MATERNITY SERVICES – Western District Health Service Hamilton
Level 4 Maternity Capability Aligned to Department of Health (Vic) Capability Framework 2010.
Level 3 Neonatal Capacity
Western District Health Service located in Hamilton has operated and maintained a maternity service for many
years. The maternity service at Hamilton is supported by a Specialist Obstetrician & Specialist GPs.
Western District Healthcare is the primary referral centre for women living in surrounding small rural communities in
the SW region. WDHS health service has the capacity to manage high risk women as defined in Level 4 capability.
Neonates requiring Level 2 Special Care Nursery Management are transferred to SWHC Warrnambool for Specialist
Paediatric Care.
WDHS operates a collaborative model of maternity care, women receive care by known midwife in collaboration
with treating Obstetrician and / or GPs. WDHS (Hamilton) provides low, medium – high risk maternity care to women
throughout pregnancy and birthing continuum. Approximately 220 women birth at WDHS per year.
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.
WDHS Hamilton - Capability Framework – Maternity Services 2011 (DRAFT 1)
2. DEFINITIONS
1. Low Risk Admission Criteria – Suitable to birth at level 2 / 3 service
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
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 WDHS Hamilton.
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 consultation antenatally and are booked for birth at WDHS
or level 6 Tertiary Centre. Identified Neonatal risk requiring post birth Paediatric / SCN care are transferred to SWHC
Warrnambool (level 5) ideally ‘in utero’ or to a level 6 service as per assessed complexity, discussed with PERS / NETS
and Specialist Pedestrians.
4. Women and Babies who may to require Level 5 or 6 (Tertiary Care). – Established formal communication
procedures with level 6 services.
Discussion & negotiation with Specialist Consultants (Obstetrician / Paediatrician) at SWHC Warrnambool
Discussion & negotiation with NETS / PERS.
Discussion & negotiation with Midwifery Manager / Nursing Supervisor SWHC (capacity to receive mother
and / or baby).
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 < 37 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 – Western District Health Service, Hamilton
Jan 2011
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ADMISSION GUIDELINES FOR PREGNANCY, BIRTHING AND POST PARTUM CARE
1.1 LOW RISK ADMISSION CRITERIA – SUITABLE TO BIRTH AT WESTERN DISCTICT HEALTHCARE, HAMILTON
(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
Rationale & risk management strategies
Maternal age less than 18
Maternal age greater than 40
Grand Multiparous
Late presentation for antenatal care
Group B Strep colonisation
Capability Framework for Victorian maternity and newborn services. Department of Health Victoria; August 2010
www.health.vic.gov.au/maternitycare
Capability framework – Western District Health Service, Hamilton
Jan 2011
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1.2
INTERMEDIATE RISK – SUITABLE TO BIRTH AT WESTERN DISTRICT HEALTHCARE, HAMILTON
Women identified in this category require consultation with Specialist GP / Obstetrician
Highlighted = women who may require level 5 / 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 GP / Obstetrician
Consultant Specialist GP / Obstetrician
Consultant Specialist GP / Obstetrician
Anaesthetic consultation – may require level 5 OR 6 management if morbid obesity with complex medical problems
/ or monitoring equipment not sufficient for accurate monitoring.
Consultant Specialist GP /Obstetrician
Collaboration with treating Physician
May require level 5 OR 6 tertiary management
Consultant Specialist GP / Obstetrician
Diabetic educator
Consultant Specialist GP / Obstetrician
Collaboration with treating Physician
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Intermediate Risk Admission Criteria:
Maternal Factors (cont)
Hypertension (essential): a pre existing
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
Auto immune disease
Maternal Pyrexia (38 degrees)
Late presentation for A/N care
Rationale & risk management strategies
Consultant Specialist GP / Obstetrician
Collaboration with treating Physician
Consultant Specialist GP / Obstetrician
Consultant Specialist GP / Obstetrician
Consultation with Paediatrician
Consultation with Women’s Alcohol & Drug Service (WADS)
Likely SCN admission for Neonatal Abstinence Syndrome. Consultation & Refer to level 5 or 6 service
Consultation with Paediatrician
Consultation with Women’s Alcohol & Drug Service (WADS
Likely SCN admission for Neonatal Abstinence Syndrome. Consultation & Refer to level 5 or 6 service)
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Consultation with primary mental health team
Consultant Specialist GP /Obstetrician
Collaboration with treating physician
May require level 5 OR 6 consultation / management
Consultant Specialist GP / Obstetrician
Consultant Specialist GP / Obstetrician
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Intermediate Risk Admission Criteria:
Obstetric Factors
Active genital herpes
Grand Multiparous
Previous Premature birth
< 34 weeks
Rationale & risk management strategies
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
Consultant Specialist GP / Obstetrician
Consultant Specialist GP / Obstetrician
Consultant Specialist GP / Obstetrician
Consultant Specialist GP/ Obstetrician
Likely SCN admission. Consultation & Refer to level 5 or 6 service / NETS.
Consultant Specialist GP/ Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Intermediate Risk Admission Criteria:
Obstetric Factors (cont)
More than 3 spontaneous or induced
abortions
Previous Severe Pre-eclampsia

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 preeclampsia
Pre-eclampsia - de novo hypertension
after 20 weeks
Previous history of 3rd trimester IUGR or
SGA
Oligohydramnios
Polyhydramnious
Intrapartum Haemorrhage
‘time critical’
Prolonged rupture of membranes
Group B Strep Colonisation
Rationale & risk management strategies
Intermediate Risk Admission Criteria:
Fetal Factors
Malpresentation/ Unstable lie persisting
after 37 weeks
Breech Presentation
Known foetal abnormality
Rationale & risk management strategies
Suspected / confirmed FDIU
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP / Obstetrician
Investigate underlying causes – may include Level 5 OR 6 (tertiary) management
Consultant Specialist GP / Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP/ Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP / Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Paediatrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist GP /Obstetrician
Consultant Specialist Paediatrician –
Likely SCN / NICU admission. Consultation & Refer to level 5 or 6 service / NETS
Consultant Specialist GP /Obstetrician
Consultant Specialist GP / Obstetrician
Blood stained liquor on rupture of
membranes
Capability framework – Western District Health Service, Hamilton
Jan 2011
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1.3 HIGH Risk Criteria – Consider (Maternal / Neonatal) suitability to Birth at WDHS Hamilton.
High Risk Criteria – not permitted to birth at Rationale & risk management strategies
PDH nor eligible for admission or ongoing Higher level care required
management.
Consultant Obstetrician Management
Obstetric Factors
Premature labour < 37 weeks
Multiple Pregnancy
Post maturity beyond 42 weeks
Suspected / confirmed IUGR
Significant macrosomia (Greater than
95
percentile)
Large
for
dates
(Primigravida)
Pre-term Premature Rupture of
Membranes (membranes rupture prior
to 37 weeks)
Placenta praevia Grade II, III and IV
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
Consultant Specialist Obstetrician / Paediatrician
Likely SCN admission. Consultation & Refer to level 5 or 6 service or NETS
Consultant Specialist Obstetrician
Consultant Specialist Obstetrician
Consultant Specialist Paediatrician
Likely SCN admission. Consultation & Refer to level 5 or 6 service OR NETS
Consultant Specialist Obstetrician / Paediatrician
Consultant Specialist Obstetrician / Paediatrician
Consultant Specialist Obstetrician
Rationale & risk management strategies
Higher level Care required
Consultant Specialist Physician
Consultant Specialist Obstetrician / Paediatrician
May require level 5 or 6 (tertiary) care
Consultant Specialist Obstetrician
May require level 5 or 6 (tertiary) care
Consultant Specialist Obstetrician
High Risk Criteria
Fetal Factors
Consultant Specialist Obstetrician / Paediatrician
Likely SCN / NICU admission. Consultation & Refer to level 5 or 6 service / NETS
Evidence of suspected foetal
compromise at any gestation
Consultant Specialist Obstetrician / Paediatrician
Likely SCN / NICU admission. Consultation & Refer to level 5 or 6 service / NETS
Antenatal non-reassuring foetal status /
foetal distress
Consultant Specialist Obstetrician / Paediatrician
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Rhesus iso-immunisation that develops
during pregnancy
Consultant Specialist Obstetrician
Consultant Specialist Paediatrician
Likely SCN / NICU admission. Consultation & Refer to level 5 or 6 service / NETS
High Risk Criteria
Post partum Factors
Consultant Specialist Obstetrician
Post –partum eclampsia
Consultant Specialist Obstetrician
May require ICU admission
Consultant Specialist Obstetrician
Uterine prolapsed
Serious psychological problem
Uterine rupture
Consultant Specialist Obstetrician
Consultant Specialist Psychiatrist
Consultant Specialist Obstetrician
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Level 3 Neonatal capability – Facilitates for stabilisation prior to retrieval and transfer out of ‘sick’ newborn infants.
Level 2 Special Care Nursery located at SWHC Warrnambool.
High Risk Criteria Neonatal
Consultant Paediatrician on call 24 /7. Paediatric registrar or
HMO on site 24 /7.
As per Neonatal Services Guidelines – Level 2 High Dependency
Any infant requiring 1:1 care > 4 hours post birth
Infants with Perinatal / birth asphyxia
Infants requiring > than 40% Oxygen to maintain O2 saturation
>92%
Infants with suspected congenital heart disease
Infants with significant or multiple congenital anomalies
‘Unwell’ infants, manifested by lethargy, poor feeding, weak cry,
cyanosis, vomiting, biliary vomiting
Periods of apnoea and / or bradycardia
Suspected sepsis
Infants with seizures
Infants bleeding from any site
Significant meconium aspiration
Persistent hypothermia
Jaundice
Rationale & risk management strategies
(Neonatal Handbook- http://www.rch.org.au)
Paediatric Consultation / Management. → Consultation with NETS → Transfer to level 6
tertiary hospital as discussed.
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation
Require transfer / ideally book to birth at tertiary level 6 centre
Paediatric Consultation → Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation / management
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Level 2 SCN care
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation → + / - Consultation with NETS
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation
May require level 2 SCN care
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Infants <2000gms
Infants <2500gms
Hypoglycaemia (BSL < 2.0) not responding to oral feeds
Paediatric Consultation → + / - Consultation with NETS
Require level 2 SCN or 6 (tertiary) care
Paediatric Consultation
May require level 2 SCN care
Paediatric Consultation
May require level 2 SCN care
Capability framework – Western District Health Service, Hamilton
Jan 2011
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Level 4; 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 18 – 20.
Level 3 Neonatal service; pp 15 – 17.
Midwifery / Nursing Staff
All nursing staff must have current registration with the Nurses Board of Victoria with midwifery
endorsement
Midwives rostered / available 24hrs per day. All labouring and birthing women cared fro by a
midwife as per EBA Ratios.
Designated midwifery educator PPT or FT
Personnel with experience in Lactation should be available.
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 GP Obstetrician 24 / 7 or HMO

Shared care program (GPs) available for low risk women from local area

Consultant Anaesthetist Available 24 / 7 or;

Credentialed GP (spinal and general anaesthesia) Available 24 /7

Consultant Paediatrician on call / available as required.

Paediatrician or GP with Paediatric skills / Neonatal ALS ‘on call’ 24 / 7.
Lnewman/SWAMI/Jan2011
Safe Practice Framework – guidelines