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					I attach my submission into the Maternity Services Review.
This submission is written in relation to endorsing Midwife Practitioners to work in Midwifery
models of care. I am aware that the Australian College of Midwives (A CMI) does not support
the implem entation of ‘Midwife Practitioners’ within the midwifery workforce. The ACMI
believe that all midwives should be able to practice at this level of advanced standing. I
believe that it takes time and experience to be able to practice at an ‘advanced pract ice’ level.

The attached proposal was written to be implemented within a Family Birth Centre model of
care. It could be modified to suit any midwifery model of care, and is presented as one
possibility.

Obviously, funding of midwifery Services appro priately is the ONLY way forward for women
and midwives to be able to achieve this partnership.



                 Implementation of Nurse/Midwife Practitione r Role
                               Family Birth Centre
                                         –
                                             Hospital


Purpose:
To improve health care delivery for women and families utilising the Family Birth
Centre (FBC) model of care, and to retain highly skilled, experienced and motivated
midwives within this model of care.

Aims:
To work towards endorsement of Nurse/Midwife practitioner roles within the FBC in
accordance with the requirements set out by the Nurses Board of Victoria (NBV).

Objectives:
To emphasise the role of the midwife as primary carer for women expecting an
‘uncomplicated’ pregnancy.

To recognise and legitimise the full aspect of the advanced role that midwives have
undertaken within the FBC, enabling senior experienced midwives to remain in the
clinical environment.

To allow extension of the scope of midwifery practice in the following areas;
       -Advanced clinical midwifery skills
       -Therapeutic medication management,
       -Referral to other health professionals,
       -Initiation and interpretation of certain diagnostic tests and procedures,
       -Admitting rights within the Family Birth Centre (some women expecting an
       uncomplicated pregnancy would not be required to visit a FBC GP).
       -Issuing of leave of absence certificates.

Improve the quality of care given to women by providing less fragmented care and a
high level of patient satisfaction.

Decrease the workload placed on the existing FBC GP’s b y more appropriate use of
resources.
To gain a high level of support from the medical team involved in the FBC in relation
to endorsement of Nurse/Midwife Practitioners.


Background:
The Family Birth Centre is a midwifery model of care and generally, women who
choose this model of care want midwives as their primary carer. The FBC was
established at the                  Hospital in 1999, and is currently running to full
capacity. There are 450 women who use this model of care to have their babies each
year.

The FBC model of care has been supported by visiting hospital VMO’s and the
obstetricians on call for the hospital. The midwifery team runs on 7 EFT, and is
staffed mainly by highly experienced and skilled midwives. All women attend an
early pregnancy visit with one of the hospital VMO’s, and are subsequently referred
back to this hospital VMO should any complications develop during the course of a
woman’s pregnancy.

Midwives working within this model are unable to order or interpret pathology tests
and obstetric ultrasounds (             does accept a midwife signature). All
pathology and ultrasounds are ordered under an FBC VMO’s name, and signed by the
VMO. The VMO is responsible for interpreting all pathology and ultrasound results,
and ordering follow up ultrasounds and pathology if necessary. Referrals to specialist
obstetricians can only be made by the FBC VMO.

All orders for medications have to be obtained from either the VMO on call for the
FBC for that day, or from obstetric residents working in delivery suite. This is often
time consuming for the FBC midwives, VMO’s, and obstetric residents. Women who
develop complications in their pregnancy are currently required to be referred to the
hospital VMO in the first instance, even when it is known that she will require
specialist obstetric referral. The current system provides fragmented care for women,
and is not cost effective.

A multidisciplinary steering committee has already been established within Eastern
Health to see the Nurse Practitioner project through stage one of the implementation
process. The concept of a Nurse/midwife practitioner role within the FBC has been
addressed in 2005. At the time, Eastern Health did not see the FBC model of care as a
priority area that would benefit from a Nurse/Midwife practitioner, yet Midwifery has
been identified as having potential for the second stage of organisational
implementation of the role.

There has also been medical resistance to the role of Nurse/Midwife practitioner being
introduced into the FBC model of care. Two possible reasons for this have been
identified. Firstly, the medical profession may envisage the role of Nurse/Midwife
practitioner as a ‘medical replacement’ role. This is, in fact, not the case. It has been
stated earlier that the role of the Nurse/Midwife practitioner would be to utilise
resources more effectively, and the focus of the role is ‘uncomplicated’ pregnancy.
Women with, or who develop complicated pregnancies would be referred by the
Nurse/Midwife practitioner to the appropriate health care professional. Secondly, the
FBC clients create a great deal of business for the FBC visiting VMO’s, who operate
their medical practices independently of the hospital, as community General
Practitioners. If the Nurse/Midwife practitioner role was to be endorsed within the
FBC at the                     Hospital, some women, who would have previously
been required to visit the FBC visiting VMO for an early pregnancy visit, and pa y the
visiting VMO a fee for this visit, would no longer be required to attend this
appointment.

The visiting VMO’s who currently see every woman booked into the FBC model of
care for a medical appointment are so heavily booked, that often women can’t get an
appointment for weeks, sometimes months in advance. Women with variations from
normal pregnancy who are referred to the visiting VMO’s by the FBC midwives often
find it very difficult to be allocated an appointment time. If the woman requires a
visit within a week time frame, these appointments have to be made by the FBC
midwives, who have to state to the VMO’s receptionists that the appointment requires
this time frame. Therefore, the introduction of Nurse/Midwife practitioner roles
within the FBC may relieve some of the excessive burden placed upon the visiting
VMO’s by the FBC clients expecting an ‘uncomplicated’ pregnancy.

The way forward in the FBC midwifery model of care is to embrace the role of the
Nurse/Midwife practitioner, together with the medical practitioners, and work towards
endorsement of Nurse/midwifery practitioners to provide women with less
fragmented, and more cost effective care.

Role of Nurse/Midwife practitione r within the FBC
A multidisciplinary committee would undertake selection of future Nurse/Midwife
practitioner candidates. This committee would consist of the Chief Executive Officer,
the Director of Nursing, Medical Professor, Nursing Unit Manager, and the Team
Leader of the Family Birth Centre.

It would be envisaged that Eastern Health would offer the Nurse/Midwife Practitioner
Candidate a 1-2 year time frame to obtain endorsement with the NBV.

Extended clinical practice guidelines would be created as required by the NBV, to be
utilised by Nurse/Midwife Practitioners within the Family Birth Centre. The general
focus of the extended clinical practice guidelines would be ‘uncomplicated’
pregnancy, labour and birth. The extended clinical practice guidelines would be
formulated in collaboration with other health care professionals such as medical
practitioners, midwifery educators, other Nurse/Midwife practitioners and
Pharmacists to formulate appropriate guidelines for extended scope of practice.

Candidates will obtain the necessary qualifications and skills required by the NBV to
be endorsed as Nurse/Midwife Practitioners within the Family Birth Centre model of
care. Further education will be sought in the areas of health assessment, expanded
clinical skills (for example advanced neonatal resuscitation, pap smear provider),
diagnostic tests and procedures, therapeutic medication management, and referral to
allied health professionals. Candidates will apply and obtain endorsement as
Nurse/Midwife Practitioner in accordance with NBV requirements. Once endorsed,
Nurse/Midwife Practitioners will demonstrate ongoing advanced clinical competence
as outlined by the NBV.
Nurse/Midwife practitioners extended scope of practice within the FBC will include
the following;
Standard/Advanced/Extended Clinical skills:
Midwives would be required to be competent in the following;
        a) Comprehensive health assessment of women
        b) Comprehensive health assessment of the term neonate
        c) Advanced clinical competence in neonatal resuscitation skills
        d) Speculum examination of the woman
        e) Perineal suturing
        f) Pap smear provider
        g) HIV counselling
        h) Imaging (AFI and presentation scans)

Ability to Prescribe : Nurse/Midwife Practitioner will be able to prescribe
medications from a limited formulatory. This would differ from ‘standing orders’ in
that a Nurse/Midwife would be able to ‘prescribe’, rather than ‘initiate’ medicines for
the women they are caring for. Once endorsed, midwife practitioners will take
responsibility for their own scrips. Some examples of prescriptions of medications
would include but not be limited to;
        a) Drugs for the management of the third stage of labour
        b) Medications for labour and for post natal pain relief
        d) Antibiotics for women who are GBS positive with Spontaneous Rupture of
        Membranes at Term and women with Urinary Tract Infections
        g) Local anaesthetic for the repair of the perineum
        h) Anti-emetics for labour and post natal use
        i) Immunisations when required
        j) Konakion for the newborn
        k) Vitamins requiring prescription (Ostalin)
        l) Contraceptives, such as oral contraceptive pill, Implanon, Mirena IUD

Diagnostic: Pathology: Nurse/Midwife Practitioners will be able to order and
interpret pathology and ultrasounds for women expecting an uncomplicated
pregnancy. This includes;
        a) Routine Antenatal screening
        b) Maternal Serum Screening
        c) Additional pathology for viral screening if indicated
        d) Additional pathology for women who are Vegans or Vegetarians

Interpretation of pathology would be the responsibility of the Nurse/Midwife
Practitioner. The nurse/midwife practitioner would be able to advise and treat women
with certain variations from normal pregnancy, such as;
        -Iron Deficiency/anaemia, including Vitamin B12 deficiency
        -Urinary Tract Infection both symptomatic and asymptomatic,
        -Gestational Diabetes diet controlled (with referral to diabetes educator, and
other health practitioners where required)
Other variations from pregnancy would require referral from the Nurse/Midwife
practitioner to the appropriate health care professional.
                Radiology: Nurse/Midwife Practitioners would be able to order and
interpret the following;
        -Early pregnancy ultrasounds, amniocentesis or chorionic villus sampling if
indicated
        -Routine mid Trimester ultrasounds
        -Repeat ultrasounds for the following reasons;
                ◦Poor foetal views on previous ultrasounds
                ◦Low lying placenta diagnosed at mid trimester ultrasound
                ◦Suspected poor foetal growth as defined by antenatal care policy
                ◦Suspected breech presentation at term
Findings of variations from normal ultrasound findings would require referral to the
appropriate health care professional.

              Cytology: The Nurse/Midwife practitioner would be expected to be a
‘pap smear provider’ and will be able to order, initiate pap smears when necessary in
early pregnancy, and 6 weeks postnatally.

Referral: Endorsed Nurse/Midwife practitioners within the FBC model of care
would be able to make direct referrals to health care professionals within the Eastern
Health Care network. This includes specialists, General Practitioners, and other allied
health care professionals. Referral pathways will be outlined in clinical practice
guidelines. Referral letters and discharge summaries will be written and signed by
Nurse/Midwife practitioners.

There are occasions where referrals can be made to health care practitioners outside
the Eastern Health setting where Eastern Health does not provide a service by the
health care professional required. For example referral can be made to the following;
        -Osteopaths
        -Chiropractors
        -Naturopaths
        -Homeopaths
        -Monash Medical Centre Foetal Medicine Unit (For the purpose of ECV for
        breech presentation)

Admitting/Discharge Rights : Women who are cared for by a Nurse/Midwife
practitioner during their pregnancy, who have not been required to see an FBC VMO,
will be able to be admitted and discharged directly under the FBC bed card.

Absence from work ce rtificates: Endorsed Nurse/Midwife Practitioners will be able
to issue women and/or their partners with absence from work certificates. These
certificates can be issued to women who are required to attend FBC antenatal
appointments and to their partners who attend during labour and birth.


Key Partners :
Partnership, co-operation and respect of the roles of health care practitioners will be
central to the implementation of Nurse/Midwife practitioners within the FBC model
of care.
The key partners involved in developing and implementing the Nurse/Midwife
practitioner role within the FBC are;
        -consumers choosing the FBC model of care,
        -midwives within the team, and within the maternity department,
        -Nurse Practitioner project officers,
        -Endorsed Nurse/Midwife Practitioners from other hospitals and Interstate,
        -Consultant Obstetricians and Paediatricians,
        -Visiting Medical Officers,
        -Pharmacy Department,
        -Other Allied Health Professionals,
        -Clinical Managers both Medical and Midwifery,
        -Director of Nursing,
        -Medical Director,
        -CEO,
        -Australian College of Midwives,
        -NBV.

Clinical Practice Guidelines for extended practice will be evidence-based and key
partners will be involved in guideline development.

Midwives will undergo yearly Midwifery Practice Review as described by the NBV.

				
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