Guidelines for Shared Maternity Care Affiliates 2010 The Shared Maternity Care Collaborative 1 GUIDELINES FOR SHARED MATERNITY CARE AFFILIATES 2010 Mercy Hospital for Women The Royal Women’s Hospital Western Health Northern Health Copyright State of Victoria 2010 This work is copyright and if reproduced reference must be cited as follows: Guidelines for Shared Maternity Care Affiliates, Mercy Hospital for Women, The Royal Women’s Hospital, Western Health and Northern Health 2010. Published by Mercy Hospital for Women, The Royal Women’s Hospital, Western Health and Northern Health, Melbourne, Victoria. All rights reserved. Except for the purposes of education, fair dealing and use within the intended environment, no portion of this document should be reproduced or copied for any purposes, including general exhibition, lending, resale and hire. November 2010 Published on the web, at the four Hospitals’ websites: www.thewomens.org.au, www.mercy.com.au, www.wh.org.au, www.nh.org.au DISCLAIMER These guidelines have been developed for the provision of shared maternity care between Mercy Hospital for Women, The Royal Women’s Hospital, Western Health and Northern Health (The Hospitals) and shared maternity care affiliates accredited at these Hospitals. Irrespective of these Guidelines, every health service provider and health professional must individually exercise the standard of professional judgment and conduct expected of them in selecting the most appropriate care for a pregnant woman and in the management of her pregnancy. Any representation implied or expressed concerning the efficacy, appropriateness or suitability of any treatment or service is expressly negatived. The Hospitals cannot and do not warrant that the information contained in these guidelines is in every respect accurate, complete or indeed appropriate for every woman and her pregnancy. Accordingly, the Hospitals will not be held responsible or liable for any errors or omissions that may be found in any of the information set out in these guidelines. These guidelines contain links to websites (“linked third party sites”) not under the direct control of the Hospitals. These links are provided as a convenience and the inclusion of any link does not imply endorsement or approval of the linked website. The Hospitals make no warranty regarding the quality, accuracy or fitness for purpose of the content or services available through linked third party sites. 2 ACKNOWLEGEMENTS Project Leads Madeleine Whinney Shared Maternity Care Guidelines Project Officer Dr Ines Rio Head General Practice Liaison Unit, The Royal Women’s Hospital Management Group Dr Leonie Griffiths General Practice Liaison Officer, Northern Health Dr Mary Anne McLean General Practice Liaison Medical Advisor, Mercy Hospital for Women Dr Ines Rio Head General Practice Liaison Unit, The Royal Women’s Hospital Dr Jo Silva General Practice Advisor, Western Health Bianca Bell General Practice Liaison Coordinator, Western Health Merran Mackie General Practice Liaison Project Officer, Mercy Hospital for Women Sue Vallance General Practice Liaison Project Officer, Northern Health Madeleine Whinney Project Officer, The Royal Women’s Hospital Steering Committee Dr Louise Kornman Clinical Director, Maternity Services, The Royal Women’s Hospital Dr Bernadette White Clinical Director, Obstetric & Maternity Services, Mercy Hospital for Women Dr Alex Teare Clinical Services Director Women’s & Children’s Health, Northern Health Dr Michael Sedgley Clinical Services Director, Division of Women’s and Children’s Services, Western Health Tanya Farrell Director Maternity Services, The Royal Women’s Hospital Theresa Bowditch Deputy Director Nursing, Maternity and Neonatal Services, Mercy Hospital for Women Susan Gannon Divisional Director Women's & Children's, Western Health Dr John Scopel Shared Maternity Care Affiliate GP representative Dr Fiona Broderick Shared Maternity Care Affiliate GP representative Dr Judy Smith Shared Maternity Care Affiliate Midwife representative Carol Lawson Shared Maternity Care Affiliate GP, Royal Australian College of General Practice representative Dr Jennifer Anderson Shared Maternity Care Affiliate GP, General Practice Victoria representative Dr Leonie Griffiths General Practice Liaison Officer, Northern Health Dr Mary Anne McLean General Practice Liaison Medical Advisor, Mercy Hospital for Women Dr Ines Rio Head General Practice Liaison Unit, The Royal Women’s Hospital Dr Jo Silva General Practice Advisor, Western Health Bianca Bell General Practice Liaison Coordinator, Western Health Merran Mackie General Practice Liaison Project Officer, Mercy Hospital for Women Sue Vallance General Practice Liaison Project Officer, Northern Health Madeleine Whinney Project Officer, The Royal Women’s Hospital Karen Irving Senior Program Advisor, Maternity Services, Department of Health (to February 2010) Melissa Brown Senior Program Advisor, Maternity Services, Department of Health (from February 2010) Special Thanks Shared Maternity Care Coordinators at the four hospitals: Jane De Marco, Sue Herlihy, Julie Brook and Francis Sweeney Other hospital staff who informed these guidelines Shared Maternity Care Affiliates and women involved in focus groups Department of Health Royal Australian College of General Practitioners Three Centres Collaboration 3 CONTENTS INTRODUCTION ....................................................................................................................................... 6 THE SHARED MATERNITY CARE MODEL .................................................................................................. 8 Definition ............................................................................................................................................. 8 Responsibilities in Shared Maternity Care .......................................................................................... 8 The Hand Held Pregnancy Record ....................................................................................................... 9 The Shared Maternity Care Coordinator ........................................................................................... 10 Accreditation and Reaccreditation of Shared Maternity Care Affiliates ........................................... 11 THE PRE-PREGNANCY CONSULTATION ................................................................................................. 13 Preventive Activities before Pregnancy ............................................................................................ 13 Pre-pregnancy Consultation Checklist .............................................................................................. 17 ANTENATAL VISITS ................................................................................................................................ 24 Confirmation of Pregnancy ............................................................................................................... 24 Shared Maternity Care at Our Hospitals ........................................................................................... 26 Hospital location maps .................................................................................................................. 27 How to Refer for Shared Maternity Care .......................................................................................... 28 Satellite Clinics ............................................................................................................................... 28 Hospital Tours ................................................................................................................................ 28 Support Services ................................................................................................................................ 29 Schedule of Visits .............................................................................................................................. 29 Shared Maternity Care Affiliate Discussion Points and Patient Information .................................... 37 ANTENATAL INVESTIGATIONS ............................................................................................................... 49 Initial Routine Investigations ............................................................................................................. 49 Initial Investigations to Consider ....................................................................................................... 50 Second Trimester Investigations ....................................................................................................... 55 Third Trimester Investigations .......................................................................................................... 55 TESTING IN PREGNANCY FOR FETAL ABNORMALITIES ......................................................................... 60 Screening versus Diagnostic Tests ..................................................................................................... 60 4 Counselling ........................................................................................................................................ 60 Down Syndrome and other Chromosomal Abnormalities ................................................................ 61 Fetal Morphology Ultrasound (18-20 weeks) ................................................................................... 67 MANAGEMENT AND REFERRAL OF ABNORMAL FINDINGS .................................................................. 71 Referral of Problems ......................................................................................................................... 71 Abnormal Results: Test for Fetal Abnormalities ............................................................................... 74 Other Abnormal Findings .................................................................................................................. 77 MENTAL HEALTH AND WELLBEING ....................................................................................................... 81 Alcohol and Drug Services ................................................................................................................. 83 Intimate Partner Violence ................................................................................................................. 83 POSTNATAL CARE .................................................................................................................................. 86 Immediate Postnatal Care ................................................................................................................. 86 Community Postnatal Care ................................................................................................................ 88 Mental Health and Wellbeing in the Postnatal Period ...................................................................... 92 Breastfeeding .................................................................................................................................... 94 Gestational Diabetes ......................................................................................................................... 95 Hepatitis B Carriers ............................................................................................................................ 95 APPENDIX 1: LEVELS OF EVIDENCE ...................................................................................................... 102 5 INTRODUCTION ‘Guidelines for Shared Maternity Care Affiliates 2010’ have been prepared for Shared Maternity Care Affiliates who are accredited to provide Shared Maternity Care at The Royal Women’s Hospital, Mercy Hospital for Women, Sunshine Hospital and Northern Health. Shared Maternity Care is a model of care in which a woman is cared for by both hospital staff and a community based Shared Maternity Care Affiliates (a General Practitioner (GP), Obstetrician or community-based Midwife) throughout her pregnancy. The baby’s birth and immediate postnatal care are managed by the hospital. Shared Maternity Care aims to provide a high quality community-based, holistic, safe and culturally appropriate model of care for women. Shared Maternity Care is a significant and important model of maternity care at The Royal Women’s Hospital, Mercy Hospital for Women, Sunshine Hospital and Northern Health. These hospitals are committed to supporting Shared Maternity Care and the involvement of Shared Maternity Care Affiliates in the ongoing development of this model of care. These guidelines have been developed through a collaborative process between The Shared Maternity Care Collaborative (comprising of General Practice Liaison Units at The Royal Women’s Hospital, Mercy Hospital for Women, Sunshine Hospital and Northern Health). While they build upon guidelines initially developed by The Royal Women’s Hospital, Mercy Hospital for Women and Sunshine Hospital in 2002, they provide much more than an update of service information. These guidelines are the result of extensive consultation and collaboration between the four hospitals, Shared Maternity Care Affiliates and specialist clinicians and services. Their goal is to support the provision of high quality Shared Maternity Care. They aim to: delineate roles, responsibilities and expectations of different providers clarify pathways of referral, care and support assist providers in the provision of evidence based care and initiatives to support quality maternity care provide useful and relevant information for both providers and women These guidelines include new and expanded information including: investigations and tests screening and testing for fetal abnormalities Rh D immunoglobulin (anti-D) in pregnancy mental health postnatal care Added components include: ‘practice notes’ designed to highlight important points throughout the guidelines direct links to useful clinical resources for Shared Maternity Care Affiliates and clinical practice guidelines at the end of each topic area direct links to a range of quality patient information 6 greater clarity of pathways for referral easily identifiable contact details In the development of these guidelines significant changes have been achieved that strengthen Shared Maternity Care at these hospitals, including: greater alignment of antenatal care schedules clarity about the use of investigations during pregnancy clearer delineation of responsibilities of both Shared Maternity Care Affiliates and hospitals mapping of referral pathways and access to specialist advice for Shared Maternity Care Affiliates the development of enhanced support for Shared Maternity Care Affiliates through access to hospital services Extracts from the most recent ‘Three Centres Consensus Guidelines on Antenatal Care’ (1) have been incorporated into these guidelines. These extracts are printed in italics text, followed by “- 3 Centres”. The Three Centres Consensus Guidelines provide a consensus statement on some aspects of clinical antenatal care for low-risk women based on the best available evidence. Levels of evidence for the Three Centres Consensus Guidelines can be found at the end of these Guidelines. The following acronyms are used throughout this document: GP General Practitioner MHW Mercy Hospital for Women NH Northern Health RWH Royal Women’s Hospital SH Sunshine Hospital. Please note. This document refers to Sunshine Hospital as maternity services are delivered at Western Health’s Sunshine campus. SMCA Shared Maternity Care Affiliate We hope these concise, up-to-date guidelines assist you in providing quality Shared Maternity Care to women who choose this popular and important model of maternity care. It is anticipated that these guidelines will also provide a useful basis for Shared Maternity Care guideline development for other maternity services in Australia. In this case, please ensure appropriate acknowledgement is included. The guidelines are accessible on each of the hospital websites: www.thewomens.org.au , www.mercy.com.au, www.wh.org.au and www.nh.org.au. 1 3 Centres Consensus Guidelines on Antenatal Care, Mercy Hospital for Women, Southern Health and Royal Women's Hospital, 2006 7 THE SHARED MATERNITY CARE MODEL Definition In the four participating hospitals, Shared Maternity Care is a model of care in which the majority of antenatal visits take place in the community with a hospital affiliated GP, Obstetrician or Midwife (SMCA). Visits also take place at key times at the hospital (the main hospital site or hospital community satellite clinic). The woman attends the hospital for the baby’s birth and immediate postnatal care. Therefore the community based SMCA and hospital-based Doctors and Midwives act as a team in the provision of a woman’s care. Wherever possible, women should be offered continuity of care, including continuity of carer (Level I evidence) – 3 Centres GP and midwifery led models of care are safe for low-risk women (Level I, II & III evidence) – 3 Centres Shared Maternity Care is available to all low-risk women, including women who use the Family Birth Centre (available at MHW). Modified Shared Maternity Care may also be available to women who are not strictly low-risk. In these cases individual plans will be developed and documented in the hand held pregnancy record by the hospital Doctor. Responsibilities in Shared Maternity Care For Shared Maternity Care to work well, a team approach is necessary between the community and hospital providers. Responsibility for a woman’s care is shared, including responsibility for communication and the management of results and abnormal findings. The following obligations form the basis of responsibilities and communication between SMCA and hospital staff. It is the responsibility of the hospital to: notify the referring Doctor of the receipt of the referral notify both the woman and the referring Doctor of first hospital appointment details and location notify the referring Doctor if the woman does not attend her first hospital appointment notify SMCA that a woman has registered for Shared Maternity Care ensure the woman has a hand held pregnancy record ensure that a woman has information on her required schedule of visits and tests (for both hospital and SMCA). Please note that women are required to make their own appointments with SMCA notify SMCA if a woman’s Shared Maternity Care is ceased notify SMCA of any discharges from hospital (including the birth of the baby) 8 It is the responsibility of the SMCA to: notify the Shared Maternity Care Coordinator if a woman does not attend her first SMCA visit contact the woman if she does not attend her first scheduled SMCA appointment notify the hospital’s Shared Maternity Care Coordinator if a women has a poor attendance record for her antenatal visits It is the responsibility of both hospital staff and SMCA to: ‘It is the primary responsibility of the record findings and management in the hand held pregnancy provider ordering a test or noting any record abnormal finding to ensure appropriate follow-up on abnormal findings follow-up, communication and management. However, all providers It is the primary responsibility of the provider ordering a test or noting any abnormal finding to ensure appropriate follow-up, communication should check that follow-up of any and management. However, all providers should check that follow-up abnormal investigation or finding has of any abnormal investigation or finding has occurred. occurred.’ The four hospitals have the following support and infrastructure to assist SMCA in the provision of Shared Maternity Care. The Hand Held Pregnancy Record Women enrolled in Shared Maternity Care require a hand held pregnancy record which is to be used at both SMCA and hospital visits. It is essential that all providers legibly complete this at every visit. All providers must record routine examination findings in the hand held pregnancy record. This includes: blood pressure reading measurement of fundal height in centimetres ‘The hand held pregnancy record is the fetal movements from 20 weeks key means of communication between fetal auscultation from 20 weeks the hospital and SMCA. Women should checking fetal presentation from 30 weeks be made aware of its importance and oedema if present bring it to each visit.’ consider urine testing for proteinuria All entries (including the ordering of tests) should be dated and signed. If a woman attends either a SMCA or hospital visit without her hand held pregnancy record, please ensure she leaves the visit with some written correspondence that she can attach to her pregnancy record. The hand held pregnancy record is the key means of communication between the hospital and SMCA. Women should be made aware of its importance and bring it to each visit. 9 The Victoria Maternity Record (VMR) is the hand held pregnancy record used at the RWH, MHW and SH. NH uses its own hand held record. The VMR has a companion booklet for women, “A guide to tests and investigations for uncomplicated pregnancies.” The Shared Maternity Care Coordinator The Shared Maternity Care Coordinator is the key person for non-urgent contact for both SMCA and women. The Shared Maternity Care Coordinator responds to issues that may arise for women and ensures that non-urgent queries from SMCA are dealt ‘The Shared Maternity Care with in a timely manner. The Shared Maternity Care Coordinator role Coordinator is the key person for varies between health services and depending on the hospital, the Shared Maternity Care Coordinator may be able to assist with the following: non-urgent contact for both SMCA organising extra appointments for additional clinical consultation and women.’ with, for example, obstetric Doctors, allied health, psychiatry, genetics and physicians non-urgent reassessment of community ultrasound results and other pathology results by the relevant department changing a woman’s contact details Shared Maternity Care Coordinator Contact Details RWH MHW SH NH Ph: 8345 2129 Ph: 8458 4120 Ph: 8345 1616 Ph: 8405 8772 Mob: 0466 130 457 Fax: 8345 2130 Fax: 8458 4205 Fax: 8345 1691 Fax: 8405 8766 Email: Email: Email: Email: [email protected] [email protected] [email protected] [email protected] Family Birth Centre Only MHW has a separate Family Birth Centre. Shared Maternity Care is available to women attending the Family Birth Centre. Referrals occur via the standard referral pathway for MHW. Suitability for Shared Maternity Care At the four hospitals, Shared Maternity Care is an option for all healthy women with a normal pregnancy. The criteria listed below generally make women unsuitable for Shared Maternity Care. However, some women with these conditions or history may still be appropriate for a modified form of Shared Maternity Care. In this situation, extra visits and investigations at either the community, hospital or both may be required and an individual care plan will be made by the hospital Doctor and documented in the hand held pregnancy record. It is the hospital’s responsibility to determine a woman’s suitability for Shared Maternity Care. It is useful for GPs to discuss and promote Shared Maternity Care to women at time of referral and indicate a woman’s preference on the referral. 10