MATERNITY SERVICES
Level 5 Service Aligned to Department of Health (Vic) Capability Framework 2010.
South West Health Care Warrnambool has operated and maintained a maternity service for many years. The
maternity service at Warrnambool is supported by Specialist Obstetricians, Paediatricians and GPs.
South West Healthcare is the primary referral centre for smaller rural services in the SW region. Portland, Terang,
Camperdown & Timboon operating low risk services refer women with identified risk to consultants & specialists in
Warrnambool. Neonates born at Western District Healthcare Hamilton, who require ongoing Paediatric Consultant
care in the Special Care Nursery are transferred to SWHC Warrnambool.
Currently Warrnambool manages approximately 590 births annually. South West Healthcare (Warrnambool)
provides medium – high risk maternity care to women throughout pregnancy and birthing continuum. Direct
consultation & referral with level 6 Tertiary services located in Melbourne for women deemed ‘high risk’ with
additional complexity.
This document, outlining the framework for the continuing provision of maternity care, must be read in conjunction
with current policies, clinical practice guidelines \ credentialing and performance indicators.
1 BACKGROUND
While it is not possible to eliminate all potential adverse outcomes from a pregnancy and/or birth, it is possible to
predict and minimise preventable adverse outcomes and reduce the likelihood of other adverse events occurring.
This can be achieved by providing appropriate management and care of the pregnant woman from conception
through to the postpartum period. Good management means that care is provided by the most appropriately
qualified health professional or team of professionals, and in the most appropriate setting.
Whilst grouping women according to their associated risks is necessary to assist health care services develop and
institute protocols and guidelines for admission and safe clinical practice, it is also critical that each pregnancy is
considered and managed individually. Continued consideration of potential risks and ongoing review by health care
professionals throughout each pregnancy is essential, given that adverse events can emerge unexpectedly even in
low-risk pregnancies.
SWHC Warrnambool - Capability Framework – Maternity Services 2011 (DRAFT 1)
2. DEFINITIONS
1. Low Risk Admission Criteria – Suitable to birth at level 2 / 3 servcie
For the purposes of this framework, low risk pregnancies are those described in Table 1.1
2. Intermediate Risk Admission Criteria – Obstetric Consultation & Referral required
South West Healthcare Warrnambool
For the purposes of this framework, intermediate risk pregnancies are those described in Table 1.2.
Women may be suitable for care and \ or birth at their local community service (2 /3) or they may require transfer to
a facility with the capacity and services to provide a higher level of care (Level 4 / 5)
Antenatal care should be provided in consultation with an obstetrician and / or other appropriate specialist.
It is highly likely women identified as having intermediate risk receives intrapartum care at SWHC Warrnambool.
3. High Risk Admission Criteria – for the purposes of this framework, high-risk pregnancies are those described in
Table 1.3 and are not suitable to be booked to birth at a low level service (level 2 / 3).
Women in this category must have specialist Obstetrician care antenatally and for birth at South West Healthcare
Warrnambool or level 6 Tertiary Centre.
4. Women and Babies who may to require Tertiary (Level 6) Care. – Established formal communication
procedures with level 6 services.
Discussion & negotiation with NETS / PERS.
Discussion & negotiation with Specialist Consultants at SWHC Warrnambool
Discussion & negotiation with Midwifery Manager / Nursing Supervisor (workforce availability).
Clinical Risk Management Assessment
 Experienced workforce availability (Specialist consultants, Anaesthetics, Midwifery)
For the purposes of this framework, high risk ‘complex’ women who may require tertiary care could include;
 Assessed ‘high risk complex’ by specialist anaesthetic team.
 Assessed ‘high risk complex’ Morbid Obesity
o Equipment not adequate to provide safe monitoring & care. (Ultrasound / fetal monitoring)
 Assessed ‘high risk complex’ no ICU or SCN beds available at SWHC Warrnambool
 Pre term labour < 32 weeks
o Skilled neonatal workforce availability
o Consultation, referral and transfer as directed by NETS.
 Pre existing complex medical conditions (e.g. Renal disease)
 Rare fetal disorder
 Haematological disorders
Capability framework – South West Healthcare Warrnambool Maternity Services
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ADMISSION GUIDELINES FOR PREGNANCY, BIRTHING AND POST PARTUM CARE
1.1 LOW RISK ADMISSION CRITERIA - BIRTHING AT SOUTHWEST HEALTHCARE WARRNAMBOOL
(Level 2 / 3)
Low Risk Admission Criteria
Age between 18 – 40 years
At term – 37 – 42 weeks
Cephalic presentation
Singleton pregnancy
Longitudinal lie
Regular antenatal attendance
Multiparous with history of
uneventful pregnancy
Maternal age less than 18
Maternal age greater than 40
Grand Multiparous
Late presentation for antenatal
care
Group B Strep colonisation
Rationale & risk management strategies
Capability Framework for Victorian maternity and newborn services. Department of Health Victoria; August 2010
www.health.vic.gov.au/maternitycare
Capability framework – South West Healthcare Warrnambool Maternity Services
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1.2
INTERMEDIATE RISK - BIRTHING AT SOUTHWEST HEALTHCARE WARRNAMBOOL
Women identified in this category require consultation with Specialist Obstetrician
Highlighted = women who may require level 6 tertiary management +/- neonates at risk.
Intermediate Risk Admission Criteria:
Maternal Factors
Maternal Age Less than 18 years
Maternal Age Greater than 40 years
Obesity where BMI > 35 and <40 at 24
to 28 weeks gestation who is assessed
as suitable for anaesthetic by
independent GP anaesthetist
Chronic illness – renal disease, cardiac
disease, NIDDM
Gestational Diabetic not on insulin
Epilepsy
Rationale & risk management strategies
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Anaesthetic consultation – may require level 6 management if morbid obesity with complex medical problems / or
monitoring equipment not sufficient for accurate monitoring.
Consultant Specialist Obstetrician
Collaboration with treating Physician
May require level 6 tertiary management
Consultant Specialist Obstetrician
Diabetic educator
Consultant Specialist Obstetrician
Collaboration with treating Physician
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Maternal Factors (cont)
Hypertension (essential): a pre existing
Consultant Specialist Obstetrician
diagnosis of hypertension pre conception or
before 20 weeks of pregnancy without
apparent underlying cause
Systolic >= 135 mmHg
Diastolic >= 85 mmHg
Uterine abnormality: where the lie of the
foetus may be compromised
Recent or recurrent drug abuse:
 Heroin
 Cocaine
 Methadone
 Stimulants
 Volatile agents (paint, glue, petrol)



Cannabis
Alcohol
Bezodiazepam
Injury to bony pelvis
Current psychiatric disturbances
Collaboration with treating Physician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultation with Paediatrician
Consultation with Women’s Alcohol & Drug Service (WADS)
Consultation with Paediatrician
Consultation with Women’s Alcohol & Drug Service (WADS
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultation with primary mental health team
Auto immune disease
Consultant Specialist Obstetrician
Collaboration with treating physician
May require level 6 consultation / management
Maternal Pyrexia (38 degrees)
Late presentation for A/N care
Consultant Specialist Obstetrician / Registrar
Consultant Specialist Obstetrician
Capability framework – South West Healthcare Warrnambool Maternity Services
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Intermediate Risk Admission Criteria:
Obstetric Factors
Active genital herpes
Grand Multiparous
Previous Premature birth
< 34 weeks
Previous difficult birth (difficult forceps,
shoulder dystocia)
Previous Post Partum Haemorrhage
Previous Caesarean section (even
when the woman has laboured
successfully post caesarean section)
Antepartum Haemorrhage,
‘time critical’
Cervical Incompetence/Cone biopsy
Rationale & risk management strategies
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
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Intermediate Risk Admission Criteria: Rationale & risk management strategies
Obstetric Factors (cont)
More than 3 spontaneous or induced Consultant Specialist Obstetrician
abortions
Previous Severe Pre-eclampsia
Consultant Specialist Obstetrician





BP >= 170 / 110 during previous
pregnancy associated with SGA
Abnormal renal function tests
Abnormal liver function tests
Required parenteral antihypertensive
during management of pre-eclampsia
Required magnesium sulphate during
management of pre-eclampsia
Pre-eclampsia - de novo hypertension
after 20 weeks
Consultant Specialist Obstetrician
Investigate underlying causes – may include Level 6 (tertiary) management
Previous history of 3rd trimester IUGR Consultant Specialist Obstetrician
or SGA
Oligohydramnios
Consultant Specialist Obstetrician
Polyhydramnious
Consultant Specialist Obstetrician
Intrapartum Haemorrhage
Consultant Specialist Obstetrician
‘time critical’
Prolonged rupture of membranes
Consultant Specialist Obstetrician
Group B Strep Colonisation
Consultant Specialist Obstetrician
Consultant Paediatrician
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Intermediate Risk Admission Criteria:
Fetal Factors
Malpresentation/ Unstable lie persisting
after 37 weeks
Breech Presentation
Known foetal abnormality
Suspected / confirmed FDIU
Blood stained liquor on rupture of
membranes
Rationale & risk management strategies
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Paediatrician – may require level 6 management
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician / registrar
1.3 HIGH Risk Criteria – Suitable to Birth at SWHC Warrnambool.
High Risk Criteria – not permitted to Rationale & risk management strategies
birth at PDH nor eligible for admission or
Higher level care required
ongoing management.
Consultant Obstetrician Management
Obstetric Factors
Premature labour < 37 weeks
Consultant Specialist Obstetrician
Multiple Pregnancy
Consultant Specialist Obstetrician
Post maturity beyond 42 weeks
Consultant Specialist Obstetrician
Suspected / confirmed IUGR
Consultant Specialist Paediatrician
Adequate equipment / workforce available / SCN cot
Significant macrosomia (Greater than Consultant Specialist Obstetrician
95 percentile) Large for dates
(Primigravida)
Pre-term Premature Rupture of
Consultant Specialist Paediatrician
Membranes (membranes rupture prior
to 37 weeks)
Placenta praevia Grade II, III and IV
Consultant Specialist Obstetrician
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High Risk Criteria
Maternal Factors
Insulin Dependent Diabetic
Severe anaemia
Obesity
where Booking BMI > 40
No antenatal care presents late in
Pregnancy or in labour
Rationale & risk management strategies
Higher level Care required
Consultant Specialist Physician
Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Consultant Specialist Obstetrician
High Risk Criteria
Fetal Factors
Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Evidence of suspected foetal
compromise at any gestation
Consultant Specialist Obstetrician
May require level 6 (tertiary) care
Antenatal non-reassuring foetal status /
foetal distress
Consultant Specialist Paediatrician
Rhesus iso-immunisation that develops
during pregnancy
Consultant Specialist Obstetrician
Consultant Specialist Paediatrician
May require level 6 (tertiary) care
Consultant Specialist Obstetrician
High Risk Criteria
Post partum Factors
Post –partum eclampsia
Consultant Specialist Obstetrician
Uterine prolapsed
Consultant Specialist Obstetrician
Serious psychological problem
Consultant Specialist Obstetrician
Consultant Specialist Psychiatrist
Consultant Specialist Obstetrician
Uterine rupture
Capability framework – South West Healthcare Warrnambool Maternity Services
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Level 2 High Dependency SCN - Uncomplicated 32 weeks gestation or more, or birth weight at least 1300gms
High Risk Criteria Neonatal
Rationale & risk management strategies
(Neonatal Handbook- http://www.rch.org.au)
Consultant Paediatrician on call 24 /7. Paediatric registrar or
Paediatric Consultation / Management. → Consultation with NETS → Transfer to
HMO on site 24 /7.
level 6 tertiary hospital as discussed.
As per Neonatal Services Guidelines – Level 2 High
Dependency
Any infant requiring 1:1 care > 4 hours post birth
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants with Perinatal / birth asphyxia
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Infants requiring > than 40% Oxygen to maintain O2 saturation Paediatric Consultation → + / - Consultation with NETS
>92%
Level 2 SCN care
May require level 6 (tertiary) care
Infants with suspected congenital heart disease
Paediatric Consultation
May require transfer / birth at tertiary level 6 centre
Infants with significant or multiple congenital anomalies
Paediatric Consultation → Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
‘Unwell’ infants, manifested by lethargy, poor feeding, weak cry, Paediatric Consultation → + / - Consultation with NETS
cyanosis, vomiting, biliary vomiting
Level 2 SCN care
May require level 6 (tertiary) care
Periods of apnoea and / or bradycardia
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Suspected sepsis
Paediatric Consultation / management
Level 2 SCN care
Infants with seizures
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Capability framework – South West Healthcare Warrnambool Maternity Services
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Infants bleeding from any site
Significant meconium aspiration
Persistent hypothermia
Jaundice
Infants <2000gms
Infants <2500gms
Hypoglycaemia (BSL < 2.0) not responding to oral feeds
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Paediatric Consultation
Level 2 SCN care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
May require level 6 (tertiary) care
Paediatric Consultation
Level 2 SCN care
Paediatric Consultation
Level 2 SCN care
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Level 5; Complexity of care, Infrastructure, Workforce, diagnostic services, Support Services,
Clinical Governance, Service Links, Education & Research.
(Ref; Capability Framework for Victorian Maternity & Newborn Services, 2010) pp 21 – 23.
Midwifery / Nursing Staff
All nursing staff must have current registration with the Nurses Board of Victoria with midwifery
endorsement
Midwives rostered 24hrs per day.
Designated midwife in charge with neonatal experience / managerial responsibility
Designated midwifery educator PPT or FT.
A neonatal / paediatric qualified nurse / midwife in charge of the SCN each shift it is occupied.
3.7 Continuing education & competency (DoH framework pp 4)
For the maintenance of competencies all health services should provide access to
educational support for health professionals involved in pregnant and birthing women and
their babies, in at least the following areas
 Antenatal & postnatal care
 Normal progress of labour
 CTG Interpretation
 Identification and management of maternity emergency situations
 Neonatal Resuscitation
 Basic / advanced adult Life support
Capacity to provide advanced Obstetric care 24/ 7 includes Caesarean Section.
Medical Staff
 24hr / 7 day Specialist Obstetrician available for consultation
 Designated Obstetric registrar 24 / 7 or HMO
 Shared care program (GPs) available for low risk women from local area
 Consultant Anaesthetist Available 24 / 7
 Anaesthetic Registrar on site 24 /7
 Consultant Paediatrician on call / available as required.
 Paediatric registrar and / or HMO on site 24 / 7.
Safe Practice Framework – guidelines