Midwifery Led Antenatal Care

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					    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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