Midwifery Group Practice A woman centred primary health care model that offers well pregnant women a care option of partnership with a known midwife. Aim Through the promotion of birth as a natural event for most women, the MGP model of care aims to increase the onset of spontaneous labour and decrease labour interventions. The ensuing outcomes will result in an increased vaginal birth rate, a decreased caesarean section rate and an increased level of satisfaction for women with regard to their childbearing journey. Overview Submission for funding arose from the NSW government initiative Towards Normal Birth Principle outcome aimed at reducing Caesarean Section Rate for women having their first baby. Overview All women will receive antenatal care and education through the provision of consistent and balanced information, support during labour, birth and post partum home care from a known midwife. Women able to be booked to the MGP will be determined by a ‘low risk’ criteria based on the Australian College of Midwives National Guidelines for Consultation and Referral (ACMI). Objectives The provision of balanced and consistent information for women and their families. To provide care and facilities which are aligned with each woman’s unique pregnancy and birthing journey and their subsequent transition to parenting. To provide the option of midwifery evidence based best practice in promoting optimal maternal and neonatal outcomes Objectives To promote women’s satisfaction during pregnancy and childbirth through collaborative participation in decision making. To offer pregnant/birthing women a choice of service To provide continuity of care by a known midwife within a dedicated group To implement an affordable and sustainable model of maternity care within the current budget. Rostering and On Call The MGP midwife will be on 24 hour call, during their rostered shifts. When not on duty or on call, the MGP midwife will divert her mobile phone to the on call MGP midwife. The MGP midwife will attend booking-in, antenatal and intra-partum care and postnatal visits as required for her caseload of women according to on call and prior work loads. Scheduled visits that cannot be rearranged for another time will be provided by the next available MGP midwife on call. Ongoing Pregnancy Care Meeting other midwives – women's’ groups Rescheduling Visits Continuation of midwifery care in collaboration with obstetric team as the need arises Antenatal Admission MGP midwife will organise a consultation with senior obstetric medical officer/Obstetric Staff Specialist for MGP women if medical management is required. On discharge from antenatal ward or DSU, the management plan will indicate the lead carer and the schedule of planned visits. Ongoing collaborative care will be between the woman, the MGP midwife and the Obstetric Staff Specialist with a clear documented management care plan. Intra-partum Care Midwives contactable by work mobile when on call. MGP midwife will contact Birth Unit for admission after ongoing consultation with the woman and arrangement to meet at Birthing Unit. If a woman presents to Birth Unit without contacting the MGP midwives Birth unit staff will contact MGP midwife on call. Midwives work a maximum of 12 consecutive hours Induction and Caesarean Section Whenever possible, the MGP midwife will conduct pre-induction assessment and consult with senior medical staff. The MGP midwife will retain lead carer role unless induction is complicated by a ‘C’ category risk. The MGP midwife will conduct the prostin pre-induction assessment Where possible, the MGP will be available for the woman’s care on the day of the LSCS. Postnatal Care Postnatal discharge is anticipated 4-6 hours after birth. The ACMI Consultation and Referral Guidelines for Postnatal Care will be utilised for determining clinical risk. MGP discharge planning will be undertaken by the MGP midwife and the woman. MGP postnatal home and/or phone visiting is available for up to 7 days with ongoing postnatal contact, parenting and breastfeeding support for six weeks postpartum. Clinical Review One day per week is scheduled for MGP midwives to attend meetings and education sessions. This includes note review, case review and reflection, peer review, clinical supervision and group meeting. Adverse outcomes are subject to the usual reporting and review mechanisms. Each MGP midwife will undertake yearly review and reflection on practice. Professional Development There is recognition of the increased responsibility, accountability and competency requirements when midwives become lead carers within the MGP model. All MGP midwives are encouraged and supported to continue their professional development and develop a professional development plan based on the ACM Self-assessment tool. Professional Development Adequate professional development and up skilling will be built into the model. MGP midwives will demonstrate competency in the following areas. – Skilled in current antenatal assessment and care – Skilled in promoting and supporting the use of water in birth – Skilled in promoting and supporting breast feeding – Skilled in promoting and supporting development of parenting capacity – Skilled in completing well mother and baby discharge assessments The Research Clinical Effectiveness of Midwifery Group Practice model of care Fewer assisted births Fewer labour inductions Less epidural analgesia Altered Patterns of perineal trauma Fewer Caesarean sections Turnbull, D., Baghurst, P., Collins, C., Cornwell, C., Nixon, A., Donnelan- Fernandez, R. and Antoniou, G. (2009). An evaluation of Midwifery Group Practice. Part 1: Clinical effectiveness. Women and Birth, 22; 3-9. The Research Maternal Satisfaction Levels MGP is associated with higher level of maternal satisfaction Noted by women - better access to quality information - participation in decision making - sense of control during labour - better relationship with caregiver Williams, K., Lago, L., Lainchbury, A. and Eagar, K. (2010). Mother’s views of caseload midwifery and the value of continuity of care at an Australian regional hospital. Midwifery, 26; 615-621. Midwifery Led Antenatal Care For well, healthy women having their first baby Schedule of Care Based on NICE guidelines 10 appointments for 1st time mothers Early Pregnancy Booking visit Options of care Obstetrix –medical history, family history, psychosocial assessment, lifestyle issues Routine Screening Generally attended urine pregnancy test at home & BHcG through GP BGA, Hb, MCV, hepatitis B, syphilis, rubella, MSU for C&S, ?Hepatitis C, ?HIV, ? Varicella Dating Scan if LMP unknown or irregular Nuchal Translucency offered Genetic counseling if appropriate 16 weeks Review test results BP, FHS Organize morphology us for 18- 20wks 25 weeks Measure & plot fundal height FHS BP Antenatal Classes 28 weeks Hb, MCV, 50gm AGT or 75gm GTT Anti D 625 IU if rhesus negative mother 31 weeks Review results of tests 34 weeks Anti D 625 IU 36 weeks Check presentation of baby- discuss options of breech LV/PA swab for GBS 38 weeks & 40 weeks Discuss options of post dates management 41 weeks Postdates assessment What happens when a pregnancy becomes complicated? Collaborative Care The Woman The Midwife The Obstetrician Other Health Care Providers History Miranda 20 years old, single G2P0 B Neg Smoker Carer for her mother Past Medical History Hospitalised with pyelonephritis at age 13 Asthma, ventolin prn Miscarriage at 5 weeks gestation 2010 Miranda’s pregnancy journey 16/02/11 – 9/40 - referred to MGP from ANC Booking in Visit 06/03/11 – 12/40 – presented to ED with a post coital bleed, given Anti D and an EPAS appointment was made 07/03/11 – EPAS - Miranda was sent for an NT scan. Result – low risk 10/03/11 – 12/40 - presented to ED with PV bleeding, abdominal pain and lower pelvic pain radiating to right loin. Treated 2 weeks prior for a UTI but had not finished the course of antibiotics Attended an ultrasound. Findings included a sub chorionic haemorrhage plus a complex mass 78x32x43mm superior to the right kidney Discharged with follow up by GP 15/03/11 – 13/40 - first visit with MGP, saw GP same day for referral to gastrointestinal specialist, discussion with O&G consultant and appointment made for High Risk Clinic 08/04/11 – 16/40 - MGP visit, seen by GIT specialist prior and awaiting MRI results High Risk Clinic 20/04/11 – 18/40 - High Risk Clinic visit with Consultant and Midwife – Provisional diagnosis by GIT specialist following discussion at medical oncology case meeting – angiomyolipoma plus abnormal right kidney with cystic component. Uncertain of pathology but feel the mass is benign and long standing. Surgical management deferred until after birth. GIT specialist requiring monthly scans of mass and follow up. Miranda’s Care Plan MGP care in consultation with High Risk Consultant Regular ultrasounds – morphology scan and then growth scans at 28/32/36 weeks gestation 04/05/2011 – scan reviewed by O&G Consultant – morphology scan NAD, mass unchanged, mild dilatation of right renal pelvis. For review at high risk clinic at 28/40 following growth scan 15/05/2011 – presented with UTI, treatment commenced The Journey Continues……..
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