal period.

Health professional trainees providing services whilst under supervision of their accredited consultant.


Feto maternal medicine services.

Established communication links with the state-wide retrieval services.


Page 35 of 80



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Not available in country WA, only in Metropolitan specialist tertiary centres.

Not applicable to WACHS

Detailed information on stabilisation and management of at risk neonates and pregnancies is contained in the Newborn Emergency Transport Service (NETS) Medical Guidelines. See Guidelines Introduction – Section 11 2009 etc.

http://www.kemh.health.wa.gov.au/development/manuals/NETS_manual/index.htm�

http://www.kemh.health.wa.gov.au/development/manuals/NETS_manual/index.htm�

http://www.kemh.health.wa.gov.au/development/manuals/NETS_manual/documents/introduction.pdf�


Page 36 of 80

MINIMUM

MATERNITY AND NEWBORN

EQUIPMENT AND MEDICATION LIST


Page 37 of 80

Minimum Maternal and Newborn Equipment and Medication List

Maternal Neonatal

For remote locations where emergency and unplanned births regularly occur.

Gloves (sterile and unsterile) Syringes/needles/alcohol

swabs / kidney dishes Tourniquet Blood specimen tubes

(including cord blood) Cord clamps Lubricant Sterile delivery pack Suture set Suture material Single use and indwelling

catheters Urine drainage bag Sterile Lignocaine Gel Sterile water for irrigation IV additive/allergy labels IV dressings and tape IV fluids IV cannula and giving set Large tagged packs, or large

tagged, sanitary napkins Plastic aprons, Safety

glasses Masks Incontinence sheets Adult resuscitation trolley

and drugs Tape measure Thermometer Sphygmomanometer /

Stethoscope Wall clock Maternal oxygen and suction

equipment Airways Yankeur suction Hudson face mask and

tubing Sonicaid Overhead light Rubbish bin Infant basket Baby scales Fetal Fibronectin kit

Neonatal resuscitation equipment comprising: Neonatal bags and masks (various sizes) Neonatal airways (various sizes) ETT tubes: oral 2.0 - 4.0 (Straight non

cuffed) Laryngoscope and blades (size 0 and 1 straight) Introducer (size 5fg) Suction catheter straight FG10 Oxygen catheter fg 6 Pedicap x 2 Meconium Aspirator NG tubes (sizes 8) Size 24 IV cannula x 3

UVC Kit Umbilical Catheter 3.5 and 5.0 fg 3 way tap x 2 3.0 suture x 2 2 ml syringe x 4 1 ml syringe x 1 Chlorhexidine swab 1% x 5 Providine-iodine swab x 5 NaCl 0.9% x 10mls x 5 Disposable instrument set x 1 Umbi tape/ tie x 1

Pneumothorax Kit (Two of each for bilateral aspiration) 10 ml syringe 3 way tap 23 g butterfly 22g x 25mm cannula pen light torch alcohol wipe

Other Gloves sterile plus disposable various

sizes Cord scissors Baby name tags Neowrap or bubble wrap Baby bonnet Oxygen Analyser Oxygen saturation monitor and strapping Overhead radiant warmer Warm towels


Page 38 of 80

Maternal Neonatal

ADULT OBSTETRIC DRUGS Celestone Chronodose

ampoules 5.7mg x 2. Magnesium Sulphate for

injection 100ml bag of 8% solution.

Calcium Gluconate 1g in 10ml

Nifedipine tablets 20mg. Ergometrine 0.5mcg in 1ml. Syntometrine. Syntocinon (10 units). Misoprostol 1000mcg. Sodium Citrate. 1% Lignocaine ampoules Salbutamol Obstetric 5mg in

5ml ampoules. Diazepam ampoules.

10mg/2ml. Hydralazine 20mg. Geloinfusion. N/Saline fluids. Hartmann’s solution 500 and

1000ml. 5% Dextrose IV fluids Narcotics e.g. Morphine,

Pethidine. Antiemetic e.g. Maxolon,

Phenergan Antibiotics. including parenteral Benzyl penicillin, and Clindamycin.

Resuscitation drugs as per adult resuscitation trolley.

NEONATAL DRUGS Konakion 2 mg. 1: 10, 000 Adrenaline ampoules x 5. N/Saline IV solution. 10% Dextrose IV. 5% Dextrose IV. Sodium Bicarbonate 8.4% ampoules Calcium Gluconate ampoule 1gm in

I0ml. Cefotaxime. Gentamicin. Benzylpenicillin. Amoxil. Glucagon. Water for injection. Saline for injection. To stabilise infant prior to arrival: Thermal pack. H/box perspex or incubator. Oxygen analyser. Oxygen saturation monitor. Overhead radiant warmer.


Page 39 of 80

Maternal Neonatal

Standard Minimum Obstetrics Equipment and Drugs for Births at Level 2 CSF.

AS ABOVE PLUS Antiseptic solution e.g. Cetrimide 0.5%

solution. Amnihooks / amnicots. Forceps (Wrigleys, Neville Barnes). Kiwi cups or Vacuum Extractor with

appropriate Tubing/Assorted cup sizes / posterior vacuum cups.

Pudendal needles. Lithotomy stirrups and straps. Jackson retractor. Sims speculum. Bakri uterine tamponade balloon. Airways. Yankeur suction. Hudson face mask and tubing Infant O2 and suction. O2 catheters (size 8 routine, size 6 on standby

for premature) and tubing. Y suction catheters (size 10) and tubing. Entenox Apparatus. Appropriate tubing/mask and bacterial Filter. Birth Suite bed. Bed steps. Bedside locker. Tissues/drinking straws. Emesis bowl. Spare linen. Delivery trolley - containing sterile delivery

pack - containing sterile handtowel, sterile gown, sterile tagged large surgical packs or large sterile tagged tampons, drapes, 2 large kidney dishes, 2 bowls, 2 clamps, 1 pair episiotomy scissors and 1 pair scissors.

Sharps container. Infant basket. Neonatal resuscitation kit comprising: Bag and masks Suction and oxygen equipment ETT tubes (various sizes) Laryngoscope (size

5 + 6) Introducer Magills forceps Neonatal drugs Cord scissors Baby name tags NG tubes size 5 and 6 Size 24 IV cannula Pedicap Mec Aspirator

AS ABOVE PLUS Naloxone 400mcg


Page 40 of 80

Maternal Neonatal

ADULT OBSTETRIC DRUGS AS ABOVE PLUS F2 alpha prostaglandin for injection.


Page 41 of 80

WACHS Maternity and Newborn Governance Structure

The WA Country Health Service is committed to providing the best quality and safest care possible in country WA. WACHS is continuing to improve clinical governance and safety throughout the State. Every health service must have a plan for the times when clinical escalation is needed either due to the deteriorating clinical condition of the patient or the need to access higher levels of clinical supervision and medical decision making. The reporting guideline seeks to identify accountability associated with reporting and escalation. Services are to ensure that for every health service there is an escalation flow chart, mapping of referral pathways and reporting. The WACHS Maternity and Newborn Services Governance Flow Chart on page 42 details the local, regional and area functions, responsibilities and communication forums in relation to governance supportive of clinical staff within WACHS sites. Memberships include Maternity Unit Managers, Senior Medical Obstetric and Gynaecologists, Senior Midwives and Regional and Area Executive. (See the WACHS Obstetrics and Gynaecology Clinical Advisory and Patient Safety Group Terms of Reference.) This structure aligns with the overarching WACHS Clinical Governance and Patient Safety Structure.

http://wachs.hdwa.health.wa.gov.au/policies/framework/main/page.php?page=version_summary&uid%5bdocument%5d=1022�



Page 42 of 80

WACHS Maternity and Newborn Services Governance Structure

AREA EXECUTIVE GROUP

AREA STRATEGIC DIRECTIONS FOR CLINICAL SAFETY & QUALITY IMPROVEMENTS IN SERVICE DELIVERY

Area Clinical Governance & Patient Safety Subcommittee

WACHS OBSTETRICS ANDGYNAECOLOGY CLINICAL ADVISORY

AND PATIENT SAFETY GROUP

Chaired by: WACHS Clinical Lead in Obstetrics and Gynaecology. (For full membership see:

Role: To identify risk management strategies and service improvements based on review of performance, priority areas, trends and projections in Maternal and Newborn Dashboard Indicators and other reports as required.

Maternal andNewborn

Clinical Guidelines

Subcommittee

WACHS Midwifery

Forum

REGIONAL EXECUTIVE GROUP

Regional Obstetric Advisory CommitteeChair: Regional Senior Medical O&G

Maternal and Newborn Dashboard Indicators and local perinatal morbidity and

mortality issues tabled.

Hospital Maternity Unit Managers review and document local

performance against Maternal and Newborn Dashboard

Indicators [updated quarterly].

Regional Clinical

Governance & Patient Safety

Subcommittees

REGIONAL IMPROVEMENTS IN OPERATIONAL SERVICE DELIVERY INFORMED BY STRATEGIC DIRECTIONS

Obstetric and Gynaecology Clinical Advisory and Patient Safety Group Terms of Reference




Page 43 of 80

APPENDICES Appendix 1: Strategic Documents, Models of Care and Clinical Safety & Quality

Appendix 2: WA Health Clinical Service Framework: Designated Levels for Obstetrics

and Neonatal Services Appendix 3: Maternity and Neonatal Services by Level Appendix 4: WACHS Maternity and Neonatal Referral Guideline Summary for Service

Levels Appendix 5: Client Information Sheet Appendix 6: Clinician Fact Sheet related to Client Information Sheet Appendix 7: Post Natal Care – Decision Making Tree for Post Natal Care at Non

Birthing Sites Appendix 8: Implementation Principles - Maternity Models of Care


Page 44 of 80

APPENDIX 1:

Strategic Background Documents, Models of Care Descriptions and Clinical Safety & Quality

A description of these documents is provided to assist maternity service professionals to identify and access current documents that guide decision-making, service development and provision. Policy Framework, Improving Maternity Services: Working Together Across WA The Policy Framework, Improving Maternity Services: Working together across WA 20077, provides a contemporary perspective for the development of these standards and guidelines for Country Maternity Services. ‘The overall goal of the Policy Framework is to maintain a high standard of maternity care for all women and their babies while particularly focusing on the following themes: 1. Improve health outcomes for Aboriginal women and babies. 2. Improve the health and wellbeing of women and their unborn babies through better

preconception and early pregnancy care. 3. Improve women’s experience of pregnancy. 4. Improve women’s experience of childbirth. 5. Improve the health and development of infants and address the needs of new parents. 6. Improve safety and accountability in all maternity services. 7. Improve the sustainability of the maternity care workforce and promote clinical

leadership and collaboration’.

Maternity Models of Care Developing and implementing new or modified models of Maternity Care is a key element in meeting the health care needs of rural and remote communities and informing regional clinical service and workforce planning. The WA Health ‘Improving Maternity Services: Working Together Across Western Australia. A Policy Framework’7 provides the evidence-based framework for the improvement of maternity services. Regional planning and implementation is required to ensure care and services are designed to meet the needs of local communities, health and service priorities are addressed and health outcomes are targeted and improved in an equitable way.

7 Improving Maternity Services: Working Together Across Western Australia A Policy Framework


Page 45 of 80

Different models of care may be suitable for different populations of women. Even when considering women’s preferences, their access to different models of care will be determined by their level of risk, place they live, and locations and availability of health care professionals and facilities. Collaboration between service providers and agencies is critical to supporting women to have access to their preferred and needed model of care. The following definitions of Models of Care are as outlined in A Policy Framework, Improving Maternity Services: Working Together across Western Australia.7 Shared Care Shared care means that a woman’s General Practitioner (GP) shares the pregnancy care with a hospital midwife and/or GP obstetrician and/or specialist obstetrician. Women can receive care from their own GP in the community and then give birth in a local hospital with a midwife, hospital accredited GP obstetrician or specialist obstetrician if required. If the woman’s GP has admitting rights as a GP obstetrician to a local health care service, her care can be continued with her own GP for the birth and immediate postnatal care in the hospital if there is an arrangement for such private care, otherwise there may be another mode of service provision within the hospital setting. Responsibility for the woman’s care, including communication and management of abnormal results and findings is shared between the midwife and doctor. The midwife, GP obstetrician and/or obstetrician can both provide labour and birth care. The midwife provides postnatal care in the hospital whilst the woman is under the care of the GP obstetrician or obstetrician. Following the woman’s return to home, a visiting midwife will continue care and then care is transitioned to the child health nurse and general practitioner.

Midwifery Models of Care The focus of midwifery models of care is to provide continuity of care and form partnerships with the woman and the families as they prepare for childbirth. This includes the care of the healthy woman prior to pregnancy and all phases of childbearing and early parenting. The midwife establishes partnerships with medical personnel and allied health professionals as needed to facilitate the best care of the woman. The primary midwife continues to provide midwifery care to women even when specialist medical intervention is required. Midwifery models of care can be accessed through self-referral or with a referral from their GP in early pregnancy. Midwifery models can be provided in group practices, caseload models or team midwifery.

General Practice Models of Care General practice based maternity care can support continuity of family health care prior to, during and beyond pregnancy for mothers and babies. GPs care for pregnant women in their general practices and offer shared care with hospital or family birth centre midwives, obstetricians and GP obstetricians. GPs without additional training do not supervise births in hospital. However once women have given birth the GP resumes the follow up care of the woman, her baby and her family.


Page 46 of 80

GP obstetricians care for women in their general practice, provide intrapartum support and may participate in shared care with midwives and specialist obstetricians in hospital. They have credentials to perform obstetric and certain gynaecological procedures and neonatal resuscitation within an accredited hospital setting. GP obstetricians work collaboratively with midwives, obstetricians, paediatricians and other healthy professionals who link with hospitals and community groups to provide an integrated multidisciplinary service and support women and their families. Consultant Led Care Obstetricians provide specialist services for pregnant women with pre-existing health problems and previous pregnancy complications and for those women who subsequently develop pregnancy complications requiring specialist obstetric intervention and support. Healthy women may choose to see an obstetrician privately for their pregnancy and birth care. A referral form from their GP is required to access this service. Specialist obstetricians see women on referral from midwives or GP/DMO obstetricians if pregnancy complications develop, for ongoing care or emergency management as required. Obstetricians provide pregnancy care, including intrapartum care expertise and support, within secondary or tertiary hospitals. Additional information regarding definitions of models of maternity care can be found in the document ‘Improving Maternity Services: Working Together Across Western Australia. A Policy Framework’. Further information is contained in two additional documents developed within Western Australia; ‘Models of Maternity Care: A Review of the Evidence’ and ‘Evaluation of pregnancy outcomes and cost-effectiveness of models of antenatal care and preferred setting for labour and birth care in women at low risk of pregnancy complications’.

Principles used to Determine Models of Maternity Care in WACHS The WA Country Health Service does not advocate one particular model of maternity care over another, and supports evidence based practice and models that align with the health priorities and service needs of the targeted communities. Eight principles are used to determine the maternity models of care available within WA Country Health Service. These are:

1. Alignment with the Revitalising WA Country Health Service directions.

2. Clearly identified need. 3. Use of appropriate service model and safety evidence.

4. Clear description of the model, highlighting the continuum of care and care as close to home as possible.

5. Multidisciplinary and partnership approach.

6. Resource effectiveness.

7. Outcomes measures to ensure clear goals and performance indicators.

8. Stakeholder consultation with women, families, communities and service providers.


Page 47 of 80

For guidance for services considering new or modified models of care, see Appendix 8 Implementation Principles - Maternity Models of Care.

WA Health Clinical Services Framework 2010-2020 The WA Health Clinical Services Framework 2010-2020 details the level of obstetric and neonatal service to be provided at each district health service within WACHS. It must be noted that although sites may be designated the same level of clinical service delineation, the availability of human and other resources within the local area may influence service provision capability. Service delineation provides a framework assisting health services structure their perinatal services to appropriately meet the needs of the local community, whilst taking account of the local services available and those that can be better provided elsewhere. It is recognised that service delineation is not static, and that regular ongoing assessment should be undertaken to account for variables that may become apparent in the organisation. The intention of the Rural Obstetric and Neonate service levels as documented in the WA Health Clinical Services Framework 2010-2020 is to:

1. Support the WA Country Health maternity, obstetric and neonatal workforce to provide safe standards and quality care, and in turn demonstrate measurable improvements in maternal and newborn health outcomes.

2. Be open with the community about the level of service offered at WA Country Health

Service sites therefore assisting women to discuss options with their families and clinicians, and make decisions suited to their needs.

There is a progressive level of risk for a pregnant women and her fetus, ranging from low to very high. Pregnant women should have their perinatal care managed at a health unit with comparable services to those determined by the woman’s needs. It should be acknowledged that a woman’s condition in pregnancy might fluctuate as a consequence of varying risk factors. It is accepted that the level of perinatal care provided is dependent upon the:

facilities available at the particular health unit

experience of medical officers (obstetric, anaesthetic and paediatric), midwives and neonatal nursing staff available at the particular health unit

availability of other services and facilities to manage the identified and potential complications.

These guidelines recognise that the complexity of clinical care provided at any given health service is predominantly determined by the relevant workforce and physical facilities available to support that care. The WA Health Clinical Services Framework 2010 – 2020 (obstetric and neonatal components) are included as Appendix 1.


Page 48 of 80

Each site providing maternity services is required to develop site specific inclusion and exclusion criteria. An example is provided in Appendix 2. Also recommended, are regular site based multidisciplinary clinical reviews whereby each individual pregnant woman’s situation, preferences and risks throughout pregnancy are considered, and recommendations regarding appropriate maternity care plans formulated, documented and communicated to the woman and relevant members of the care team. Guidelines for referral are available for midwives and GP obstetricians in the following documents:

King Edward Memorial Hospital (KEMH) Antenatal Shared Care Australian College of Midwives - National Midwifery Guidelines for Consultation and Referral (2nd edition) 20088 RANZCOG College Statement C-Obs 30: Suitability Criteria for Models of Care and Indicators for Referral Within and Between Models of Care March 2009.9

It is a requirement of all clinicians working with pregnant women that these women are made aware of the Clinical Service Levels available at their local and regional maternity care units (Refer Appendix 3). Where birthing services cannot be sustained in smaller communities, there is to be a focus on supporting antenatal and postnatal services where needed, integrating services provided by WACHS with community based services provided by private GPs, Aboriginal Medical Services and RFDS, and with metropolitan based service providers. In 2010 a metropolitan maternity services mapping process conducted by the Statewide Obstetric Support Unit demonstrated that services provide midwifery care for on average five days post birth either as an inpatient or as follow up home visits. In a small number of services, women may return to the service for review and follow up care. In terms of equity of access, as a minimum standard, wherever possible, women in rural areas are to receive five days postnatal care by a midwife. Refer Appendix 6 - Postnatal Care.

Clinical Safety & Quality Safety and quality in all WA Health services is of paramount importance. WA Health has adopted the four pillars of clinical governance to ensure that safety and quality are embedded in all services (Office of Safety & Quality, 2001). The WA Clinical Governance Framework is based on the following four key pillars:

1. Consumer Value 2. Clinical Performance and Evaluation 3. Clinical Risk and 4. Professional Development and Management.

8 National Midwifery Guidelines for Consultation and Referral, 2nd Edition, 2008, Australian College of Midwives. 9 Suitability Criteria for Models of Care and Indicators for Referral Within and Between Models of Care

http://kemh.health.wa.gov.au/development/manuals/guidelines/A4_antenatal_shared_care.pdf�

http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?pageid=10037�

http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?pageid=10037�

http://www.ranzcog.edu.au/publications/statements/C-obs30.pdf�

http://www.ranzcog.edu.au/publications/statements/C-obs30.pdf�


Page 49 of 80

Pillar One - Consumer Value The first pillar is consumer value, which encourages health services to involve their communities and stakeholders in maintaining and improving the performance of their Health Service and in the planning for the organisation’s future. Pillar Two – Clinical Performance and Evaluation The second pillar aims to guarantee the introduction, use, monitoring and evaluation of evidence-based clinical standards. The outcome is a culture where evaluation of organisational and clinical performance, including clinical audit is commonplace and expected in every clinical service. The tools that assist WACHS to achieve the ultimate goal of clinical practice improvement are access to data, clinical audit against clinical standards and clinical indicators. Clinical standards incorporate clinical guidelines, pathways and local practice protocols. WACHS specific Obstetric Clinical Guidelines and some site specific guidelines are currently available via WACHS Policies Online. Maternity and Newborn Clinicians can refer to the KEMH Obstetric and Midwifery Guidelines for guidance. Clinical indicators are measures or benchmarks that enable health services to compare themselves against similar health services. Evidence gathered in the WACHS review of selected obstetric data sources 200910 has identified a set of indicators to measure improvements in Maternal and Newborn health outcomes. Preliminary Maternal and Newborn Indicators

WACHS Obstetric Dashboard: Smoking in pregnancy (by ATSI) Provision of Antenatal Care at 13 and 20 weeks gestation (by ATSI) Deliveries with a birth weight less than 2500g (by ATSI)

Selected Primipara who undergo Induction of labour Selected Primipara who undergo an instrumental vaginal birth Selected Primipara who undergo caesarean section Selected Primipara requiring surgical repair of the perineum for a third degree tear

Obstetric trauma: vaginal delivery with instrument Obstetric trauma: vaginal delivery without instrument Decision to delivery interval for emergency caesarean section (under consideration) Women who undergo an emergency Caesarean Section after failed attempt at

instrumental birth

Total number of babies born with an Apgar Score of less than 7 at five minutes post delivery

Postpartum haemorrhage requiring blood transfusion Transfer of a labouring woman (intra/inter region) (by ATSI) Transfer of an unwell mother (by ATSI) Transfer of an unwell neonate (intra/inter region)(by ATSI)

10 Review of Selected Obstetrics Data Sources, 2009, Western Australian Country Health Services

http://wachs.hdwa.health.wa.gov.au/policies/�

http://www.kemh.health.wa.gov.au/services/SOSU/links.php#maternity�

http://www.kemh.health.wa.gov.au/services/SOSU/links.php#maternity�


Page 50 of 80

Clinical audits analyse the quality of clinical care outcomes, including the procedures used for diagnosis and treatment, the use of resources, and the adequacy of evaluation of clinical outcomes and patient quality of life. Videoconferencing is to be utilised to facilitate regional involvement in clinical review activities wherever possible. Pillar Three - Clinical Risk The third pillar concentrates on minimising clinical risk and improving overall clinical safety. This is achieved through identifying and reducing potential risks and examination of adverse incidents for causative and contributing factors and trends within and across services. To maximise learning opportunities, lessons should be shared at the local, state wide and national levels. Some aspects of clinical risk management are:

incident and adverse event reporting, monitoring and trend analysis

sentinel event reporting, monitoring and clinical investigation

risk profile analysis includes the identification, investigation, analysis and evaluation of clinical risks and the selection of the most appropriate method of correcting, eliminating or reducing identifiable risks.

review of local performance against the Maternal & Newborn Dashboard Indicators including regional perinatal mortality and morbidity occurs on a regular basis, involving WACHS district maternity service providers.

the Regional Obstetric Advisory Committee is responsible for review and implementation of any recommendations arising.

Pillar Four – Professional Development and Management The fourth pillar supports the selection and recruitment of clinical staff, their ongoing professional development, the maintenance of their professional standards and the control and monitoring of new and innovative procedures.

This incorporates:

competency standards: The employing health service must be confident its staff have adequate skills and experience and are properly trained within their field, in order to undertake the responsibilities of their position within the health service. This includes an assessment by the health service upon appointment and regular assessment throughout their employment.

continuing professional development, which includes ongoing and regular education and research activities linked to the responsibilities and needs of the clinicians employed by the health service. Appointed obstetricians, specialist GPs and midwives are expected to be able to demonstrate periodic upskilling and assessment with respect to neonatal resuscitation and fetal surveillance knowledge, and participate in emergency obstetric skills development and learning activities on a regular basis.



Page 51 of 80

APPENDIX 2: WA Health Clinical Service Framework 2010-2020 Designated Levels for Obstetrics and Neonates

Designated Levels for OBSTETRICS

Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

Obstetrics

No planned births.

If required, inpatient care following birth elsewhere.

Antenatal, postnatal care is carried out by visiting medical officers, private GPs, ACCHO GPs or RFDS GPs, with or without the assistance of AHWs or RNs/RMs depending on the type of patient care needed.

As for level 1 plus: Normal low-risk

pregnancies and births and management of newborns > 37+0 weeks gestation with minimal complications.

Service by GPs/GP obstetricians /DMOs and midwives.

Caesarean section transferred elsewhere but must be within safe timeframe.

As for level 2 plus: Elective and

emergency caesarean capability.

24hr anaesthetic service provided.

Visiting obstetrician.

Access to some allied health services.

As for level 3 plus: Planned births

of low and moderate risk mothers / babies.

Access to specialist obstetricians, paediatricians and anaesthetists.

On-call roster for obstetricians and anaesthetists.

Access to designated allied health services.

Some allied health undergraduate education.

As for level 4 plus: Births of low,

moderate and high risk mothers / babies.

Service provided to high risk mothers / babies by specialist obstetricians, neonatal paediatricians and anaesthetists.

Onsite 24hr medical officer obstetric cover by specialist or above.

As for level 5 plus: Tertiary

obstetric services.

Specialist obstetric services including subspecialty maternal fetal medicine, obstetric medicine, genetic services.

Dedicated HDU facilities.

Onsite access to ICU.

Has facilities to undertake obstetric and fetal research.

Continued….



Page 52 of 80

Designated Levels for OBSTETRICS Continued…


Obstetrics

Continued…

Access to 24hr telephone support from obstetricians.

Access to allied health.

Access to e-health or Telehealth.



24hr cover by specialist obstetricians, paediatricians and anaesthetists.

Access to HDU/ICU facility.

Regional referral role.



Coordinates training of specialist obstetricians and specialist midwives.

Onsite Level 6 NICU.



Page 53 of 80

Designated Levels for NEONATES


Neonatology

Continued….

A neonatal service is not applicable, but for postnatal care of newborn infants, the standards within Level 2 (onsite Level 1 neonatal facilities) are to be applied.


Normal low-risk pregnancies and births and management of newborns > 37 +0 weeks gestation with minimal complications.

24hr onsite access to a health professional skilled in initiating (accredited) neonatal resuscitation.

Phototherapy for physiological jaundice.

As for level 2

As for level 3 plus:

Onsite neonatal facilities with low dependency patients and apnoea monitoring, low-level Oxygen therapy (including monitoring) and nasal /oral-gastric feeding.


As for level 4 plus: Onsite

neonatal facilities with high dependency patients and provision of short-term mechanical ventilation (<6 hours) pending transfer, nasal CPAP with facilities for arterial blood gas monitoring

Non invasive BP monitoring.

Has access to clinical and diagnostic paediatric subspecialties.

Service led by neonatal paediatricians.


As for level 5 plus: Onsite Level 6

NICU with high dependency patients and provision of medium-long term mechanical ventilation and full life support.

Neonatal paediatricians on-call 24 hours,

High-risk, high dependency pregnancies and births,

Management of newborns <32+0 weeks gestation,



Page 54 of 80


Neonatology

Continued…

Telephone access to emergency care and transport.

Access to some allied health services.

Low to moderate risk pregnancies and births and management of newborns >34+0 weeks gestation with minimal complications.

Short term intravenous therapy available.

All patients are referred for management by attending paediatrician.

Access to designated allied health services.

Some allied health undergraduate education.

Paediatric registrar or above on site 24 hours.

Moderate to high-risk pregnancies and births and management of newborns >32+0 weeks gestation with minimal complications

Access to specialist SRN

Role in post graduate medical and nursing education

Careful consideration to receiving transfers from L1 neonatal facilities (Level 2 or 3 hospital)


Undertakes neonatal surgery and care for complex congenital and metabolic diseases of the newborn.

Coordinates state wide retrieval service.

Coordinates post graduate medical and nursing neonatal education.

Has neonatology research.



Page 55 of 80

References:

1. Framework for the care of neonates in Western Australia, 2009. Department of Health, Western Australia.

2. Department of Health and Ageing Licensing Requirements Commonwealth of Australia, “Neonatal facilities for the treatment of newly born children approval under the Health Insurance Act 1973”, Circular HBF583/PH340, September 1999.

http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Framework_for_the_Care_of_Neonates_in_WA.pdf�

http://www.health.gov.au/internet/main/publishing.nsf/Content/33083B10C712A3D9CA256F190016C996/$File/583_340.pdf�

http://www.health.gov.au/internet/main/publishing.nsf/Content/33083B10C712A3D9CA256F190016C996/$File/583_340.pdf�



Page 56 of 80

Appendix 3: Maternity and Neonatal Services by Level

Em

erg

ency

Car

e A

vaila

ble

An

ten

atal

, Bir

thin

g a

nd

P

ost

nat

al s

ervi

ces

avai

lab

le o

n s

ite

Mid

wiv

es a

vaila

ble

24/

7

Ob

stet

ric

pra

ctit

ion

ers

avai

lab

le 2

4/7

An

aest

het

ic s

ervi

ces

avai

lab

le 2

4/7

C/S

cap

abil

ity

Pae

dia

tric

ian

ava

ilab

le

24/7

Pat

ho

log

y

Ph

arm

acy

Dia

gn

ost

ic m

edic

al

imag

ing

ICU

Neo

nat

al S

ervi

ces

Level 6

24/7

on site

On call 24/7

On call 24/7

Level 6 NICU

Level 5

24/7

on site

On call 24/7

On call 24/7

Level 5 – high dependency

Level 4

On call 24/7

Advice 24/7

On call 24/7

Level 1

Level 4 – low dependency

Level 3 GP

care Limitedlocal

Limitedlocal

Limitedlocal

Low risk .37/40 – old Level 1

Level 2 Low risk > 37/40 – old

Level 1

Level 1 Emergency care only


Page 57 of 80

APPENDIX 4: WACHS Maternity and Neonatal Referral Guideline Summary for Service Levels

Preface: The following summary indicating appropriate clinical settings for women and babies with various health issues complicating pregnancy and the post partum and neonatal periods is a guide. It is neither an exhaustive list of possible clinical scenarios, nor is it meant to be prescriptive. In particular, individual WACHS clinical service units may not necessarily have the appropriate infrastructure or clinical resources to support all the clinical situations listed as appropriate to the designated service level of the unit. In addition, unit clinical and infrastructure resources may change over time. Each unit may individualise the referral guidelines according to resources available at any one time. This information is to be readily available for reference by all clinicians and managers working in the unit. The individual social, psychological and clinical needs of each woman and her baby/babies must be considered when decisions are made concerning appropriate care during pregnancy and the puerperium. Where the woman and her clinical team decide on care which falls outside the recommended referral guidelines, the clinical situation and decision-making process must be carefully recorded in the clinical record. Some of the clinical situations listed cover a broad spectrum of conditions. In such situations it is impossible to define a set referral pattern. The recommended pathway is to individualise care, usually with reference to specialist (obstetric, paediatric or anaesthetic) advice. In some situations, the decision whether or not to manage a woman and/or her baby/babies locally, may be determined by the availability or not, of appropriate midwifery and/or nursing expertise. In general, the best interests of the mother and baby/babies are to be served by good communication in association with well-executed, collaborative team decision-making, involving the woman and her family, at each step along the way. This referral guideline summary has been developed with reference to the National Midwifery Guidelines for Consultation and Referral (2nd Edition)8 by the Australian College of Midwives and the RANZCOG Guideline: Suitability Criteria for Models of Care and Indications for Referral Within and Between Models of Care.11

11 RANZCOG Guideline: Suitability Criteria for Models of Care and Indications for Referral within and

between Models of Care, 2009, Royal Australian and New Zealand College of Obstetricians and Gynaecologists



Page 58 of 80

APPENDIX 4 Continued: WACHS Maternity and Neonatal Referral Guideline Summary for Service Levels CSF Levels Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

GP or

RM SPECIALIST KEMH

AN IP AN IP AN IP AN IP AN IP AN IP PREVIOUS PREG COMPLICATIONS Eclampsia S X S X S X � � � � � � Cervical incompetence S X S X S TERM � � � � � � Placenta accrete S X S X S X � � � � � � Post-partum psychosis S X S X S X � � � � � � Preterm birth <35/40 S X S TERM S TERM � � � � � � MEDICAL CONDITIONS Malignant hypertension S X S X S X � � � � � � Neuromuscular disease S X S X S X � � � � � � Endocrine disorders on Rx S X S X S I � � � � � � Known thrombophilia S X S X S I � � � � � � Bleeding disorder S X S X S X � � � � � � Thromboembolism S X S X S X � � � � � � Epilepsy with seizure past 12/12 S X S X S X � � � � � � Renal function disorder S X S X S X � � � � � � Mod to severe asthma S X S X S X � � � � � � Connective tissue disorders S X S X S X � � � � � � Blood Group antibodies; risk HDN or XM problem S X S X S X S I S I � � Trophoblastic disease S X S X S X � � � � � � Cardiac disease S X S X S X � I � � � � Alcohol or drug dependency S X S X S X � � � � � � Previous anaesthetic complications S X S X S X � � � � � � Infectious diseases in pregnancy HIV infection S X S X S X S X S X � � Active TB S X S X S X S X S X � � Varicella/Zoster infection S X S X S X S X S X � � Active genital herpes S X S X � � � � � � � �



Page 59 of 80

CSF Levels Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

GP or

RM SPECIALIST KEMH

AN IP AN IP AN IP AN IP AN IP AN IP ANTENATAL Diabetes requiring insulin S X S X S X � � � � � � CIN 3 S X S � S � � � � � � � Cancer of cervix S X S X S X S X S X � � Pre eclampsia/PIH: mild 140/90, proteinuria and No Other Abnormalities Detected X X X X S � � � � � � � Pre eclampsia - moderate/severe or Eclampsia X X X X X X � � � � � � Multiple pregnancy X X S X S X � � � � � � Twin to twin transfusion X X X X X X S X S X � � Perinatal death X X X X I I � � � � � � Placenta praevia X X X X X X � � � � � � Placenta praevia accrete X X X X X X X X X X � � Preterm ROM < 34 weeks X X X X X X X X � � � � Preterm ROM 34 - 37 weeks X X X X X X � � � � � � VBAC S X S X not IOL � � � � � � Abnormal presentation > 36 weeks X X S X I I � � � � � � IUGR <10th centile for gestational age X X S X S X � � � � � � IUGR <3rd centile for gestational age X X S X S X � � � � � � Suspected macrosomia S X S X S X � � � � � � BMI 35 - 39.9 S X S X S I � � � � � � BMI ≥ 40 (refer WACHS Maternity Body Mass Risk Management Policy) S X S X S X I I � � � � Oligohydramnios X X X X X X � � � � � � Polyhyramnios X X X X X X � � � � � � APH X X I I I I � � � � � � Cervical amputation S X S TERM S TERM � � � � � � Bi-cornuate uterus S X S X � � � � � � � � Active blood group incompatibility S X S X S X S X S X � �





Page 60 of 80

CSF Levels Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

GP or

RM SPECIALIST KEMH

AN IP AN IP AN IP AN IP AN IP AN IP INTRAPARTUM 34 - 37 weeks X X X X X X � � � � � � 32 - 34 weeks X X X X X X X X � � � � <32 weeks X X X X X X X X X X � � 4th degree tear X X X X X X � � � � � � Active primary genital herpes X X X X X X � � � � � � Induction of labour X X I I � � � � � � � � Unsuccessful induction of labour X X X X I I � � � � � � Operative vag birth - no head on view X X I I I I � � � � � � Non-reassuring CTG X X I I � � � � � � � � Malpresentation X X X X I I � � � � � � POSTPARTUM Thromboembolism X X X X X X � � � � � � PPH > 1000 ml X X X X S I � � � � � � Eclampsia X X X X X X � � � � � � PP NEONATAL Apgar less than 7 at 5 minutes X X X � � � Cord pH < 7 X X X � � � Cord lactate > 6.1 no resus required and no features of neonatal compromise (refer WACHS SW Umbilical Cord Blood Collection/Analysis for Acidaemia Site Instruction) X I I � � � Cord lactate > 6.1 with features of neonatal compromise (refer WACHS SW Umbilical Cord Blood Collection/Analysis for Acidaemia Site Instruction) X X X I � � Birth weight < 2000gm X X X I � � Birth weight 2000-2500gm X X I I � �









Page 61 of 80

Continued… CSF Levels Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

GP or

RM

SPECIALIST

KEMH

PP NEONATAL 34 - 37 weeks X X X � � � 32 - 34 weeks X X X X � � <32 weeks X X X X X � Congenital abnormalities requiring treatment or investigation X X X I I � Abnormal heart rate or pattern X X X I I � Suspected seizure activity X X X X � � Persistent hypoglycaemia X X X I � � Jaundice in first 24 hours of life X I X X � � Jaundice > 250 mmol/l within 1st 48 hours X I I I � � Jaundice > 300 mmol/l after 48 hours X I I I � � Persistent cyanosis or pallor X X X X � � Readmission, BW < 1500 gm X X X X � �

S = Shared care with regional centre with specialist obstetrician, paediatrician or in consultation with medical / anaesthetic consultant as appropriate to the clinical situation S = Shared care with tertiary centre subspecialist required I = Individualise treatment according to condition and advice from specialist X = No � = Yes AN = Antenatal IP = Intrapartum PP = Peripartum


Page 62 of 80

APPENDIX 5: Client Information Sheet - Sample The aim is for this client information sheet to be completed by the clinician in conversation with the mother seeking the service. It is to be modified to include the specific site details then be made available for clinical use. It is important that the mother has accurate information about the level of service at her booking hospital and the possibility of changes in service capability, especially in relation to availability of workforce. The principles underpinning this conversation and the ongoing discussions between the mother and clinician are:

1. Consideration of the safety of the mother and newborn are paramount and influence the WA Country Health Service decision-making about the availability of the maternity and newborn services.

2. The facts about the service capacity and possible service variability are to be available to the mother.

3. The family and individual circumstances within the community they reside. Each region, district and site should modify the information in this sheet to reflect the local context. This information sheet is to initially be completed when arranging booking of the woman for birth. The document and discussion is to be revisited when maternal and or service circumstances alter and/or when the woman is 36 weeks. An initial conversation regarding service availability is to occur once a pregnant woman has attended for review at anytime from the second trimester of pregnancy onward, to enable her to make an informed choice regarding ongoing pregnancy care. Each maternity site is to determine a process to delegate responsibility for initiation and documentation of the discussion.


Page 63 of 80

CLIENT INFORMATION SHEET - SAMPLE Birthing Options and Issues for Discussion The WA Country Health Service is committed to improving health outcomes for all women and newborns in country areas by providing care closer to home, where a safe and sustainable service can be provided. Service availability is not always static in rural areas. Service availability is influenced by the availability of qualified and skilled maternity and newborn staff, access to additional services such as pathology, radiology, operating theatres, blood products and in smaller sites competing service demands. If the local health service does not have a birthing service or, if the level of birthing or neonatal service is not suitable for your clinical needs, you will be asked to re-locate to the town that has safe birthing options available. There is no set time for leaving your community. The time is determined between you and your clinician and is based on health indicators associated with your pregnancy, including the wellbeing of you and your child and the distance to your required birthing service. The evidence available to the WA Country Health Service indicates that for a normal pregnancy, the safest option for you is to be close to the required delivery service from at least 37 weeks onwards. Issues regarding relocation need to be discussed with your clinician and local health service. You have a right to be given the facts and informed advice, so you can make your own informed decision. Your clinician and health service will consider the wellbeing of you and your child foremost when providing advice. Should you choose to make a decision that differs from the advice given, the WA Country Health Service will provide the best service it can within the limitations of local health service capacity and will seek to transfer you according to the clinical needs for you and your baby. This confirms that you are booked to birth at the ____________________ Hospital.

This facility is currently designated as Level Maternity, and Level

________ Newborn Services. This means that the services available for maternity and

newborn care at this site include: (Ante natal, delivery, post natal, newborn, lactation and

child health services and support should be listed)

A

B

C

D

E

F


Page 64 of 80

If there is a change in the service provision at your booked hospital, you will be notified as

soon as possible to enable you to choose an alternative service.

The closest alternative hospital available to meet your needs is the _________________

_____________________________________ Hospital.

You may also wish to also explore services elsewhere in case there is a local service change. Should you develop additional risk factors related to your pregnancy, it may be necessary for the plan of care to change and for your booking to be transferred to another hospital. Please ensure you have a comprehensive discussion with your clinician and health service so that you are aware of all the options available to you and can make an informed decision with their assistance.

Should I need to relocate the travel and accommodation options plus PATS support available are as follows: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Should I have any questions my contact is:

Name:__________________________________________________________________

Phone: _________________________________________________________________

Location:________________________________________________________________

The outstanding issues that I am required to follow up are:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

It has been agreed that:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________


Page 65 of 80

I acknowledge that possible options in relation to the place of birth and any requirements

for me to relocate have been discussed.

(client name)

(client signature) (date)

(signature) (date)


Page 66 of 80

APPENDIX 6: Clinician Fact Sheet related to

Client Information Sheet For pregnant women who live in WACHS regions and who are booked to give birth in maternity unit distant from home, a decision must be made as to when to leave home to await birth closer to their maternity unit. For some women the move is sensibly made early in the third trimester e.g. known major placenta praevia, twin pregnancy, cervical suture in situ, high risk of preterm birth etc. For women with uncomplicated pregnancies it is recommended that they plan to move close to their maternity unit by 37 weeks gestation. The pregnancy outcome data for women resident in WACHS postcodes for the years 2008 & 2009 demonstrated that by 37 weeks, there was a 1 in 25 chance of going into spontaneous labour during the following week. Where intrapartum care services are not close at hand, management of spontaneous labour necessitates emergency transfer or birth in a sub-optimally resourced setting. The table below shows the percentage of women resident in WACHS regions, of whom gave birth in 2008 and 2009, and who experienced spontaneous onset of labour at each week of gestation, between 34 and 39 weeks. There was no difference between nulliparous and multiparous women.

Gestation in Weeks

Percentage of women who experienced spontaneous onset of labour between 34 and 39 weeks

Within

week

Within

2 weeks

Within

3weeks

Within

4weeks

Within

5weeks

34 1 2 4 8 15

35 1 3 7 15

36 2 6 14

37 4 12

38 9

Source: 2008 and 2009 Midwifery Notification Data for all Women residing within regional WA post codes Denominator: All women reaching the completed weeks gestation regardless of

subsequent birth outcome. Numerator: All women labouring spontaneously within each indicated timeframe

(excluding women who underwent caesarean section without labour or induction of labour).


Page 67 of 80

ANTENATAL CARE Antenatal care is to be provided by the most appropriate health professional taking into account risk and ensuring continuous health assessment throughout the pregnancy to achieve the best outcome for mothers and babies. Local services are to be targeted to the needs of rural and remote women, ensuring integration and a seamless transfer of care when required. The WA Policy Framework for Maternity Services7 is clear that antenatal, post natal and newborn care is to be provided locally for women in rural and remote WA with healthy and uncomplicated pregnancies. While the Policy Framework asserts that the majority of antenatal care is to be community based, local service provision may differ across the WA Country Health Service. Regardless of the model of service provision, continuity of care is to be emphasised when planning maternity care in partnership with women and their families. When transfer of care is necessary, discussion with the mother is to occur to balance clinical care needs with family and cultural support.


Page 68 of 80

POSTNATAL CARE The WA Country Health Service is keen to support women returning to their families and communities as soon as possible. Women may birth outside their local area for a variety of reasons based on choice, a need for a service that addresses complex health care needs or lack of local access to a birthing service. Once the baby is born, women and their babies can be suitable to be transferred back to their local community where there may or may not be a birthing service. It is an expectation that wherever possible, the WA Country Health Service will assist in the provision of antenatal and postnatal care within the local community. Every effort is to be made to accept postnatal transfers within their clinical service delineation. Other service providers such as GPs and non government organisations (NGOs) are also to be sourced to support the mother’s return to the community. As a standard, postnatal women without complications are to receive midwifery support in the early postnatal period with access to a midwifery review on a daily basis until the fifth day following the birth of the baby. This may be in a hospital or in the community. See Appendix 7 (below) for decision making tree for acceptance of women for postnatal care at non-birthing site.


Page 69 of 80

APPENDIX 7: Post Natal Care Decision-Making Tree Decision making tree for acceptance of women for postnatal care at non-birthing site:

Unsuitable for transfer

Needs to remain with higher level

service

No Is the woman’s care able to be

provided locally? Yes

Is the woman suitable for discharge? Home with daily checks? Consider distance? Support?

Access to the range of needed services?

Is the woman 48 hours post birth Medically stable Not at increased risk of complications Is the baby > 37 weeks > 2500g

Yes

Is the GP prepared to accept admission?

Yes

Is there a midwife who can do a daily assessment?

Yes

Yes Admit to local site

Discharge with follow up at

local site

Review woman’s needs. If unsuitable for transfer to remain within a higher level of service

No

No

No

No


Page Error!


IMPLEMENTATION PRINCIPLES

MATERNAL AND NEWBORN MODELS OF CARE

July 2009

Author: Executive Director of Nursing Services

APPENDIX 8: Maternal and Newborns Models of Care Implementation Principles

Page 71 of 80


IMPLEMENTATION PRINCIPLES Introduction Developing and implementing new or modified models of Maternity Care as a key element in meeting the health care needs of rural and remote communities and informing regional clinical service and workforce planning. Whilst the ‘WA Health Improving Maternity Services: Working Together Across Western Australia. A Policy Framework’ produced by the Women’s and Newborn’s Health Network provides the evidence based framework for the improvement of maternity services, regional planning and implementation is now required to ensure care and services are designed to meet the needs of local communities, priorities are addressed and to ensure improvement of specific health outcomes. Different models of care may be suitable for different populations of women. Even when considering women’s preferences, their access to different models of care will be determined by their level of risk, place they live, and locations and availability of health care professionals and facilities. WACHS does not advocate one particular model of maternity care over another, but supports various models that are sustainable, needs and evidence based and are resource effective and efficient. An overview of various models of maternity care and their evidence/outcomes is included at Appendix 1 for information. This paper provides principles and process guidelines to facilitate the development and implementation of local models of maternity care in a timely and well structured manner ensuring appropriate stakeholder and consumer consultation and alignment with broader regional health service planning and resource availability. Principles New or adapted Models of Maternity Care implemented within WA Country Health Service must demonstrate: 1. Alignment with the Revitalising WA Country Health Service directions:

A fair share for country health

Service delivery according to need

Closing the Gap to improve Indigenous health

Workforce stability and excellence 2. Clearly identified need:

Why the model is required

How the model aligns with regional health service priorities

What health gaps or clinical risks are addressed by this model

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3. Use of appropriate evidence:

How does the model align with the seven themes/goals of the ’WA Health Improving Maternity Services: Working Together Across Western Australia. A Policy Framework’ 1. Improve health outcomes for Aboriginal women and babies 2. Improve the health and wellbeing of women and their unborn babies through

better preconception and early pregnancy care 3. Improve women’s experience of pregnancy 4. Improve women’s experience of childbirth 5. Improve the health and development of infants and address the needs of new

parents 6. Improve the safety and accountability in all maternity services 7. Improve the sustainability of the maternity care workforce and promote clinical

leadership and collaboration.

4. Clear description of the model highlighting:

The continuum of care

Clear referral points

Regional approach to service provision

Care as close to home as possible 5. Multidisciplinary and partnership approach:

Shared care/team based approaches where possible

Partnerships with other health care and human service providers where possible

6. Resource effectiveness: The model should provide information regarding costs and required budget

Comparison to any existing model if the proposed model is adapting a service that currently or previously existed

Where a new or additional model is proposed, how will the service be funded?

Opportunities for revenue enhancement 7. Outcomes measure:

How will you know the model will deliver the stated goals/outcomes?

What monitoring of clinical or other indicators will occur?

Outline the governance process for this monitoring

8. Stakeholder consultation: Women and families

Community

Other health care providers

Multidisciplinary team members

9. Workforce issues What workforce issues are there

How will industrial issues be addressed

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Approval Process The following development and approval checklist is recommended for the endorsement of local and regional based models of care: Model of Care Development Model of care concept or proposal to develop is supported by relevant

manager/executive.

Environment scan - review of other regions/health services - is this concept being used in another community/health service?

Principles are used to guide development.

Consultative, multidisciplinary approach.

Business case developed.

Model of Care Endorsement 1. Business case addressing principles.

2. Budget preparation with regional finance team.

3. Implementation plan.

4. Consultation and sign off with relevant regional, community and WACHS stakeholders including relevant clinical and program leaders.

5. Endorsement in line with the WACHS Policy Framework.

6. Implementation, Governance and Evaluation.

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Attachment 1: Overview Models of Care Several models of maternity care are outlined in Improving Maternity Services: Working Together Across Western Australia. A Policy Frameworki and include:

shared care

midwifery models of care

team midwifery care

midwifery group practice (sometime called caseload midwifery)

general practice (GP) models of care Recently Henderson, Hornbuckle and Doherty12 undertook a literature review of the evidence supporting the different models of maternity care. The following table is information taken directly from that report. Table 1: Summary of models and outcomes

Type of Care Description Outcome / Evidence

Continuity of care models include: Team midwifery Midwifery group practice (or caseload midwifery) GP shared care

Care that helps a woman develops a relationship with the same carer, or group of carers, throughout pregnancy, birth and after the birth. All carers share common ways of working and a common philosophy. Continuity of care can be provided in different ways and to varying degrees. Team midwifery: care during pregnancy, childbirth and the early postpartum period by a small team of usually six to seven midwives. The philosophy is continuity of care rather than individual caregivers. Caseload midwifery: women receive all their care from one principal midwife throughout pregnancy, labour and birth and postnatal period GP shared care: a cooperative arrangement between a maternity hospital and community based general practitioners for providing care during pregnancy and after birth.

Continuity of midwifery care models are more acceptable to women, while being associated with fewer intrapartum interventions and no increase in adverse outcomes. Women with high-risk pregnancies may also safely access this model providing there is appropriate obstetric support. There are no associated increased costs and there may be small savings. There is no evidence that personal caseloads offer improvements in outcomes compared with team midwifery, and they may have negative consequences for midwifery work patterns and their lifestyle.

12 Henderson J, Hornbuckle J, & Doherty, D (2007) Models of Maternity Care: A Review of the Evidence.

Perth: Western Australian Department of Health



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Women assessed to be at high risk of complications

High Risk – a term used by clinicians to describe women who have a history of problems in a previous pregnancy or have an existing medical condition or have some potential risk of complications that might require speedy or specialist treatment.

Women with high-risk pregnancies requiring frequent antenatal assessment, especially those of lower socioeconomic status, have improved perinatal outcomes and require fewer days in hospital when a significant proportion of their antenatal care is delivered in the home by advanced nurse practitioners. Significant cost benefits are associated with this model of care. In-Home care programs undertaken by experienced health professionals and ‘home-maker services,’ with adherence to diagnostic criteria and managed according to defined protocols, safely provide antenatal care to high-risk women including those with preterm labour, preterm pre-labour rupture of membranes, multiple pregnancy and those with pre-eclampsia or essential hypertension Antenatal Day Care or Day Assessment Units reduce the need for formal hospital admission for high-risk pregnancies and deliver safe care with no difference in maternal or neonatal outcomes. Women prefer day attendance, even on a daily basis, than admission to hospital.

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For high-risk pregnancies requiring frequent fetal heart rate surveillance domiciliary visits by experienced midwives and telephonic fetal heart rate monitoring reduces hospital visits and is cost-effective both for institution and the woman and her family. Aboriginal and Torres Strait Islanders have better antenatal attendance and greater satisfaction in integrated community-based antenatal care programs.

Telemedicine

Telehealth (or telemedicine) – refers to any health services using information and communications technology that removes or mitigates the effect of distance in health care.

Telemedicine programs enable women with medical and pregnancy complications, and their health providers to access tertiary level services not previously readily available due to their remote location. Benefits include reduced rates of transfer and reduced stay in the tertiary centre.

Home visiting following early postnatal discharge

In healthy women with term infants, early postnatal discharge within 48 hours of birth is not associated with any increase in adverse maternal or neonatal outcomes when women receive midwifery home visiting. There is no evidence of improvements in breastfeeding or maternal health outcomes after early discharge with home visiting programs. There are no additional benefits when compared to hospital-based postnatal follow-up programs. A program of early postnatal discharge for women with gestational diabetes or pregnancy induced hypertension is not associated with any increase in adverse outcome providing the women are well educated about possible complications and they receive intensive home visiting by a qualified nurse or midwife. There are cost savings associated with this model of care.

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The report also made comments on the alternative locations for birth. These are summarised in Table 2: Table 2: Summary of location outcomes

Location Definition Outcome / Evidence

Home Birth – usually a planned event where the woman decides to give birth at home, with care provided by the midwife.

Planned home birth with a qualified home birth practitioner is a safe alternative for women determined to be at low obstetric risk by established screening criteria. Women should be counselled about the potential for transfer to hospital if complications arise and systems should be put in place for smooth transition to hospital care in the case of complications.

Birth centres

Birth centre – (freestanding) a geographically separate from a maternity unit, where healthy women can give birth and receive midwifery-based care with continuity of care throughout pregnancy, birth and the early postnatal period. Birth Centre – (In-hospital) a home like environment established within the grounds of or attached to a maternity care hospital where healthy women can give birth and receive midwifery-based care with continuity of care throughout pregnancy, birth and the early postnatal period.

Freestanding or in-hospital birth centres where antenatal, intrapartum and postpartum care is provided to low-risk women by appropriately skilled midwives reduces intrapartum intervention rates without an increase in perinatal adverse outcome. In addition, women report higher levels of satisfaction compared with hospital based care.

Cost comparison A second report was commissioned by Doherty et al13 to determine the cost effectiveness of the various models. The following is a summary of the reported analysis.

13 Doherty D, Hornbuckle J, Hutchinson M, Henderson J, Montague G, & Newnham J. (2008) Evaluation of

pregnancy outcomes and cost-effectiveness of models of antenatal care and preferred setting for labour and birth care in women at low risk of pregnancy complications. Perth, Western Australian Department of Health

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Twelve different models of maternity care involving midwives, GP’s, GP obstetricians and traditional public obstetric led care were evaluated. These models included planned home birth, family birth centres co-located at a hospital site and secondary and tertiary hospitals. Evaluation of models of care included rates of antenatal, intrapartum and postpartum transfers between models of care along with clinical outcomes and associated costs. Midwifery led models of care, where out of hospital birth was planned, were cost effective when women continued in a low risk model of care throughout their pregnancy, labour and birth. These were either parous women under 35 years of age with BMI <30; or women aged 35 and over with parity 1-4 and BMI<30. Due to the high rates of adverse pregnancy outcomes amongst Aboriginal women, out-of hospital models of care were not considered suitable. Average costs of care in the hospital-based models were the highest in the tertiary hospital and the lowest in the secondary hospital. Within tertiary and secondary hospital settings, midwifery lead model of care incurred the lowest costs of antenatal and birth care, partly because of the effects of the continuity of care that translated into lowered rates of intervention in labour and lower rates of caesarean deliveries.


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ABBREVIATIONS AND GLOSSARY

ACCHO .............Aboriginal Community Controlled Health Organisation AHW..................Aboriginal Health Worker ANF...................Australian Nursing Federation ANMC ...............Australian Nursing & Midwifery Council CTG .................Cardiotocograph DDI....................Decision to Delivery Interval- time to Caesarean Section DoHA ................Department of Health & Ageing DMOs................District Medical Officers FTE ...................Full Time Equivalent GP.....................General Practitioner NETS WA..........Neonatal Emergency Transport Service of Western Australia NGOs ................Non-Government Organisations RANZCOG ........Royal Australian & New Zealand College of Obstetricians and

Gynaecologists RFDS ................Royal Flying Doctor Service RN.....................Registered Nurse RM ...................Registered Midwife SRN ..................Senior Registered Nurse WACHS.............West Australian Country Health Service 24/7 ...................Twenty four hours each day, seven days per week.


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Relevant Reading Australian Health Ministers Advisory Council 2008 Primary Maternity Services in Australia: A Framework for Implementation for Primary Maternity Services in Australia. Doherty, D., Hornbuckle, J., Hutchinson, M., Henderson, J., Montague, G., & Newnham, J. 2008. Evaluation of pregnancy outcomes and cost-effectiveness of models of antenatal care and preferred setting for labour and birth care in women at low risk of pregnancy complications. Perth, WA: University of Western Australia. Henderson, J., Hornbuckle, J., & Doherty, 2007. Models of Maternity Care: A Review of the Evidence. Western Australia Department of Health Department of Health and Ageing National Maternity Services Review Report. Rural Health Workforce Australia. 2007. National Consensus Framework for Rural Maternity Services. WACHS Regional Resource Centre and Integrated District Health Service Levels, 2009 WACHS Maternal & Newborn Models of Care, Implementation Principles, July 2009 WA Health Clinical Services Framework, 2010 – 2020 Standards for Maternal and Neonatal Services in South Australia 2010

http://www.ahmac.gov.au/cms_documents/Primary Maternity Services in Australia.pdf�

http://www.healthnetworks.health.wa.gov.au/docs/Models_of_Maternity_Care_Review_of_Evidence.pdf�

http://www.healthnetworks.health.wa.gov.au/docs/Models_of_Maternity_Care_Review_of_Evidence.pdf�

http://www.health.gov.au/internet/main/publishing.nsf/Content/maternityservicesreview-report�

http://www.midwives.org.au/lib/pdf/documents/National Concensus Framework.pdf�

http://www.midwives.org.au/lib/pdf/documents/National Concensus Framework.pdf�
