Guidelines for Shared Maternity Care Affiliates - The Royal Women's ...

Guidelines forShared Maternity Care Affiliates2010The Shared Maternity Care Collaborative1

GUIDELINES FOR SHARED MATERNITY CARE AFFILIATES 2010Mercy Hospital for WomenThe Royal Women’s HospitalWestern HealthNorthern HealthCopyright State of Victoria 2010This work is copyright and if reproduced reference must be cited as follows:Guidelines for Shared Maternity Care Affiliates, Mercy Hospital for Women, The Royal Women’s Hospital, Western Healthand Northern Health 2010.Published by Mercy Hospital for Women, The Royal Women’s Hospital, Western Health and Northern Health, Melbourne,Victoria.All rights reserved. Except for the purposes of education, fair dealing and use within the intended environment, no portionof this document should be reproduced or copied for any purposes, including general exhibition, lending, resale and hire.November 2010Published on the web, at the four Hospitals’ websites: www.thewomens.org.au, www.mercy.com.au, www.wh.org.au,www.nh.org.auDISCLAIMERThese guidelines have been developed for the provision of shared maternity care between Mercy Hospital for Women, TheRoyal Women’s Hospital, Western Health and Northern Health (The Hospitals) and shared maternity care affiliatesaccredited at these Hospitals.Irrespective of these Guidelines, every health service provider and health professional must individually exercise thestandard of professional judgment and conduct expected of them in selecting the most appropriate care for a pregnantwoman and in the management of her pregnancy.Any representation implied or expressed concerning the efficacy, appropriateness or suitability of any treatment or serviceis expressly negatived.The Hospitals cannot and do not warrant that the information contained in these guidelines is in every respect accurate,complete or indeed appropriate for every woman and her pregnancy.Accordingly, the Hospitals will not be held responsible or liable for any errors or omissions that may be found in any of theinformation set out in these guidelines.These guidelines contain links to websites (“linked third party sites”) not under the direct control of the Hospitals. Theselinks are provided as a convenience and the inclusion of any link does not imply endorsement or approval of the linkedwebsite. The Hospitals make no warranty regarding the quality, accuracy or fitness for purpose of the content or servicesavailable through linked third party sites.2

ACKNOWLEGEMENTSProject LeadsMadeleine WhinneyDr Ines RioShared Maternity Care Guidelines Project OfficerHead General Practice Liaison Unit, The Royal Women’s HospitalManagement GroupDr Leonie GriffithsDr Mary Anne McLeanDr Ines RioDr Jo SilvaBianca BellMerran MackieSue VallanceMadeleine WhinneyGeneral Practice Liaison Officer, Northern HealthGeneral Practice Liaison Medical Advisor, Mercy Hospital for WomenHead General Practice Liaison Unit, The Royal Women’s HospitalGeneral Practice Advisor, Western HealthGeneral Practice Liaison Coordinator, Western HealthGeneral Practice Liaison Project Officer, Mercy Hospital for WomenGeneral Practice Liaison Project Officer, Northern HealthProject Officer, The Royal Women’s HospitalSteering CommitteeDr Louise KornmanClinical Director, Maternity Services, The Royal Women’s HospitalDr Bernadette WhiteClinical Director, Obstetric & Maternity Services, Mercy Hospital for WomenDr Alex TeareClinical Services Director Women’s & Children’s Health, Northern HealthDr Michael SedgleyClinical Services Director, Division of Women’s and Children’s Services, Western HealthTanya FarrellDirector Maternity Services, The Royal Women’s HospitalTheresa BowditchDeputy Director Nursing, Maternity and Neonatal Services, Mercy Hospital for WomenSusan GannonDivisional Director Women's & Children's, Western HealthDr John ScopelShared Maternity Care Affiliate GP representativeDr Fiona BroderickShared Maternity Care Affiliate GP representativeDr Judy SmithShared Maternity Care Affiliate Midwife representativeCarol LawsonShared Maternity Care Affiliate GP, Royal Australian College of General Practice representativeDr Jennifer AndersonShared Maternity Care Affiliate GP, General Practice Victoria representativeDr Leonie GriffithsGeneral Practice Liaison Officer, Northern HealthDr Mary Anne McLean General Practice Liaison Medical Advisor, Mercy Hospital for WomenDr Ines RioHead General Practice Liaison Unit, The Royal Women’s HospitalDr Jo SilvaGeneral Practice Advisor, Western HealthBianca BellGeneral Practice Liaison Coordinator, Western HealthMerran MackieGeneral Practice Liaison Project Officer, Mercy Hospital for WomenSue VallanceGeneral Practice Liaison Project Officer, Northern HealthMadeleine WhinneyProject Officer, The Royal Women’s HospitalKaren Irving Senior Program Advisor, Maternity Services, Department of Health (to February 2010)Melissa Brown Senior Program Advisor, Maternity Services, Department of Health (from February 2010)Special ThanksShared Maternity Care Coordinators at the four hospitals:Jane De Marco, Sue Herlihy, Julie Brook and Francis SweeneyOther hospital staff who informed these guidelinesShared Maternity Care Affiliates and women involved in focus groupsDepartment of HealthRoyal Australian College of General PractitionersThree Centres Collaboration3

CONTENTSINTRODUCTION ....................................................................................................................................... 6THE SHARED MATERNITY CARE MODEL .................................................................................................. 8Definition ............................................................................................................................................. 8Responsibilities in Shared Maternity Care .......................................................................................... 8The Hand Held Pregnancy Record ....................................................................................................... 9The Shared Maternity Care Coordinator ........................................................................................... 10Accreditation and Reaccreditation of Shared Maternity Care Affiliates ........................................... 11THE PRE-PREGNANCY CONSULTATION ................................................................................................. 13Preventive Activities before Pregnancy ............................................................................................ 13Pre-pregnancy Consultation Checklist .............................................................................................. 17ANTENATAL VISITS ................................................................................................................................ 24Confirmation of Pregnancy ............................................................................................................... 24Shared Maternity Care at Our Hospitals ........................................................................................... 26Hospital location maps .................................................................................................................. 27How to Refer for Shared Maternity Care .......................................................................................... 28Satellite Clinics ............................................................................................................................... 28Hospital Tours ................................................................................................................................ 28Support Services ................................................................................................................................ 29Schedule of Visits .............................................................................................................................. 29Shared Maternity Care Affiliate Discussion Points and Patient Information .................................... 37ANTENATAL INVESTIGATIONS ............................................................................................................... 49Initial Routine Investigations ............................................................................................................. 49Initial Investigations to Consider ....................................................................................................... 50Second Trimester Investigations ....................................................................................................... 55Third Trimester Investigations .......................................................................................................... 55TESTING IN PREGNANCY FOR FETAL ABNORMALITIES ......................................................................... 60Screening versus Diagnostic Tests ..................................................................................................... 604

Counselling ........................................................................................................................................ 60Down Syndrome and other Chromosomal Abnormalities ................................................................ 61Fetal Morphology Ultrasound (18-20 weeks) ................................................................................... 67MANAGEMENT AND REFERRAL OF ABNORMAL FINDINGS .................................................................. 71Referral of Problems ......................................................................................................................... 71Abnormal Results: Test for Fetal Abnormalities ............................................................................... 74Other Abnormal Findings .................................................................................................................. 77MENTAL HEALTH AND WELLBEING ....................................................................................................... 81Alcohol and Drug Services ................................................................................................................. 83Intimate Partner Violence ................................................................................................................. 83POSTNATAL CARE .................................................................................................................................. 86Immediate Postnatal Care ................................................................................................................. 86Community Postnatal Care ................................................................................................................ 88Mental Health and Wellbeing in the Postnatal Period ...................................................................... 92Breastfeeding .................................................................................................................................... 94Gestational Diabetes ......................................................................................................................... 95Hepatitis B Carriers ............................................................................................................................ 95APPENDIX 1: LEVELS OF EVIDENCE ...................................................................................................... 1025

INTRODUCTION‘Guidelines for Shared Maternity Care Affiliates 2010’ have been prepared for Shared Maternity Care Affiliates whoare accredited to provide Shared Maternity Care at The Royal Women’s Hospital, Mercy Hospital for Women,Sunshine Hospital and Northern Health.Shared Maternity Care is a model of care in which a woman is cared for by both hospital staff and a communitybased Shared Maternity Care Affiliates (a General Practitioner (GP), Obstetrician or community-based Midwife)throughout her pregnancy. The baby’s birth and immediate postnatal care are managed by the hospital. SharedMaternity Care aims to provide a high quality community-based, holistic, safe and culturally appropriate model ofcare for women.Shared Maternity Care is a significant and important model of maternity care at The Royal Women’s Hospital, MercyHospital for Women, Sunshine Hospital and Northern Health. These hospitals are committed to supporting SharedMaternity Care and the involvement of Shared Maternity Care Affiliates in the ongoing development of this model ofcare.These guidelines have been developed through a collaborative process between The Shared Maternity CareCollaborative (comprising of General Practice Liaison Units at The Royal Women’s Hospital, Mercy Hospital forWomen, Sunshine Hospital and Northern Health). While they build upon guidelines initially developed by The RoyalWomen’s Hospital, Mercy Hospital for Women and Sunshine Hospital in 2002, they provide much more than anupdate of service information.These guidelines are the result of extensive consultation and collaboration between the four hospitals, SharedMaternity Care Affiliates and specialist clinicians and services. Their goal is to support the provision of high qualityShared Maternity Care. They aim to:delineate roles, responsibilities and expectations of different providersclarify pathways of referral, care and supportassist providers in the provision of evidence based care and initiatives to support quality maternity careprovide useful and relevant information for both providers and womenThese guidelines include new and expanded information including:investigations and testsscreening and testing for fetal abnormalitiesRh D immunoglobulin (anti-D) in pregnancymental healthpostnatal careAdded components include:‘practice notes’ designed to highlight important points throughout the guidelinesdirect links to useful clinical resources for Shared Maternity Care Affiliates and clinical practice guidelines atthe end of each topic areadirect links to a range of quality patient information6

greater clarity of pathways for referraleasily identifiable contact detailsIn the development of these guidelines significant changes have been achieved that strengthen Shared MaternityCare at these hospitals, including:greater alignment of antenatal care schedulesclarity about the use of investigations during pregnancyclearer delineation of responsibilities of both Shared Maternity Care Affiliates and hospitalsmapping of referral pathways and access to specialist advice for Shared Maternity Care Affiliatesthe development of enhanced support for Shared Maternity Care Affiliates through access to hospitalservicesExtracts from the most recent ‘Three Centres Consensus Guidelines on Antenatal Care’ (1) have been incorporatedinto these guidelines. These extracts are printed in italics text, followed by “- 3 Centres”. The Three CentresConsensus Guidelines provide a consensus statement on some aspects of clinical antenatal care for low-risk womenbased on the best available evidence. Levels of evidence for the Three Centres Consensus Guidelines can be found atthe end of these Guidelines.The following acronyms are used throughout this document:GPMHWNHRWHSHSMCAGeneral PractitionerMercy Hospital for WomenNorthern HealthRoyal Women’s HospitalSunshine Hospital.Please note. This document refers to Sunshine Hospital as maternity services are delivered atWestern Health’s Sunshine campus.Shared Maternity Care AffiliateWe hope these concise, up-to-date guidelines assist you in providing quality Shared Maternity Care to women whochoose this popular and important model of maternity care.It is anticipated that these guidelines will also provide a useful basis for Shared Maternity Care guidelinedevelopment for other maternity services in Australia. In this case, please ensure appropriate acknowledgement isincluded.The guidelines are accessible on each of the hospital websites: www.thewomens.org.au , www.mercy.com.au,www.wh.org.au and www.nh.org.au.1 3 Centres Consensus Guidelines on Antenatal Care, Mercy Hospital for Women, Southern Health and Royal Women's Hospital, 20067

THE SHARED MATERNITY CARE MODELDefinitionIn the four participating hospitals, Shared Maternity Care is a model of care in which the majority of antenatal visitstake place in the community with a hospital affiliated GP, Obstetrician or Midwife (SMCA). Visits also take place atkey times at the hospital (the main hospital site or hospital community satellite clinic). The woman attends thehospital for the baby’s birth and immediate postnatal care.Therefore the community based SMCA and hospital-based Doctors and Midwives act as a team in the provision of awoman’s care.Wherever possible, women should be offered continuity of care, including continuity of carer (Level I evidence) – 3CentresGP and midwifery led models of care are safe for low-risk women (Level I, II & III evidence) – 3 CentresShared Maternity Care is available to all low-risk women, including women who use the Family Birth Centre(available at MHW). Modified Shared Maternity Care may also be available to women who are not strictly low-risk. Inthese cases individual plans will be developed and documented in the hand held pregnancy record by the hospitalDoctor.Responsibilities in Shared Maternity CareFor Shared Maternity Care to work well, a team approach is necessary between the community and hospitalproviders. Responsibility for a woman’s care is shared, including responsibility for communication and themanagement of results and abnormal findings.The following obligations form the basis of responsibilities and communication between SMCA and hospital staff.It is the responsibility of the hospital to:notify the referring Doctor of the receipt of the referralnotify both the woman and the referring Doctor of first hospital appointment details and locationnotify the referring Doctor if the woman does not attend her first hospital appointmentnotify SMCA that a woman has registered for Shared Maternity Careensure the woman has a hand held pregnancy recordensure that a woman has information on her required schedule of visits and tests (for both hospital andSMCA). Please note that women are required to make theirown appointments with SMCAnotify SMCA if a woman’s Shared Maternity Care is ceasednotify SMCA of any discharges from hospital (including the birth of the baby)8

It is the responsibility of the SMCA to:notify the Shared Maternity Care Coordinator if a woman does not attend her first SMCA visitcontact the woman if she does not attend her first scheduled SMCA appointmentnotify the hospital’s Shared Maternity Care Coordinator if a women has a poor attendance record for herantenatal visitsIt is the responsibility of both hospital staff and SMCA to:record findings and management in the hand held pregnancyrecordfollow-up on abnormal findingsIt is the primary responsibility of the provider ordering a test or notingany abnormal finding to ensure appropriate follow-up, communicationand management. However, all providers should check that follow-upof any abnormal investigation or finding has occurred.‘It is the primary responsibility of theprovider ordering a test or noting anyabnormal finding to ensure appropriatefollow-up, communication andmanagement. However, all providersshould check that follow-up of anyabnormal investigation or finding hasoccurred.’The four hospitals have the following support and infrastructure toassist SMCA in the provision of Shared Maternity Care.The Hand Held Pregnancy RecordWomen enrolled in Shared Maternity Care require a hand held pregnancy record which is to be used at both SMCAand hospital visits. It is essential that all providers legibly complete this at every visit.All providers must record routine examination findings in the hand held pregnancy record. This includes:blood pressure readingmeasurement of fundal height in centimetresfetal movements from 20 weeksfetal auscultation from 20 weekschecking fetal presentation from 30 weeksoedema if presentconsider urine testing for proteinuria‘The hand held pregnancy record is thekey means of communication betweenthe hospital and SMCA. Women shouldbe made aware of its importance andbring it to each visit.’All entries (including the ordering of tests) should be dated and signed. If a woman attends either a SMCA or hospitalvisit without her hand held pregnancy record, please ensure she leaves the visit with some written correspondencethat she can attach to her pregnancy record.The hand held pregnancy record is the key means of communication between the hospital and SMCA. Womenshould be made aware of its importance and bring it to each visit.9

The Victoria Maternity Record (VMR) is the hand held pregnancy record used at the RWH, MHW and SH. NH uses itsown hand held record. The VMR has a companion booklet for women, “A guide to tests and investigations foruncomplicated pregnancies.”The Shared Maternity Care CoordinatorThe Shared Maternity Care Coordinator is the key person for non-urgent contact for both SMCA and women.The Shared Maternity Care Coordinator responds to issues that may arisefor women and ensures that non-urgent queries from SMCA are dealt‘The Shared Maternity Carewith in a timely manner. The Shared Maternity Care Coordinator rolevaries between health services and depending on the hospital, the Shared Coordinator is the key person forMaternity Care Coordinator may be able to assist with the following: non-urgent contact for both SMCAorganising extra appointments for additional clinical consultation and women.’with, for example, obstetric Doctors, allied health, psychiatry,genetics and physiciansnon-urgent reassessment of community ultrasound results and other pathology results by the relevantdepartmentchanging a woman’s contact detailsShared Maternity Care Coordinator Contact DetailsRWH MHW SH NHPh: 8345 2129 Ph: 8458 4120 Ph: 8345 1616Mob: 0466 130 457Ph: 8405 8772Fax: 8345 2130 Fax: 8458 4205 Fax: 8345 1691 Fax: 8405 8766Email:Email:Email:Email:sharedcare@thewomens.org.ausharedcare@mercy.com.aumaternitysharedcare@wh.org.aumaternitysharedcare@nh.org.auFamily Birth CentreOnly MHW has a separate Family Birth Centre. Shared Maternity Care is available to women attending the FamilyBirth Centre. Referrals occur via the standard referral pathway for MHW.Suitability for Shared Maternity CareAt the four hospitals, Shared Maternity Care is an option for all healthy women with a normal pregnancy.The criteria listed below generally make women unsuitable for Shared Maternity Care. However, some women withthese conditions or history may still be appropriate for a modified form of Shared Maternity Care. In this situation,extra visits and investigations at either the community, hospital or both may be required and an individual care planwill be made by the hospital Doctor and documented in the hand held pregnancy record.It is the hospital’s responsibility to determine a woman’s suitability for Shared Maternity Care. It is useful for GPs todiscuss and promote Shared Maternity Care to women at time of referral and indicate a woman’s preference on thereferral.10

Exclusion Guide for Shared Maternity Care:Medical and social history• Pre-pregnancy BMI >35 or

ResourcesHospital Shared Maternity Care InformationRoyal Women’s Hospitalhttp://www.thewomens.org.au/SharedMaternityCareAffiliatesMercy Hospital for Womenhttp://www.mercy.com.au/html/s02_article/article_view.asp?id=882&nav_cat_id=207&nav_top_id=84Western Health (Sunshine Hospital)http://www.wh.org.au/GP_Liaison/Shared_Care/Shared_Maternity_Care/index.aspxNorthern Healthhttp://www.nh.org.au/antenatal-shared-care/w1/i1001234/Victorian Maternity Record:http://www.health.vic.gov.au/maternitycare/downloads/vic_maternity_record_form.pdfRWH Shared Maternity Careinformation for affiliatesMHW Shared Maternity Careinformation for affiliatesSH Shared Maternity Careinformation for affiliatesNH Shared Maternity Careinformation for affiliatesThe hand held pregnancyrecord used at RWH, MHWand SH12

THE PRE-PREGNANCY CONSULTATIONMany of the most important maternity interventions resulting in improved health outcomes are best initiated priorto conception. These include immunisation, smoking cessation, folate supplementation and screening of prospectiveparents for inherited disorders such as cystic fibrosis, haemoglobinopathies and Fragile X syndrome (amongstothers).GPs are in the unique position of seeing a woman in the context of her life prior to pregnancy and therefore are ableto provide opportunistic pre-pregnancy activities and screening.The aim of the pre-pregnancy consultation is to:provide the optimum situation for conception and pregnancy to occur in order to optimise the health ofmother and childidentify and manage potential problems for the fetus and mother, based on personal and family historyprovide education about the health care system and choices availabledevelop rapport with a woman and her familyPreventive Activities before PregnancyThe following is taken from “Guidelines for preventive activities in general practice. Chapter 1: Preventive activitiesbefore pregnancy, pp 1-3”.Every woman aged 15–49 years should be considered for preconception care (C). Preconception care is a set ofinterventions that aim to identify and modify biomedical, behavioral and social risks to a woman’s health orpregnancy outcome through prevention and management.45 This should include smoking cessation (A)46 and adviceto consider abstinence from alcohol (especially in the early stages of pregnancy),47 folic acid supplementation (A),48review of immunisation status (C),49 medications (B),50 and chronic medical conditions, especially glucose control inpatients with diabetes (B).51There is evidence to show improved birth outcomes with preconception health care in women with diabetes,phenylketonuria and nutritional deficiency,52 as well as benefit from the use of folate supplementation and areduction in maternal anxiety.53 The following table lists the potential interventions recommended by expert groupsin preconception care (C).What does preconception care include?Medical issuesReproductive life planAssist your patient in developing a reproductive life plan that includes whether they want to have children and if so,discuss the number, spacing and timing of children.Reproductive historyHave there been any problems with previous pregnancies such as infant death, fetal loss, birth defects, low birthweight, preterm birth, or gestational diabetes? Are there any ongoing risks that could lead to a recurrence in any13

future pregnancy?Medical historyAre there any medical conditions that may affect future pregnancies? Are chronic conditions such as diabetes,thyroid disease, hypertension, epilepsy and thrombophilias well managed?Medication useReview all current medications, including over-the-counter medications, vitamins and supplements.Genetic/family historyAssess risk of chromosomal/genetic disorders, based on family history/ethnic background (eg. neural tube defects[NTD], cystic fibrosis, fragile X syndrome, Tay-Sachs disease, thalassaemia, sickle cell anaemia, and phenylketonuria).General physical assessmentPap test and breast examinations should be conducted before pregnancy if due or indicated respectively. Also assessbody mass index (BMI), blood pressure (BP) and ask about periodontal disease.Substance useAsk about tobacco, alcohol and illegal drug use.VaccinationsVaccinations can prevent some infections that may be contracted during pregnancy. If previous vaccination historyor infection is uncertain, testing should be undertaken to determine immunity to varicella and rubella, so thatvaccination can be provided to nonimmune women. Women receiving live viral vaccines such asmeasles/mumps/rubella (MMR) and varicella should be advised against falling pregnant within 28 days ofvaccination.If indicated, MMR and varicella (in those without a clear history of chickenpox or nonimmune on testing)should be given at least 28 days before conceptionInfluenza is recommended during pregnancy to protect against infection (if in second or third trimesterduring influenza season)Diphtheria/tetanus/pertussis (to protect the newborn from tetanus or pertussis) should be consideredbefore conceptionLifestyle IssuesFamily planningBased on the patient’s reproductive life plan, discuss fertility awareness, chance of conception and risk of infertilityand fetal abnormality. For women not planning to become pregnant, discuss effective contraception and emergencycontraceptive options.Folic acid supplementationWomen should take a 0.4–0.5 mg supplement of folic acid per day for at least 1 month before pregnancy and for thefirst 3 months after conception. In women at high risk (ie. those with a reproductive or family history of NTD, thosewho have had a previous pregnancy affected by NTD, those on antiepileptics, or those who have diabetes) the doseshould be increased to 5 mg/day.14

Healthy weight, nutrition and exerciseDiscuss weight management and caution against being over or underweight. Recommend regular moderate intensityexercise and assess risk of nutritional deficiencies (eg. vegan diet, lactose intolerant, calcium or iron, vitamin Ddeficiency due to lack of sun exposure).Psychosocial healthProvide support and identify coping strategies to improve your patient’s emotional health and wellbeing.Smoking, alcohol and illegal drug cessation (as indicated)Smoking and illegal drug use during pregnancy can have serious consequences for an unborn child and should bestopped before conception. There are no safe limits of alcohol consumption during pregnancy.Healthy environmentRepeated exposure to hazardous toxins in the household and workplace environment can impact on fertility andincrease the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections:• toxoplasmosis – avoid cat litter, garden soil, and raw/undercooked meat, unpasteurised milk products, wash allfruit and vegetables• cytomegalovirus, parvovirus B19 (fifth disease) – discuss the importance of frequent hand washing (and theadditional risk reduction by the use of gloves when changing nappies in child and health care workers)• listeriosis – avoid paté, soft cheeses (eg. feta, brie, blue vein), pre-packaged salads, deli meats, and chilled/smokedseafood. Wash all fruit and vegetables before eating• fish – limit the amount of fish containing high levels of mercury.Intervention Technique ReferencesFolatesupplementationSmoking cessationAlcohol and illicitdrug use• High risk women: 5 mg/day supplementation ideally beginning at least 1 monthbefore conception and for first trimester• Most women 0.5 mg/day supplementation ideally beginning at least 1 month beforeconception and for first trimesterWomen should be informed that tobacco affects fetal growth and all women shouldbe advised to stop smoking. Evidence exists to suggest improved cognitive ability inchildren of mothers who quit smoking during gestation (III A). Pharmacotherapyshould be considered when a pregnant woman is otherwise unable to quit, and whenthe likelihood and benefits of cessation outweigh the risks of pharmacotherapy andpotential continued smokingWomen should be informed of the potential harmful effects of alcohol to the fetusand should be advised that there are no safe limits of alcohol consumption duringpregnancy. Women should be informed that illicit drug use may harm the fetus andadvised to avoid use48,54–56574715

Inter pregnancyintervalChronic diseasesPreconceptioncare resources forGPs and patientsWorse perinatal outcomes with inter pregnancy intervals 59 months,namely pre-term birth, low birth weight and small for gestational ageOptimise control of existing chronic diseases (eg. diabetes, hypertension, epilepsy).Avoid teratogenic medicationsAddress risk factors using Pregnancy Lifescripts. Available athttp://www.health.gov.au/internet/quitnow/publishing.nsf/Content/lifescripts5856Health inequalityLess than 50% of women in Victoria and New South Wales supplement their diet with folate periconceptually. Thisfigure is lower in:59• women in lower socioeconomic groups• indigenous women• rural women• younger women• multiparous womenStrategyRefer to general principles as discussed in the introduction and as outlined in the ‘green book’.References:45. Johnson K, et al. Recommendations to improve preconception health and health care-United States. MMWRRecomm Rep 2006;55(RR–6):1–23.46. Lumley J, et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev2004;4.47. National Health and Medical Research Council. Australian alcohol guidelines for low-risk drinking. Canberra:NHMRC, in press.48. Lumley J, et al. Periconceptual supplementation with folate and/or multivitamins for preventing neural tubedefects (Cochrane review). Oxford: The Cochrane Library, 2001.49. National Health and Medical Research Council. Australian Immunisation Handbook. 9th edn. Canberra: NHMRC,2008.50. Australian Department of Health and Aged Care. Prescribing medicines in pregnancy. 4th edn. Therapeutic GoodsAdministration, 1999.51. Korenbrot CC, et al. Preconception care: a systematic review. Matern Child Health J 2002;6:75–88.52. Gjerdingen DK, Fontaine P. Preconception health care: A critical task for family physicians. J Am Board Fam Pract1991;4:237–50.53. de Jong-Potjer LC, et al. GP-initiated preconception counselling in a randomised controlled trial does not induceanxiety. BMC Fam Pract 2006;7:66.54. US Preventive Services Task Force. Guide to clinical preventive services. 2nd edn. Washington, DC: Office ofDisease Prevention and Health Promotion, 2004.55. Wilson RD, et al. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in combinationwith a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J ObstetGynaecol Can 2007;29:1003–26.16

56. National Collaborating Centre for Women’s and Children’s Health. Diabetes in pregnancy: Management ofdiabetes and its complications from preconception to the postnatal period. NICE, 2008.57. Zwar N, et al. Smoking cessation guidelines for Australian general practice. Canberra: CommonwealthDepartment of Health and Ageing, 2004.58. Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: Ameta-analysis. JAMA 2006;295:1809–23.59. Watson LF, Brown SJ, and Davey MA. Use of periconceptional folic acid supplements in Victoria and New SouthWales, Australia. Aust N Z J Public Health 2006;30:42–9.Copyright: The Royal Australian College of General Practitioners, 2005. Reproduced with permission.Pre-pregnancy Consultation ChecklistResourcesReproductive historyMedical historyGenetic/family historyPsychosocial historyGeneral physical assessmentMedicine useSubstance use and cessationVaccinationsFolic acid supplementationHealthy weight/nutrition/exerciseHealth environment (toxoplasmosis, cytomegalovirus, parvovirus, listeria, fish)Dental healthGeneralPreparing forpregnancyMaternityservices andmodels of care(Victoria)Preventive healthRoyal Women’s Hospitalhttp://www.thewomens.org.au/PreparingforPregnancyRoyal Australian And New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs3.pdfVictoria Department of Healthhttp://www.health.vic.gov.au/maternity/Better Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_birth_choices?openThe Royal Australian College of General Practitionershttp://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/TheRedBook/redbook_7th_edition_May_2009.pdfDepartment of Health and Ageinghttp://www.health.gov.au/internet/quitnow/publishing.nsf/Content/lifescriptsConsumer fact sheets: Preparing forpregnancy. Includes: thinking it through, yourcareer, the financial impact of having a baby,medical issues, drug facts, the environmentClinician information: pre-pregnancycounselling & antenatal screening testsConsumer information on maternity servicesand models of care in VictoriaConsumer information on birth choicesClinician information: RACGP Guidelines forPreventive Health in General Practice (TheRed Book)Clinician information: Pregnancy Lifescripts(smoking, alcohol, nutrition)17

Medical historyAsthmaDiabetesEpilepsyThyroid diseaseGeneticsGeneralBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Asthma_and_pregnancy?openNational Asthma Council Australiahttp://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdfNational Asthma Council Australiahttp://www.nationalasthma.org.au/content/view/291/655/National Institute for Health and Clinical Excellence (UK)http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdfAustralasian Diabetes in Pregnancy Societyhttp://www.adips.org/images/stories/documents/adips_pregdm_guidelines.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Gestational_diabetes?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/DiabetesMellitusManagementofPreexistingDiabetesMellitusinPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Epilepsy_lifestyle_issuesEpilepsy Foundation of Victoriahttp://www.epinet.org.au/articles/epilepsy_and_your_lifestage/pregnancy/American Academy of Neurologyhttp://www.neurology.org/cgi/content/full/73/2/142The Endocrine Society (USA)http://www.endo-society.org/guidelines/Current-Clinical-Practice-Guidelines.cfmThe Australian Thyroid Foundationhttp://www.thyroidfoundation.com.au/information/information.htmlGenetic Health Services Victoriahttp://www.genetichealthvic.net.au/sections/Patients/?docid=e5ac4a89-9f9c-4313-9bc0-9a9300b93ba8National Health and Medical Research Councilhttp://www.nhmrc.gov.au/your_health/egenetics/practitioners/gems.htmConsumer fact sheet: Asthma and pregnancyClinical information: Asthma managementhandbook (p.101 Pregnancy and asthma)Consumer information: Pregnancy andasthmaClinical guideline: Management of Diabetesand its complications from pre-conception tothe postnatal periodClinical guidelines: Management of patientswith of Type 1 and Type 2 Diabetes in relationto pregnancyConsumer information: Gestational DiabetesClinical Practice Guideline: pre-existingDiabetes in pregnancyConsumer information: Epilepsy lifestyleissuesConsumer information on epilepsy inpregnancy. Includes: pre-pregnancycounselling, pregnancy and anti-epilepticdrugs, anti-epileptic drugs and the developingbaby, pregnancy and seizures, labour,motherhood and breastfeedingClinician information: management issues forwomen with epilepsy. Focus on pregnancy:Vitamin K, folic acid, blood levels, andbreastfeedingClinical practice guideline: management ofthyroid dysfunction during pregnancy andpostpartum.Consumer information: thyroid conditionsand iodine deficiencyConsumer information: Planning a pregnancyClinician information: Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners18

Cystic FibrosisFragile XTay Sachs diseaseMedicine useVaccinationsGeneralWorld Health Organisation (WHO)http://www.who.int/genomics/public/geneticdiseases/en/index2.html#tsGenetic Health Services Victoriawww.genetichealthvic.net.auGenetic Health Services Victoriahttp://www.cfscreening.com.au/Genetic Health Services Victoriahttp://www.cfscreening.com.au/Documents/CF_brochure.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/fact_sheets/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/11%20-%20Fragile%20X%20syndrome%20WEB.pdfFragile X Association of Australiahttp://www.fragilex.org.au/http://www.genetichealthvic.net.au/Documents/PDF/TaySachsBrochure.pdfMercy Hospital for Womenhttp://www.mercy.com.au/files/NRR6CEQQCO/Psychotropic%20drugs%20%20pregnancy%202nd%20Edn.pdfRoyal Women’s HospitalPregnancy and Breastfeeding Medicines GuideAvailable from Pharmacy DepartmentPh: 9345 3190E: rwh.pharmacy@thewomens.org.auTherapeutic Goods Administrationhttp://www.tga.gov.au/docs/html/medpreg.htmRoyal Women’s Hospitalhttp://www.thewomens.org.au/HerbalpreparationsinpregnancyAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/WHO monogenic diseases information.Includes:ThalassaemiaSickle cell anaemiaHaemophiliaCystic FibrosisTay Sachs diseaseFragile X syndromeHuntington's diseaseConsumer and health professionalinformationConsumer and clinician information: Cysticfibrosis carrier screening program (populationcarrier screening)Consumer brochure: Cystic Fibrosis carriertesting (population carrier screening)Clinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Cystic FibrosisConsumer fact sheet from Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Cystic FibrosisClinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Fragile X syndromeConsumer information: Fragile XConsumer and clinician information: CarrierTesting for Tay Sachs and related conditions.For people with Ashkenazi Jewish ancestryClinician information. PsychotropicMedication in Pregnancy/LactationClinician information: Pregnancy andBreastfeeding Medicines GuideClinician information: Prescribing Medicinesin Pregnancy. An Australian categorisation ofrisk of drug use in pregnancyConsumer fact sheet: Herbal preparations inpregnancyClinician information: vaccination of womenplanning pregnancy, pregnant or19

Measles, mumpsand rubellaVaricellaInfluenzaDiphtheria,tetanus, pertussisFolateIodineHandbook-specialrisk232Australian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measlesAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-mumpsAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-rubellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-varicellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-influenzaAustralian & State and Territory Governmentshttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/IMM123-cnt/$File/imm123-fs-2010.pdfAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-diphtheriaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-tetanusAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-pertussisFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Fact%20Sheet%20-%20Folic%20Acid%20(July%2009).pdfFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomen/folicacidfolateandpr4598.cfmFamily Planning Victoriahttp://www.fpv.org.au/2_9_4.htmlRoyal Women’s Hospitalhttp://www.thewomens.org.au/FolateinPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Folate_for_women?openFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Fact%20Sheet%20-%20Iodine%20(July%2009).pdfbreastfeeding women, and preterm infantsClinician information: Measles immunisationClinician information: Mumps immunisationClinician information: Rubella immunisationClinician information: Varicella immunisationClinician information: Influenza immunisationClinician fact sheet: Influenza vaccination2010Clinician information: DiphtheriaimmunisationClinician information: Tetanus immunisationClinician information: Pertussis immunisationClinician and consumer fact sheet: Mandatoryfolic acid fortification in AustraliaConsumer information: Folic Acid/FolateConsumer information: Folic acidClinical Practice Guideline: Folate inPregnancyConsumer fact sheet: Folate for WomenClinician and Consumer fact sheet:Mandatory iodine fortification20

Food Standards Australia New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomen/iodineandpregnancy.cfmBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Iodine_explainedDiet, nutrition and food safetyGeneralDepartment of Health & Ageinghttp://www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/pregnant-womenRoyal Women’s Hospitalhttp://www.thewomens.org.au/HealthyeatingforpregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_diet?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/WeightgaininpregnancyConsumer information: Iodine advice forpregnant womenConsumer fact sheet: Iodine explainedConsumer information: Healthy eatingguidelines for pregnant women. Includes:general dietary advice and information oniron, folate, iodine, morning sickness,indigestion, listeria, mercury and caffeineConsumer fact sheet: Healthy eating forpregnancyConsumer fact sheet: Pregnancy and dietConsumer fact sheet: Weight gain inpregnancyFood safetyVegetarian andvegan dietsVitamins andmineralsRoyal Women’s Hospitalhttp://www.thewomens.org.au/FoodsafetyduringpregnancyFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomenFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Listeria.pdfFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/scienceandeducation/factsheets/factsheets2005/listeriacommonlyaske3115.cfmFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/_srcfiles/mercury_in_fish_brochure_lowres.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Mercury_in_fish?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/VegetarianeatingandpregnancyQueensland Healthhttp://www.health.qld.gov.au/nutrition/resources/antenatal_veget.pdfQueensland Healthhttp://www.health.qld.gov.au/nutrition/resources/antenatal_vegan.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/IronpregnancyRoyal Women’s HospitalConsumer fact sheet: Food safety inpregnancyConsumer information: Food safety advice forpregnancy. Includes links to furtherinformation on folic acid, iodine, fish andmercury, listeria prevention, alcohol caffeineConsumer brochure: Listeria and food- advicefor people at riskClinician and consumer information: Listeriaand food- commonly asked questionsConsumer brochure: Mercury in fishConsumer fact sheet: Mercury in fishConsumer fact sheet: Vegetarian eating andpregnancyConsumer information: Healthy eating forvegetarian pregnant and breastfeedingmothersConsumer information: Healthy eating forvegan pregnant and breastfeeding mothersConsumer fact sheet: Iron in pregnancyConsumer fact sheet: Vitamin D and21

ExerciseInfectionsToxoplasmosisParvovirusCytomegalovirusInfluenzahttp://www.thewomens.org.au/VitaminDandpregnancyVictorian Department of Healthhttp://www.health.vic.gov.au/chiefhealthofficer/publications/low_vitamin_d_med.htmRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminDAntenatalScreeningRoyal Australian and New Zealand College of Obstetricians andGynaecologistshttp://www.ranzcog.edu.au/publications/statements/C-obs25.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminB12inPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_exercise?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_sport?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Toxoplasmosis_reducing_the_risks?openAustralian Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/cdapubs-cdi-2000-cdi2403s-cdi24msa.htmVictorian Department of Health and Ageinghttp://www.health.vic.gov.au/ideas/bluebook/erythemaVictorian Department of Health and Ageinghttp://www.health.vic.gov.au/ideas/bluebook/erythema/erythema_pregnant_infoBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Slapped_face_disease?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Cytomegalovirus_(cmv)Victorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/cmvRoyal Women’s Hospitalhttp://www.thewomens.org.au/PregnancyandflupregnancyClinician information: Low Vitamin D inPregnancy- Key Messages for Doctors, Nursesand Allied HealthClinical practice Guideline: vitamin Dantenatal screeningClinician information: Vitamin and mineralSupplementation in pregnancyClinical Practice Guideline: Vitamin B12 inpregnancyConsumer fact sheet: Pregnancy and exerciseConsumer fact sheet: Pregnancy and sportConsumer fact sheet: Toxoplasmosisreducingthe riskClinician information: Parvovirus B19infection and its significance in pregnancyClinician information: Guidelines for thecontrol of infectious diseases -ParvovirusConsumer information: Slapped cheekinfection information for pregnant womenConsumer fact sheet: Slapped cheek infectionConsumer fact sheet: CytomegalovirusClinician information: CytomegalovirusConsumer fact sheet: Pregnancy and FluprecautionsSubstance use and cessationGeneralDepartment of Health and Ageinghttp://www.health.gov.au/internet/quitnow/publishing.nsf/Content/lifescriptsClinician information: Pregnancy Lifescripts:smoking, alcohol, nutritionSmokingQUIThttp://www.quit.org.au/article.asp?ContentID=pregnancyConsumer information: Smoking andpregnancy22

AlcoholDrug UseDental HealthQUIThttp://www.quit.org.au/article.asp?ContentID=media_bkground_pregnancyQUIThttp://www.quit.org.au/browse.asp?ContainerID=pregnancy_nicotine_replacementBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_smoking?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/TobaccoNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/publications/synopses/ds10syn.htmDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/aod_pregnancy/aod_pregnancy.htmlBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Foetal_alcohol_syndrome?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/AlcoholNew South Wales Department of Healthhttp://www.health.nsw.gov.au/pubs/2006/pdf/ncg_druguse.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/AlcoholDrugsDuringPregnancyDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/aod_pregnancy/aod_pregnancy.htmlDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/cannabis_factsheets/cannabis_pregnancy.htmlBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_drugs?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Teeth_and_pregnancy?openConsumer information: Common myths aboutsmoking and pregnancyConsumer information: pregnancy, quittingsmoking and nicotine replacement therapyConsumer information: Pregnancy andsmokingConsumer fact sheet: Tobacco in pregnancyClinician information: Australian Guidelines toReduce Health Risks from Drinking Alcohol(p. 67 Guideline 4: Pregnancy andBreastfeeding)Consumer information: Alcohol, other drugsand pregnancy for women who arepregnant/considering pregnancyConsumer fact sheet: fetal alcohol syndromeConsumer fact sheet: Effects on pregnancy,breastfeeding and infant developmentClinician information: National clinicalguidelines for the management of drug useduring pregnancy, birth and the earlydevelopment years of the newbornConsumer fact sheets: Alcohol and drugsduring pregnancy. Includes alcohol,amphetamines, benzodiazepines,buprenorphine, cannabis, heroin and otheropiates, inhalants, methadone, tobaccoConsumer information. Alcohol, other drugsand pregnancy: for women who arepregnant/considering pregnancyConsumer information: Cannabis use inpregnancyConsumer fact sheet: Pregnancy and drugs.Includes over the counter and vitaminsConsumer fact sheet: Teeth and pregnancy23

ANTENATAL VISITSThe following information is a synopsis of the minimum routine antenatal visits for Shared Maternity Care. It includesbrief descriptions of issues to consider at these visits. While there is considerable alignment between the fourhospitals, the antenatal schedule does vary.For further information on antenatal investigations, please see the Initial Routine Investigations and TESTING INPREGNANCY FOR FETAL ABNORMALITIES sections of these Guidelines.Confirmation of PregnancyWomen may present to their GP at any stage to confirm they are pregnant. It is best if this is done early in thepregnancy in order to facilitate preventative health interventions and offer appropriate counselling for prenatalscreening.In addition to the aims of a pre-pregnancy consultation, the aims of the early pregnancy consultation are to:confirm pregnancyrefer to hospitalrefer for counselling of inheritable conditions where appropriateThe table below lists some of the issues that should be considered in an early pregnancy consultation.Confirmation of Pregnancy/GP VisitWhen Who Aim Clinical InvestigationsUsually atGPConfirmGeneral history andIt is appreciated if initial investigations are4-10 weekspregnancyexamination including:ordered by the GP and copies of results are sentEnsure theLNMP/EDCwith the women to the first hospital visitwomen is inAgeoptimal health forHistory:Please note. The ordering provider is responsiblepregnancy- reproductivefor the follow-up of abnormal resultsIdentify andand obstetricmanage potential- medicalFor more information on initial investigations seeproblems for the- nutritionalthe Initial Routine Investigations section of thesefetus and mother- mental healthGuidelinesbased on personal- smokingand family history- drug andInitial investigations recommended:Provide educationalcoholBlood groupabout the health- social andAntibody screencare systemoccupationalFBE (including MCV/MCH)choices availableUse of medicinesHepatitis B screening for carrier statusDevelop rapportFamily history ofSyphilis serologywith the womaninheritableRubella antibodiesand her familyconditionsHIV serology24

Appropriate follow-up ofidentified problemsincluding:Referral forcounselling ofinheritableconditionsIn pre-existingconditions, reviewmedication andmanagement.Consider earlyreferral for specialistphysician review.Urinalysis/MSU M&CConsider:Dating ultrasoundFerritin (routine at RWH and SH)Haemoglobin electrophoresis (routine atSH)/DNA analysis for Alpha ThalassaemiaHepatitis C serology (routine at MHW, NHand SH)Varicella antibodiesChlamydia (urine or cervical swab)Vitamin D level (routine at NH and SH)Thyroid stimulating hormone (TSH)Glucose tolerance test (GTT)Pap test if dueDiscuss testing for fetal abnormalities:ORCombined First Trimester Screening (this isnot generally available via the hospitals)Second Trimester Maternal Serum ScreeningFetal morphology ultrasoundConsider tests for fetal abnormalities/geneticcarrier status:CVS/amniocentesisCystic Fibrosis testingFragile X testingOthers as relevantFor more information on prenatal screening andtesting, see the TESTING IN PREGNANCY FORFETAL ABNORMALITIES section of theseGuidelines25

“Maternal alcohol consumption can harm the developing fetus orbreastfeeding baby. For women who are pregnant or planning apregnancy, not drinking is the safest option. For women who arebreastfeeding, not drinking is the safest option.” - NHMRC (2009)‘Australian Guidelines to Reduce Health Risks from DrinkingAlcohol’.Ask about family history of inheritable conditions on both sides ofthe family. Genetic Services are a resource for secondary advice,counselling and testing.‘Maternal alcohol consumption can harmthe developing fetus or breastfeedingbaby. For women who are pregnant orplanning a pregnancy, not drinking is thesafest option. For women who arebreastfeeding, not drinking is the safestoption.’‘Ask about family history of inheritableconditions on both sides of the family.Genetic Services are a resource forsecondary advice, counselling andtesting.’Shared Maternity Care at Our HospitalsA summary of the models of maternity care and maternity care hospitals available in Victoria can be found on the“Having a Baby in Victoria”, Department of Health website: http://www.health.vic.gov.au/maternity/The majority of pregnancies and births do not require tertiary care and can be managed at a woman’s nearestmaternity hospital. To ensure all women can access the level of maternity care they require, women experiencinglow-risk pregnancies should attend their nearest maternity hospital for their pregnancy care.If a GP or SMCA thinks a woman needs to go to either of the tertiary centres (MHW or RWH), and they are not thewoman’s nearest maternity hospital, her needs must be specified on the referral to MHW or RWH. In this instance, ifMHW or RHW believe the woman is best served at her local hospital they will contact the referring Doctor so theycan arrange another referral to that hospital.If at any time a woman’s pregnancy becomes complicated, or is considered to be high-risk, she can be referred byher local maternity hospital to MHW or RWH.26

Hospital location maps27

It is not necessary for women to have chosen a model of maternity care prior to their first hospital visit, although it ishelpful if they have discussed their options, including Shared Maternity Care, with their GP.It is important that both hospital and community providers are supportive of the Shared Maternity Care model; thatthey are respectful and professional in their approach to a woman’s decision to undertake shared care, and that theydo not attempt to divert her into another model of care unless this is medically indicated.How to Refer for Shared Maternity CareTo refer women for maternity care at the hospitals, GPs or SMCA need to send a referral and relevant investigationsas soon as practicable. Please provide as much relevant information as possible so women can be appropriatelytriaged. Doctors can refer women by using any referral letter or template. The ‘Victorian Statewide Referral Form(VSRF) + Maternity’ is designed to provide high quality information to facilitate referral and triage. As well asstandard demographic and clinical information, the VSRF+ Maternity form includes medical and obstetric risk factorsand pregnancy investigations/clinical checklist. In addition, some of the hospitals also have their own templates thatSMCA are welcome to use or modify.Hospital Maternity Referral DetailsRWH MHW SH NHFax: 8345 3036 Fax: 8458 4205 Fax: 8345 1691 Fax: 8405 8761Ph: 8345 2058 Ph: 8458 4100 Ph: 8345 1727 Ph: 8405 8335Both the woman and the referring GPwill receive notification of the appointment details and locationSatellite ClinicsAll four hospitals have community satellite clinics in addition to the main hospital campus. If a woman prefers toattend one of these sites, GPs are advised to request this on the referral. Women are also able request thissubsequently.RWH MHW SH NHFawknerIvanhoeFootscrayHoppers CrossingBroadmeadowsMoonee PondsPrestonSt AlbansBraybrookCraigieburnKensingtonDeer ParkWatergardensKingsvilleSeabrookHospital ToursWomen and their families are welcome to arrange a tour at the hospital they have been booked to give birth at.Tours can be arranged via the hospital’s Childbirth/Parent Education Department (RWH and MHW), at the midwifeantenatal preadmission appointment (SH), or via the maternity ward at (NH).28

Support ServicesIn addition to social work services, the hospitals provide additional support services for:young motherswomen with alcohol and drug issuesAboriginal and Torres Straight Islander womenwomen who have been circumcisedwomen with intellectual disabilities and learning difficultieswomen with physical disabilitiesPlease indicate on the referral if additional support is required. The Shared Maternity Care Coordinator may also beable to arrange access to these services for women.Schedule of VisitsThe tables below provide an overview of antenatal visits for Shared Maternity Care and are generally consistent withthe “Three Centres Consensus Guidelines” and Victorian Maternity Record (VMR). This is the minimum routineschedule of visits for low-risk women. The schedule should be tailored to a woman’s individual needs.For low-risk women, irrespective of model of care, the traditional schedule of 14 visits may be safely reduced tobetween seven and ten visits without adversely affecting perinatal outcomes (Level I evidence) - 3 CentresThe number and timing of visits should be flexible to suit the needs of individual women. Additional visits should beprovided if women or their midwife or doctor perceive a need, or as complications arise. (Level II evidence) - 3 CentresIt is important to establish each person’s expectations and understanding, as women may have a differentperspective on the purpose and timing of antenatal visits. (Consensus opinion) - 3 CentresThe option and timing of additional visits, and a mechanism by which such visits may be accessed, should bediscussed with all women. (Consensus opinion) - 3 Centres29

Routine Antenatal Visits for Shared Maternity Care: SummaryThis reflects minimum visits. Additional visits should be arranged as appropriate.For more detail on antenatal visits, see the remainder of this sectionLocation Timing (approximately) Who sees Notes1 st Hospital Visit 10-16 weeks Midwife and Doctor(at SH women mightonly see a midwife)Antenatal checkInvestigationsDoctor and Midwife components may be ondifferent daysSMCA 16 weeks Antenatal checkSecond Trimester Maternal Serum Screeningdiscussed and organised or result checkedFetal morphology ultrasound appointmentconfirmedSMCAHospitalFor SH, this is a SMCA visit. If anti-D is required, women access thisvia SH Pregnancy Day Stay UnitSMCA22 weeksNH does not routinely have this22 week visitNH has a 20 week hospital visitand a 24 week SMCA visit28 weeks Midwife(+ Doctor review ifrequired)32 weeksNH has an additional 30 weekSMCA visitFetal morphology ultrasound result checkedAntenatal checkInvestigations (Gestational Diabetestest/FBE/antibodies)Anti-D (if required)Antenatal checkSMCAThis is replaced by a hospital visitfor women requiring anti-D34 weeks Anti-D (if required)HospitalThis is a SMCA visit for womenwho attended the hospital at 34weeks for anti-DSMCASMCASMCA (RWH, SH)Hospital (MHW, NH)36 weeks Doctor(At SH only midwife ifshared care unlessprevious caesareansection)38 weeksNH has an additional 37 weekSMCA visit39 weeksNot routine at RWH40 weeks Doctor at NH andMHWSMCA at RWH and SHAntenatal checkGBS swabFor women with past history of caesarean section:discussion with the hospital Doctor and decisionregarding vaginal birth after caesarean (VBAC) orelective caesarean is finalised at this visitAntenatal checkAntenatal checkAntenatal checkHospital 41 weeks Doctor Antenatal checkInvestigations30

For further information on antenatal investigations, please see the Initial Routine Investigations and TESTING INPREGNANCY FOR FETAL ABNORMALITIES sections of these Guidelines.Women also have a Midwife Antenatal Pre-admission (MAP) appointment during their pregnancy. This includesdiscussion about admission and discharge, labour and birth (including when to come to hospital and what to bring),breastfeeding and accessing community support services.First Hospital Antenatal Visit (Booking-in Visit and Antenatal Check)All women have a detailed health and social assessment performed at the ‘booking-in visit’ by a Midwife. Thisprovides the opportunity to explore many aspects of maternity care and for women to discuss models of care. At thisvisit the woman is officially booked for birth at the hospital. The woman then sees a Doctor for a detailed clinicalassessment (except at SH where women with low-risk pregnancies are usually seen by a Midwife). As part of thisprocess, a decision is made by the hospital as to whether Shared Maternity Care is appropriate.Usually, the first antenatal visit and booking-in visit occur on the same day and takeup to three hours.Women who enrol in Shared Maternity Care are provided with written informationby the hospital on Shared Maternity Care and their schedule of visits. The womanneeds to make her own appointments with the SMCA. The SMCA is informed of thewoman’s enrolment into shared care by letter within 72 hours. If the woman doesnot attend the first SMCA visit, please notify the Shared Maternity CareCoordinator.First trimester visits are primarily to assess maternal and fetal wellbeing; inparticular to assess, the risk of complication, to date the pregnancy, take acomprehensive history, discuss smoking behaviour and establish care options. Thevisits are scheduled in order to offer screening tests.‘First trimester visits areprimarily to assess maternaland fetal wellbeing; inparticular to assess, the risk ofcomplication, to date thepregnancy, take acomprehensive history,discuss smoking behaviourand establish care options.The visits are scheduled inorder to offer screening tests.’First Hospital VisitTiming Who Clinical Investigations Issues for Discussion(in addition to maternalconcerns)AllMidwife andMidwife and ObstetricIt is preferable that initial investigationsEnsure woman has handhospitalsDoctorConsultationare ordered by the GP with copies ofheld pregnancy record10-16(at SH onlyComprehensiveresults sent with the woman to the firstModels of careweeksMidwife if sharedmedical, obstetric andhospital visit. If investigations have notSchedule of visitscare)These visits mayor may not beconcurrentsocial historyPhysical examinationAppropriate referralsas requiredDecide on agreedbeen done, they will be arranged at thefirst hospital visit.For more information on initialinvestigations see the Initial RoutineInvestigations section of theseChanges in pregnancySmoking cessationAlcohol/other drugsMedicines (prescriptions,over the counter31

estimated date ofconfinement anddocument this in handheld pregnancy recordOrganise investigationsthat have not beendone by GPDiscuss/arrangeprenatal tests thathave not been done byGPConsider referral forprenataldiagnosis/counsellingArrange fetalmorphologyultrasound if notorganised by GPIf Rhesus negative andno antibodies, discussRhesus (D)immunoglobulin (anti-D)GuidelinesInitial investigations recommendedBlood groupAntibody screenFBE (including MCV/MCH)Hepatitis B screening for carrierstatusSyphilis serologyRubella antibodiesHIV serologyUrinalysis/MSU M&CConsiderDating ultrasoundFerritin (routine at RWH and SH)Haemoglobin electrophoresis(routine at SH)/DNA analysis forAlpha ThalassaemiaHepatitis C serology (routine atMHW, NH and SH)Varicella antibodiesChlamydia (urine or cervical swab)Vitamin D level (routine at NH andSH)Thyroid stimulating hormone (TSH)Glucose tolerance test (GTT).(Glucose challenge test (GCT)routine at NH)Pap test if duemedicines and vitamins)Diet and nutritionListeria infectionpreventionToxoplasmosispreventionHospital and communitysupports (how and whento seek help)Childbirth educationclasses (booking in)BreastfeedingIf Rhesus negative:indications for the use ofRh D immunoglobulin(anti-D)If previous caesareansection, options for birthDiscuss testing for fetal abnormalitiesORCombined First Trimester Screening(this is not generally available viathe hospitals)Second Trimester Maternal SerumScreeningFetal morphology ultrasound32

Consider tests for fetalabnormalities/genetic carrier statusCVS/amniocentesisCystic Fibrosis testingFragile X testingOthers as relevantFor more information on prenatalscreening and testing, see the TESTINGIN PREGNANCY FOR FETALABNORMALITIES section of theseGuidelinesThe Hospital should confirm agreed estimated date of confinement at 1 st Hospital visit and document this on thehand held pregnancy record.The Standard Antenatal ExaminationA standard antenatal examination referred to throughout the scheduleincludes:general wellbeing‘The Hospital should confirm agreedblood pressure checkestimated date of confinement at themeasurement of fundal height in centimetres1 st Hospital visit and document this onfetal movements from 20 weeksthe hand held pregnancy record.’fetal auscultation from 20 weekschecking fetal presentation from 30 weeksinspection of legs for oedema (a sign of preeclampsia and thromboembolic disease) and looking for othersigns of thromboembolic diseaseconsider urine testingThis should be documented in the hand held pregnancy record.‘Second trimester visits are primarilyscheduled to monitor fetal growth,Second trimester visits are primarily scheduled to monitor fetalmaternal wellbeing and signs ofgrowth, maternal wellbeing and signs of pre-eclampsia.pre-eclampsia.’33

SMCA visit approximately 16 weeksRWHMHWSHNHStandard antenatal examinationReview of pregnancy record entriesEnsure testing for Down Syndrome has been discussed/organisedEnsure fetal morphology ultrasound has been discussed/organisedSMCA visit approximately 22 weeksRWHMHWSHNHStandard antenatal examinationReview and document investigation results including fetalmorphology ultrasoundNH has additional 20 week hospital visit and a 24 week SMCA visitThird trimester visits are primarily to monitor fetal growth, maternalwellbeing, signs of pre-eclampsia, and to assess and prepare women foradmission, labour and going home. These visits include bacteriologicalscreening for Group B Streptococcus.Hospital visit approximately 28 weeksFor women at SH this is a SMCA visit and the SMCA performs theantenatal examination and organises the investigations.‘Third trimester visits are primarily tomonitor fetal growth, maternalwellbeing, signs of pre-eclampsia, andto assess and prepare women foradmission, labour and going home.These visits include bacteriologicalscreening for Group B Streptococcus.’Who Clinical Investigations Issues for Discussion(in addition to maternal concerns)RWHMidwifeStandardGCT or GTT if high-The following issues are discussed at the Midwifeantenatalrisk (MHW does GTTAntenatal Pre-admission (MAP) visit at allMWHMedical review mayexaminationfor all women).hospitals. At NH the MAP component is at 30be requested at anyOrderFBEweeks.NHof the hospitals byinvestigationsAntibody screenAdmission and dischargeSMCA if indicated,Review ofDiscuss andChildbirth educationby contacting thepregnancy recordorganise anti-DPrevious birth experienceShared Maternityentriesprophylaxis asLabour and birth including:Care Coordinator orMidwifeindicated for Rhesus- signs of labourGP hotline (MHW)Antenatal Pre-negative women- when to come to hospitalAdmission (MAP)- where to goappointment- birth plan(except SH where- pain reliefit is done at first- monitoring34

hospital visit) - episiotomy- labour support- what to bring to hospitalInfant feeding (breastfeeding supported)Community support services (includingestablishing a support network)Neonatal screening test (Guthrie Test)- PKU- Congenital hypothyroidism- Cystic Fibrosis- selected metabolic disordersHearing screenVitamin KHepatitis B immunisationChild safety/car restraintsContraceptionSHFor women undertaking Shared Maternity Care at SH this is a SMCA visit and the SMCA performs the antenatal check andorganises the investigations. If anti-D is required, this is given via Pregnancy Day Stay Unit at SH. This appointment is eitherarranged by SH or the woman can call the Pregnancy Day Stay Unit for an appointment.All hospitals arrange routine 28 and 34 week anti-D for women who are Rhesusnegative with no antibodies. SMCA should send women who also require anti-D due to a sensitising event to the hospital’s emergency department.SMCA visit approximately 32 weeksRWHStandard antenatal examinationMHWReview and document investigation resultsSHNHNH has an additional 30 week routine SMCA visit‘All hospitals arrange routine 28and 34 week anti-D for womenwho are Rhesus negative with noantibodies. SMCA should sendwomen who also require anti-Ddue to a sensitising event to thehospital’s emergencydepartment.’SMCA visit approximately 34 weeksThis is a hospital visit for women requiring prophylactic anti-D and replaces the 36 week hospital visitRWHMHWSHNHStandard antenatal examinationReview and document investigation results35

Hospital visit approximately 36 weeksWho Clinical Investigations Issues for Discussion(in addition to maternal concerns)RWHDoctorStandardGBS screeningIf previous lower uterine segmentMHW(at SH onlyantenatalConsidercaesarean section (LUSCS), documentSHMidwifeexaminationFBE/Ferritindecision on whether woman willNHunlessReview ofattempt a vaginal birth after caesareanpreviouspregnancy(VBAC) or have an elective LUSCScaesareanrecord entriesIf elective caesarean, a pre-operativesection)visit is be arranged by the hospitalSMCA visit approximately 38 weeksRWHMHWSHNHStandard antenatal examinationReview and document investigation resultsNH has an additional 37 week routine SMCA visitSMCA visit approximately 39 weeksWomen undertaking Shared Maternity Care at RWH do not routinely have this visitMHWSHNHStandard antenatal examinationReview and document investigation resultsSMCA/hospital visit approximately 40 weeksFor women undertaking Shared Maternity Care at MHW and NH, this is a hospital visitFor women undertaking Shared Maternity Care at RHW and SH, this is a SMCA visitRWHMWHSHNHStandard antenatal examinationReview and document investigation results36

Hospital visit: approximately 41 weeksWho Clinical Investigations(organised and undertaken athospital)Issues for Discussion(in addition to maternalconcerns)RWHDoctorStandardCardiotocographFurther monitoring/MHWantenatal(CTG)arrangement ofSHexaminationAmniotic Fluid Indexinduction if applicableNHReview of(AFI)pregnancyrecord entriesShared Maternity Care Affiliate Discussion Points and Patient InformationDuring the pregnancy, it is ideal if health care providers (both hospital and SMCA) check that, when relevant, thefollowing information has been discussed with the woman (in addition to maternal concerns). Resources (withhyperlinks) supporting these discussion points can be found in the resource section.Throughout thePregnancyEarly in Pregnancy Later in Pregnancy In the Final Weeks ofPregnancySmokingModels of careSymptoms/signsNewborn carecessationFolate supplementationof prematureBaby immunisationsBreastfeedingDrug and alcohol uselabour (discussedPostpartum maternalMental healthMedicines (prescription, over the counter,at hospital visit)immunisationand wellbeingand vitamins including Vitamin A derivatives)Establishing- BoostrixIntimatePromote Shared Maternity Caresupport networks- VaricellapartnerInfluenza vaccinationReview labour- RubellaviolenceListeria preventionToxoplasmosis preventionDiet and nutritionCalcium and pregnancyCommon discomforts in pregnancyAnti-DExerciseSexWorkingTravelInformation sourcesand birthincludingexpectations(discussed athospital visit)Vaginal birth aftercaesarean(discussed athospital visit)Baby productsand safetyPostnatal GP checkfor mother and babyCommunity maternaland child healthservicesExpectations of pregnancy/birthDental care37

ResourcesMaternity Services and Models of Care (Victoria)Victoria Department of Healthhttp://www.health.vic.gov.au/maternity/Consumer information on maternityservices and models of care in VictoriaHospital Shared Maternity CareTools for sharedmaternity careBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_birth_choices?openVictorian Department of Healthhttp://www.health.vic.gov.au/maternitycare/downloads/vic_maternity_record_form.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/ReferralsOtherResourcesGeneral Practice Victoriahttp://www.gpv.org.au/content.asp?cid=11,137&VSRF#get2009vsrfConsumer information on birth choicesVictorian Maternity Record.The hand held pregnancy record used atRWH, MHW and SHPregnancy fast fax referral form for RWH.Either this form or VSRF+ Maternity can beused to refer for maternity care at RWH.Victorian Statewide Referral Form (VSRF) +Maternity. Optional referral form for allpregnancy referralsHospital SharedMaternity CarewebsitesRoyal Women’s Hospitalhttp://www.thewomens.org.au/SharedMaternityCareAffiliatesMercy Hospital for Womenhttp://www.mercy.com.au/html/s02_article/article_view.asp?id=882&nav_cat_id=207&nav_top_id=84Northern Healthhttp://www.nh.org.au/antenatal-shared-care/w1/i1001234/Western Health (Sunshine Hospital)http://www.wh.org.au/GP_Liaison/Shared_Care/Shared_Maternity_Care/index.aspxRWH Shared Maternity Care information foraffiliatesMHW Shared Maternity Care informationfor affiliatesNH Shared Maternity Care information foraffiliatesSH Shared Maternity Care information foraffiliatesStandard antenatal checkBlood pressuremeasurementRoyal women’s Hospitalhttp://www.thewomens.org.au/StandardAntenatalCheckThree Centreshttp://3centres.com.au/guidelines/routine-blood-pressuremeasurement-in-pregnancy/Clinical practice guideline: standardantenatal checkClinician information: 3 Centre ConsensusGuidelines on Antenatal Care- Routineblood pressure measurement in pregnancyFundal heightmeasurementThree Centreshttp://3centres.com.au/guidelines/symphyseal-fundal-heightmeasurement/Clinician information: 3 Centre ConsensusGuidelines on Antenatal Care- symphysealfundal (S-F) height measurementUrine testingThree Centreshttp://3centres.com.au/guidelines/urinalysis-by-dipstick-forproteinuria/Clinician information: 3 Centre ConsensusGuidelines on Antenatal Care- Urinalysis bydipstick for proteinuria38

Fetal heartauscultationMedical HistoryAsthmaThree Centreshttp://3centres.com.au/guidelines/auscultation-of-the-fetal-heart/American Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp156.cfmBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Asthma_and_pregnancy?openClinician information: 3 Centre ConsensusGuidelines on Antenatal Care- auscultationof the fetal heartConsumer information: how your babygrows during pregnancyConsumer fact sheet: Asthma andpregnancyDiabetesEpilepsyThyroid diseaseGeneticsNational Asthma Council Australiahttp://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdfNational Asthma Council Australiahttp://www.nationalasthma.org.au/content/view/291/655/National Institute for Health and Clinical Excellence (UK)http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdfAustralasian Diabetes in Pregnancy Societyhttp://www.adips.org/images/stories/documents/adips_pregdm_guidelines.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Gestational_diabetes?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/DiabetesMellitusManagementofPreexistingDiabetesMellitusinPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Epilepsy_lifestyle_issuesEpilepsy Foundation of Victoriahttp://www.epinet.org.au/articles/epilepsy_and_your_lifestage/pregnancy/American Academy of Neurologyhttp://www.neurology.org/cgi/content/full/73/2/142The Endocrine Society (USA)http://www.endo-society.org/guidelines/Current-Clinical-Practice-Guidelines.cfmThe Australian Thyroid Foundationhttp://www.thyroidfoundation.com.au/information/information.htmlClinical information: Asthma managementhandbook (p.101 Pregnancy and asthma)Consumer information: Pregnancy andasthmaClinical guideline: Management of Diabetesand its complications from pre-conceptionto the postnatal periodClinical guidelines: Management of patientswith of Type 1 and Type 2 Diabetes inrelation to pregnancyConsumer information: GestationalDiabetesClinical Practice Guideline: Pre-existingDiabetes in pregnancyConsumer information: Epilepsy lifestyleissuesConsumer information on epilepsy inpregnancy. Includes: pre-pregnancycounselling, pregnancy and anti-epilepticdrugs, anti-epileptic drugs and thedeveloping baby, pregnancy and seizures,labour, motherhood and breastfeedingClinician information: Management issuesfor women with epilepsy. Focus onpregnancy: Vitamin K, folic acid, bloodlevels, and breastfeedingClinical practice guideline: management ofthyroid dysfunction during pregnancy andpostpartumConsumer information: thyroid conditionsand iodine deficiencyGeneral Genetic Health Services Victoria Consumer information: Planning a39

Cystic FibrosisFragile XTay Sachs diseaseMedicine Usehttp://www.genetichealthvic.net.au/sections/Patients/?docid=e5ac4a89-9f9c-4313-9bc0-9a9300b93ba8National Health and Medical Research Councilhttp://www.nhmrc.gov.au/your_health/egenetics/practitioners/gems.htmWorld Health Organisation (WHO)http://www.who.int/genomics/public/geneticdiseases/en/index2.html#tsGenetic Health Services Victoriawww.genetichealthvic.net.auGenetic Health Services Victoriahttp://www.cfscreening.com.au/Genetic Health Services Victoriahttp://www.cfscreening.com.au/Documents/CF_brochure.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/fact_sheets/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/11%20-%20Fragile%20X%20syndrome%20WEB.pdfFragile X Association of Australiahttp://www.fragilex.org.au/http://www.genetichealthvic.net.au/Documents/PDF/TaySachsBrochure.pdfpregnancyClinician information: Genetics in FamilyMedicine: The Australian Handbook forGeneral PractitionersWHO monogenic diseases information.Includes:ThalassaemiaSickle cell anaemiaHaemophiliaCystic FibrosisTay Sachs diseaseFragile X syndromeHuntington's diseaseConsumer and health professionalinformationConsumer and clinician information: Cysticfibrosis carrier screening program(population carrier screening)Consumer brochure: Cystic Fibrosis carriertesting (population carrier screening)Clinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Cystic FibrosisConsumer fact sheet from Genetics inFamily Medicine: The Australian Handbookfor General Practitioners. Cystic FibrosisClinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Fragile X syndromeConsumer information: Fragile XConsumer and clinician information: CarrierTesting for Tay Sachs and related conditions.For people with Ashkenazi Jewish ancestryMercy Hospital for Womenhttp://www.mercy.com.au/files/NRR6CEQQCO/Psychotropic%20drugs%20%20pregnancy%202nd%20Edn.pdfRoyal Women’s Hospital Drug Information Line Ph: 8345 3190Royal Women’s Hospital Drug Information Email: drug.information@thewomens.org.auClinician information: PsychotropicMedication in Pregnancy/LactationRoyal Women’s HospitalPregnancy and Breastfeeding Medicines GuideAvailable from Pharmacy DepartmentPh: 8345 3190E: rwh.pharmacy@thewomens.org.auTherapeutic Goods AdministrationClinician information: Pregnancy andBreastfeeding Medicines GuideClinician information: Prescribing Medicinesin Pregnancy. An Australian categorisation40

http://www.tga.gov.au/docs/pdf/medpreg.pdfof risk of drug use in pregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/HerbalpreparationsinpregnancyConsumer fact sheet: herbal preparations inpregnancyVaccinationsGeneralMeasles, mumps andrubellaVaricellaInfluenzaDiphtheria, tetanus,pertussisAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-specialrisk232Australian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measlesAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-mumpsAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-rubellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-varicellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-influenzaAustralian & State and Territory Governmentshttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/IMM123-cnt/$File/imm123-fs-2010.pdfAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-diphtheriaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-tetanusAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-pertussisClinician information: Vaccination of womenplanning pregnancy, pregnant orbreastfeeding women, and preterm infantsClinician information: MeaslesimmunisationClinician information: Mumps immunisationClinician information: Rubella immunisationClinician information: VaricellaimmunisationClinician information: InfluenzaimmunisationClinician fact sheet: influenza vaccination2010Clinician information: DiphtheriaimmunisationClinician information: Tetanus immunisationClinician information: PertussisimmunisationLifestyle (general pregnancy)Royal Women’s Hospitalhttp://www.thewomens.org.au/TakingcareofyourselfinearlypregnancyDepartment of Health and Ageinghttp://www.health.gov.au/internet/quitnow/publishing.nsf/Content/lifescriptsConsumer fact sheet: Taking care of yourselfin early pregnancy. Available in: English,Arabic, Chinese, Turkish and Vietnamese.Clinician information: Pregnancy Lifescripts:smoking, alcohol, nutritionFolateFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Fact%20Sheet%20-Clinician and consumer fact sheet:Mandatory folic acid fortification in41

%20Folic%20Acid%20(July%2009).pdfFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomen/folicacidfolateandpr4598.cfmFamily Planning Victoriahttp://www.fpv.org.au/2_9_4.htmlRoyal Women’s Hospitalhttp://www.thewomens.org.au/FolateinPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Folate_for_women?openAustraliaConsumer information: Folic Acid/FolateConsumer information: Folic acidClinical Practice Guideline: Folate inPregnancyConsumer fact sheet: Folate for WomenIodineFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Fact%20Sheet%20-%20Iodine%20(July%2009).pdfFood Standards Australia New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomen/iodineandpregnancy.cfmBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Iodine_explainedClinician and Consumer fact sheet:Mandatory iodine fortificationConsumer information: Iodine advice forpregnant womenConsumer fact sheet: Iodine explainedDiet, Nutrition and Food SafetyGeneralFood safetyDepartment of Health & Ageinghttp://www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/pregnant-womenRoyal Women’s Hospitalhttp://www.thewomens.org.au/HealthyeatingforpregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_diet?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/WeightgaininpregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/FoodsafetyduringpregnancyFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/consumerinformation/adviceforpregnantwomenFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/_srcfiles/Listeria.pdfFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/scienceandeducation/factsheets/facConsumer information: Healthy eatingguidelines for pregnant women. Includes:general dietary advice and information oniron, folate, iodine, morning sickness,indigestion, listeria, mercury and caffeine.Consumer fact sheet: Healthy eating forpregnancyConsumer fact sheet: Pregnancy and dietConsumer fact sheet: Weight gain inpregnancyConsumer fact sheet: Food safety inpregnancyConsumer information: Food safety advicefor pregnancy. Includes links to furtherinformation on folic acid, iodine, fish andmercury, listeria prevention, alcoholcaffeineConsumer brochure: Listeria and foodadvicefor people at riskClinician and consumer information: Listeriaand food- commonly asked questions42

tsheets2005/listeriacommonlyaske3115.cfmVegetarian and vegandietsVitamins and mineralsInfectionsToxoplasmosisParvovirusFood Standards Australia & New Zealandhttp://www.foodstandards.gov.au/_srcfiles/mercury_in_fish_brochure_lowres.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Mercury_in_fish?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/VegetarianeatingandpregnancyQueensland Healthhttp://www.health.qld.gov.au/nutrition/resources/antenatal_veget.pdfQueensland Healthhttp://www.health.qld.gov.au/nutrition/resources/antenatal_vegan.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/IronpregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminDandpregnancyVictorian Department of Healthhttp://www.health.vic.gov.au/chiefhealthofficer/publications/low_vitamin_d_med.htmRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminDAntenatalScreeningRoyal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs25.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminB12inPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Toxoplasmosis_reducing_the_risks?openAustralian Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/cdapubs-cdi-2000-cdi2403s-cdi24msa.htmVictorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/erythemaVictorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/erythema/erythema_pregnant_infoBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Slapped_face_disease?openConsumer brochure: Mercury in fishConsumer fact sheet: Mercury in fishConsumer fact sheet: Vegetarian eating andpregnancyConsumer information: Healthy eating forvegetarian pregnant and breastfeedingmothersConsumer information: Healthy eating forvegan pregnant and breastfeeding mothersConsumer fact sheet: Iron in pregnancyConsumer fact sheet: Vitamin D andpregnancyClinician information: Low Vitamin D inPregnancy- Key Messages for Doctors,Nurses and Allied HealthClinical practice guideline: Vitamin Dantenatal screeningClinician information: Vitamin and mineralSupplementation in pregnancyClinical Practice Guideline: Vitamin B12 inpregnancyConsumer fact sheet: Toxoplasmosisreducingthe riskClinician information: Parvovirus B19infection and its significance in pregnancyClinician information: Guidelines for thecontrol of infectious diseases -ParvovirusConsumer information: Slapped cheekinfection information for pregnant womenConsumer fact sheet: Slapped cheekinfection43

CytomegalovirusInfluenzaExerciseBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Cytomegalovirus_(cmv)Victorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/cmvRoyal Women’s Hospitalhttp://www.thewomens.org.au/PregnancyandfluBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_exercise?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_sport?openAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp119.cfmConsumer fact sheet: CytomegalovirusClinician information: CytomegalovirusConsumer fact sheet: Pregnancy and FluprecautionsConsumer fact sheet: Pregnancy andexerciseConsumer fact sheet: Pregnancy and sportConsumer information: exercise duringpregnancySubstance Use and CessationGeneralSmokingAlcoholDepartment of Health and Ageinghttp://www.health.gov.au/internet/quitnow/publishing.nsf/Content/lifescriptsQUIThttp://www.quit.org.au/article.asp?ContentID=pregnancyQUIThttp://www.quit.org.au/article.asp?ContentID=media_bkground_pregnancyQUIThttp://www.quit.org.au/browse.asp?ContainerID=pregnancy_nicotine_replacementBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_smoking?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/TobaccoThree Centreshttp://3centres.com.au/guidelines/provision-of-smoking-cessationinterventions-during-pregnancy/National Health and Medical Research Councilhttp://www.nhmrc.gov.au/publications/synopses/ds10syn.htmDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/aod_pregnancy/aod_pregnancy.htmlBetter Health ChannelClinician information: Pregnancy Lifescripts:smoking, alcohol, nutritionConsumer information: Smoking andpregnancyConsumer information: Common mythsabout smoking and pregnancyConsumer information: Pregnancy, quittingsmoking and nicotine replacement therapyConsumer information: Pregnancy andsmokingConsumer fact sheet: Tobacco in pregnancyClinician information: 3 Centre ConsensusGuidelines on Antenatal Care- Provision ofsmoking cessation interventions duringpregnancyClinician information: Australian Guidelinesto Reduce Health Risks from DrinkingAlcohol(p. 67 Guideline 4: Pregnancy andBreastfeeding)Consumer information: Alcohol, other drugsand pregnancy for women who arepregnant/considering pregnancyConsumer fact sheet: Fetal alcohol44

Drug UseDental HealthMental HealthAdult mental healthservices. Includingcrisis assessment andtreatment (CAT)teamsAntenatal andPostnatal depressionEmotional healthduring pregnancyhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Foetal_alcohol_syndrome?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/AlcoholNew South Wales Department of Healthhttp://www.health.nsw.gov.au/pubs/2006/pdf/ncg_druguse.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/AlcoholDrugsDuringPregnancyDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/aod_pregnancy/aod_pregnancy.htmlDrug info clearinghousehttp://www.druginfo.adf.org.au/druginfo/fact_sheets/cannabis_factsheets/cannabis_pregnancy.htmlBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_drugs?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Teeth_and_pregnancy?openVictorian Department of Healthhttp://www.health.vic.gov.au/mentalhealth/services/adult/index.htmBeyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload&fid=1279Post and Antenatal Depression Association (PANDA)http://www.panda.org.au/images/stories/PDFs/Antenatal_Depression.pdfAustralian Government Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-m-mangp-toc~mental-pubs-m-mangp-app~mental-pubs-mmangp-app-12Beyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=94.751&tmp=FileDownload&fid=1334syndromeConsumer fact sheet: Effects on pregnancy,breastfeeding and infant developmentClinician information: National clinicalguidelines for the management of drug useduring pregnancy, birth and the earlydevelopment years of the newbornConsumer fact sheets: Alcohol and drugsduring pregnancy. Includes alcohol,amphetamines, benzodiazepines,buprenorphine, cannabis, heroin and otheropiates, inhalants, methadone, tobaccoConsumer information: Alcohol, other drugsand pregnancy: for women who arepregnant/considering pregnancyConsumer information: Cannabis use inpregnancyConsumer fact sheet: Pregnancy and drugs.Includes over the counter and vitaminsConsumer fact sheet: Teeth and pregnancy24 hour psychiatric triage information,assessment and referral. Including crisisassessment and treatment (CAT) teams.Adult Mental Health Service Areas and LocalGovernment AreasClinician information: Antenatal andPostnatal Depression - A Guide tomanagement for health professionalsConsumer fact sheet: Antenatal DepressionClinician information: Edinburgh Perinataldepression scaleConsumer brochure: Emotional healthduring pregnancy and early parenthoodIntimate Partner ViolenceDomestic Violence and Incest Resource centreConsumer and clinician information:Includes referral to specialist support45

http://www.dvirc.org.au/Women’s Domestic Violence Crisis ServicePh: 9373 0123 or 1800 015 188Immigrant Women’s Domestic Violence Service8413 6800www.iwdvs.org.auVicHealthhttp://www.vichealth.vic.gov.au/en/Programs-and-Projects/Freedomfrom-violence/Intimate-Partner-Violence.aspxservices helpful pamphlets and websitesStatewide 24 hour crisis support and safeaccommodation (refuges) for women andtheir childrenConsumer information: Support to CALDwomen in their primary languageClinician information: ‘The Health Costs ofViolence’ VicHealth burden of diseasereport on intimate partner violenceFemale Genital Mutilation (FGM)FGMFamily andReproductive RightsEducation Program(FARREP)Royal Women’s Hospitalhttp://www.thewomens.org.au/uploads/downloads/HealthProfessionals/FGM/FGM_Health_Professionals_Fact_Sheet_2009.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/FemaleGenitalMutilationCuttingRoyal Women’s Hospitalhttp://www.thewomens.org.au/CaesareansectionissuesforwomenaffectedbyFGMRoyal Women’s Hospitalhttp://www.thewomens.org.au/FARREPClinician fact sheetClinical informationIncludes links to: FGM maternity clinicalpractice guideline, fact sheet for healthprofessionals, caesarean sectioninformation and links to other usefulresourcesClinician information: Caesarean sectioninformation for women affected by FGMConsumer and clinician information: Familyand Reproductive Rights Education Program(FARREP). Includes information in Amharic,Arabic, Somali, and TigrinyaCommon Discomforts of PregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/CopingWithCommonDiscomfortsOfPregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Carpal_tunnel_syndromeBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Restless_legs_syndromeBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Heartburn_is_a_form_of_indigestionBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Morning_sickness?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/NauseaandvomitinginpregnancymorniConsumer information: Coping withcommon discomforts of pregnancy.Includes: morning sickness, constipation,food cravings, heartburn tiredness,haemorrhoids cramps, backacheConsumer information: Carpal tunnelsyndromeConsumer information: Restless legsConsumer information:HeartburnConsumer information: Morning sicknessConsumer information: Nausea andvomiting in pregnancy. Available in: English,46

ngsicknessContinence Foundation of Australiahttp://www.continence.org.au/resources.php?keyword=&topic%5B%5D=Pregnancy&language=English&type=&submitted=SearchAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp115.cfmAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp169.cfmArabic, Chinese, Somali, Turkish andVietnamese.Consumer information: Pregnancy andincontinenceConsumer information: easing back pain inpregnancyConsumer information: skin conditionsduring pregnancySex During and After PregnancyFamily Planning Victoriahttp://www.fpv.org.au/3_9_1.htmlConsumer information: Sex during and afterpregnancyTravel During PregnancyBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_and_travel?openCentre for Disease Control and Preventionhttp://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-8/travelingwhile-pregnant.aspxAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp055.cfmConsumer fact sheet: Pregnancy and travelClinician information: travelling whilepregnant. Includes guidance on preparationfor travel, air travel, high altitudes, Malaria,immunisation and travel kit.Consumer information: travel duringpregnancyLabour and ChildbirthStages of labourPain relief optionsMedical interventionsCaesareanVaginal Birth AfterCaesarean (VBAC)Royal Women’s Hospitalhttp://www.thewomens.org.au/StagesOfLabourBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_stages_of_labour?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Childbirth_pain_relief_options?openAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp086.cfmBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Childbirth_medical_interventions?openBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Caesarean_section?openAmerican Congress of Obstetricians and Gynaecologistshttp://www.acog.org/publications/patient_education/bp006.cfmRoyal Women’s Hospitalhttp://www.thewomens.org.au/VBACVaginalBirthafterCaesareanAntenatalManagementConsumer fact sheet: Stages of labourConsumer fact sheet: Stages of labourConsumer fact sheet. Includes: Non drugpain relief, TENS, nitrous oxide, pethidine,epidural.Consumer information: pain relief duringchildbirth and labourConsumer fact sheet. Includes: Induction,augmentation, episiotomy, forceps delivery,vacuum deliver, caesarean sectionConsumer fact sheet: Caesarean sectionsConsumer information: caesarean birthClinician information: Clinical PracticeGuideline- VBAC antenatal management47

Royal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs38.pdfClinician information: planned vaginal birthafter caesarean sectionBaby Products and SafetyChild safety restraintsBreastfeedingNewborn CareVicRoadshttp://www.vicroads.vic.gov.au/Home/SafetyAndRules/SaferVehicles/ChildRestraints/Australian Breastfeeding Associationhttp://www.breastfeeding.asn.au/bfinfo/index.htmlWorld Health Organisationhttp://www.who.int/topics/breastfeeding/enRoyal Women’s Hospitalhttp://www.thewomens.org.au/BreastfeedingBestPracticeGuidelinesVictorian Department of Healthhttp://www.health.vic.gov.au/maternity/yourpregnancy/ongoingcare.htmRaising Children Networkhttp://raisingchildren.net.au/Consumer information on choosing thecorrect child safety restraintConsumer information on breastfeedingincluding support and adviceClinician and consumer information:BreastfeedingClinical practice guideline: Breastfeedingbest practiceConsumer information: Having a baby inVictoria - Ongoing care after you have yourbaby.Postnatal domiciliary careVictorian Child Health RecordMaternal and child health servicesSix-week postnatal check for motherand babyContraceptionSex after pregnancyBirth RegistrationInfant car restraintsCrying babySleep baby sleepImmunisation programSudden infant death syndromeWide range of patient and healthprofessional information about children andparenting48

ANTENATAL INVESTIGATIONSThe following section provides details of the routine and commonly considered antenatal tests offered anddiscussed. While there is considerable alignment between the four hospitals, routine antenatal investigations dovary. For information on prenatal tests see the ‘Testing in Pregnancy for Fetal Abnormalities’ section of theseGuidelines.Antenatal tests and prenatal tests (for fetal abnormalities) can be performed either in the community or at thehospital. If a test is performed in the community, a copy of the results (if available) should accompany the woman toher hospital visits.As a woman’s first hospital visit is often around 12-16 weeks,‘It is the primary responsibility of theconsidering the time-sensitive nature of some investigations and theprovider ordering a test or noting anytimely intervention for some conditions, it is preferable thatabnormal finding to ensureinvestigations are performed by a woman’s GP prior to her first hospitalappropriate follow-up, communicationvisit.and management. However, allIt is the primary responsibility of the provider ordering a test or notingproviders should check that follow-upany abnormal finding to ensure appropriate follow-up, communicationof any abnormal investigation hasand management. However, all providers should check that follow-up ofoccurred.’any abnormal investigation has occurred.TestInitial Routine InvestigationsNotesFBE(including MCV/MCH forhaemoglobinopathyscreen)Blood groupGeneral screen: Haemoglobin, platelets etc.Also a basic Thalassaemia/haemoglobinopathy screen by examination of the Mean Cell Volume(MCV) and Mean Cell Haemoglobin concentration (MCH)- Ferritin and haemoglobin electrophoresis is ordered if a low MCV/MCH is detected onFBE. Partner screening (FBE, Ferritin, Haemoglobin Electrophoresis) should also beconsidered at this stageCommunity providers should follow-up low Haemoglobin/MCV/MCH on FBE if this is performedin the communityIf a woman is Rhesus negative (Rh –ve) and has no Rh antibodies she should:Be offered routine anti-D at 28 and 34 weeks (this is undertaken at the hospital)In addition women should be referred to her closest maternity hospital’s emergency departmentin the event of a sensitising event.Sensitising events include:ectopic pregnancymiscarriagetermination of pregnancy (medical or surgical)following curettageinvasive prenatal diagnostic procedures (including chorionic villus sampling, amniocentesis andcordocentesis)49

abdominal trauma considered sufficient to cause fetomaternal haemorrhageAntibody screenUrinalysis/MSU M & CHepatitis B screening forcarrier statusSyphilis serologyRubella antibodiesHIV serologyexternal cephalic versionThe minimum period of gestation at which antibodies may be formed and anti-D should be given for asensitising event is unknown. The RANZCOG recommendation states that 6 weeks is a reasonableminimum period of gestation http://manualtransfusioncomau.ozstaging.com/Pregnancy-and-anti-D/Frequently-asked-questions/Anti-D-Clinical-FAQs.aspx#qa64For threatened miscarriage in the first trimester, no anti-D is required.This is recommended for every woman in every pregnancy as antibodies may develop over time, evenif she is Rhesus positiveUrine testing for asymptomatic bacteriuriaAll pregnant women should be offered screening for asymptomatic bacteriuria – 3 CentresIt is recommended that a midstream urine (MSU) sample be sent to microscopy, culture andsensitivity (Level III-2 evidence) – 3 CentresWhen asymptomatic bacteriuria is detected it should be treated to improve outcomes withrespect to pyelonephritis, preterm birth and low birth weight (Level 1 evidence) – 3 CentresAll Women should be offered a screening test for hepatitis B virus at their first antenatal visit (Level IVevidence) – 3 CentresAntenatal serological screening for syphilis should be offered to all pregnant women. (Level III-2 & IVevidence) – 3 CentresScreening for syphilis should be undertaken at the first antenatal visit, ideally prior to 16 week’sgestation. (Level IV evidence) – 3 CentresIf non-immune the hospital offers immunisation post deliveryAll pregnant women should be offered screening for HIV. (Level I evidence)Selective screening fails to identify a significant proportion of HIV positive women (consensusbackground) – 3 CentresInitial Investigations to ConsiderBased on the woman’s particular history and examinationConsider To Look For Common Reasons to Order NotesDatingEstimatedUnsure of datesOptimal timing 7 to 10 weeks so crownultrasounddate ofElective lower uterine caesarean sectionrump length can be measuredconfinementplanned and 12 week ultrasound not plannedFerritinIronVegetarian/veganOffered to all women at RWHdeficiencyLow MCV/anaemiaHepatitis CHepatitisHepatitis C testing should be offered toOffered to all women at MHW and SHserologycarrier statuspregnant women who believe that they are atincreased risk of infection or exposure. Current50

evidence suggests that the detection ofHepatitis C Virus (HCV) during pregnancy doesnot assist with long term management. Thereasons for testing are to:- Provide ongoing advice- Provide appropriate referral- Follow-up babies of infected mothersThe risk factors for HCV which should be consideredduring history taking are:High-Risk:- Injecting drug use (IDU) (~ 40% of infectedmothers)- A history of migration from a country witha high rate of endemic HCV (SouthernEuropean, African and Asia/Pacificcountries- A history of transfusion of blood productsprior to HCV screening in 1990- A period of incarceration (~67% of womenin Victorian prisons are HCV positive)Low-Risk:- Persons engaging in high-risk sexualactivity- Sexual partners of HCV positive individuals- Household contactIt is important to note that 40-50% of womeninfected with HCV have no identifiable risk factors.(Level IV evidence) – 3 CentresVitamin D levelVitamin DDark skinned and non-Caucasian womenOffered to all women at NH and SHdeficiencyVeiled womenWomen who have low sunlight exposurePap testScreening forIf dueDo not use cytobrushcervicalcancerPap smears can generally beundertaken during pregnancy toat least 28 weeks gestationVaricellaVaricellaNo known immunisationIf non-immune, women need toantibodiesimmunityNo clear history of varicellaarrange immunisation post delivery51

with their GP (two doses required)Chlamydia (urineChlamydiaWomen 4kgPolycystic ovarian syndromeGlycosuriaStrong family history of diabetesHaemoglobin AbnormalMCV< 80electrophoresis/ haemoglobin ORFerritins including β MCH

Haemoglobin electrophoresis canyield a false negative for BThalassaemia if a woman is irondeficient. Therefore, if a womanhas iron deficiency anaemia andThalassaemia cannot be excluded,partner screening isrecommended. If the partnertesting is normal, no furtherinvestigation is requiredDNA analysisAlphaIf MCV and MCH low in the presence of normalPartner screening (FBE, ferritin,ThalassaemiaFerritin and no abnormal haemoglobinhaemoglobin electrophoresis) shoulddetected on electrophoresisalso be considered at this stageIf results of FBE/ferritin/Haemoglobinelectrophoresis suggest alpha thalassaemiaCystic FibrosisFor thoseThose with a family history of CF or whoseIdeally before pregnancy(CF)with a familyrelative carries a known CF mutation (testing isDiagnostic testing for those with atestinghistoryfree in Victoria)known family historyThose whose partner is affected or is a knownBlood test which identifiescarrier of CF (testing is free in Victoria)particular gene alterationsThis is consistent with Royal Australian CollegeOptions are:of General Practitioners “Guidelines for1. Refer for investigation by doctor.preventive activities in general practice (7 thProvide a description of familyedition)”.member (affected or carrier)relationship, name and date ofbirth. Also provide detail of thetype of mutation if known or,2. Refer early in pregnancy toGenetic Services for investigationPartner testing should also beundertaken at the same timeCystic FibrosisFor those atThose patients who are from northernIdeally before pregnancy(CF) populationincreased riskEuropean, Ashkenazi Jewish background orPopulation carrier screening is:carrier screeningdue towho are consanguineous (ie. cousins married- Available to everyonepopulationto each other) can access Cystic Fibrosis carrierincluding people with nogrouptesting through the population carrierknown family or partnerscreening program (no Medicare rebatehistoryavailable).- Buccal swab test identifiesonly common CFTR genealterations. Overall coverage isapproximately 80% ,but this53

Fragile X testingWomen with a family history of Fragile Xsyndrome. These women can access Fragile Xscreening through their GP or a geneticcounselling service. A Medicare rebate isavailable.Women with a family history of intellectualdisability, developmental delay and/or autismof unknown cause. These women can bereferred to a genetic counselling service forconsideration of Fragile X carrier testing.Women with no family history of Fragile Xsyndrome who wish to pursue carrier testingfor reproductive planning purposes.varies for different populationgroups- Out of pocket expenses areincurred (no Medicare rebateavailable)- Testing kits available fromGenetic Health Services andcan be accessed by individualwomen or GP clinicsAll tests must be requested by aGPIdeally before pregnancyBlood test can be ordered by GP,but for women who are alreadypregnant, consider early referralto Genetic ServicesFor patients with a family orpersonal history, a Medicarerebate is available for part oftesting. If further testing isrequired, out of pocket expensesmay be incurredWhen ordering investigations for genetic conditions (e.g.Thalassaemia, Cystic Fibrosis, Fragile X syndrome) for a pregnantwoman and her partner, indicate on the referral form that thewoman is pregnant (and her partner details if this is partnertesting) so that the result and analysis can be expedited.‘When ordering investigations for geneticconditions (e.g. Thalassaemia, Cystic Fibrosis,Fragile X syndrome) for a pregnant woman andher partner, indicate on the referral form thatthe woman is pregnant (and her partner detailsif this is partner testing) so that the result andanalysis can be expedited .’54

Second Trimester InvestigationsTest When NotesFBE 26-30 weeks RWH, MHW and NH ordered by hospital staffSH ordered by SMCAAntibody screen 26-30 weeks RWH, MHW and NH ordered by hospital staffSH ordered by SMCAScreening for GestationalDiabetes(Glucose challenge test (GCT) orglucose tolerance test (GTT))24-28 weeksIf women agree to screening, it shouldbe carried out between 24 to 28 weeksgestation (consensus opinion) –3CentresRWH, MHW and NH ordered by hospital staffSH ordered by SMCA (as a GCT, this can eitherbe a 50g or 75g glucose load)At MHW GTT is routineAt RWH, SH and NH a GTT is undertaken if highriskand GCT is undertaken for all other womenGCT does not require fastingGTT requires 10-12 hour fastingThird Trimester InvestigationsTest When NotesScreening for Group BStreptococcus (GBS)35-37 weeks Performed at the hospital. Women areoffered opportunity to take swabthemselvesFBE/ferritin 36 weeks Not done routinely.Consider if previous low haemoglobin orferritin or clinical indicationResourcesFor further resources about testing in pregnancy for fetal abnormalities including Down syndrome screening anddiagnostic tests refer to the TESTING IN PREGNANCY FOR FETAL ABNORMALITIES section of these Guidelines.Routine InvestigationsTests andInvestigations generalThalassaemia andotherhaemoglobinopathies3 Centres Collaborationhttp://3centres.com.au/consumers/Royal Australian And New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs3.pdfGenetic Health Services Victoriahttp://www.genetichealthvic.net.au/sections/Patients/?docid=68dcb73b-9469-4db6-9064-9a9300d353aeNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/12%20-%20Haemoglobanopathies%20WEB.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/ThalassaemiaandAbnormalHaemoglobinsinPregnancyConsumer information: A guide to testsand investigations in uncomplicatedpregnanciesClinician information: pre-pregnancycounselling & antenatal screening testsConsumer information: ThalassaemiascreeningClinician information: Genetics in FamilyMedicine - The Australian Handbook forGeneral Practitioners:Haemoglobinopathies chapterClinical practice guideline: Thalassaemiaand abnormal haemoglobins inpregnancy. Covers Thalassaemia55

screening, referring for testing andcounselling, investigations and treatmentand specific considerationsAntibody ScreenRhesus negative bloodgroups and Anti-DBacteriuriaHepatitis BSyphilisRubellaWorld Health Organisation (WHO)http://www.who.int/genomics/public/Maphaemoglobin.pdfThalassaemia Australiahttp://www.thalassaemia.org.au/Royal Australian and New Zealand College of Obstetricians andGynaecologists & Australian and New Zealand Society of BloodTransfusionhttp://www.ranzcog.edu.au/womenshealth/pdfs/ANZSBT-antenatalguidelines.pdfRed Cross Blood Servicehttp://manualtransfusioncomau.ozstaging.com/Pregnancy-and-Anti-D.aspxAustralian Red Cross Blood Servicehttp://manualtransfusioncomau.ozstaging.com/admin/file/content2/c7/You%20and%20Your%20Baby%20brochure.pdfAustralian Red Cross Blood Servicehttp://manualtransfusioncomau.ozstaging.com/admin/file/content2/c7/HDN%20brochure.pdfNational Blood Authorityhttp://www.nba.gov.au/pubs/pdf/glines-anti-d.pdfRoyal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs6.pdfThree Centreshttp://3centres.com.au/guidelines/antenatal-screening-forasymptomatic-bacteriuria/Three Centreshttp://3centres.com.au/guidelines/antenatal-screening-for-hepatitis-bvirus-hbv/Three Centreshttp://3centres.com.au/guidelines/antenatal-screening-for-syphilis/Victorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/rubellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Global distribution of haemoglobindisordersConsumer fact sheets on: BetaThalassaemia, Alpha Thalassaemia,Haemoglobin E, Sickle Cell Anaemia,family planning.Available in: Arabic, Cantonese, Greek,English, Italian, Mandarin, Nuer,Sinhalese, Tamil and VietnameseGuidelines for blood grouping andantibody screening in the antenatal andperinatal settingTransfusion medicine manual- Pregnancyand Anti-D. Includes: Guidelines for theuse of Rh Immunoglobulin, Anti-D testingin pregnancy, frequently asked questionsand educational support materialConsumer information. You and yourbaby: important information for Rh (D)negative womenConsumer information: Importantinformation for Rh (D) Negative Women:Prevention of Haemolytic Disease of theNewborn. For women who experienceearly fetal lossClinician information: Guidelines on theprophylacticuse of Rh D immunoglobulin(anti-D) in obstetricsClinician information: guidelines for theuse of Rh D Immunoglobulin (anti-D)inobstetrics in AustraliaClinician information:3 Centre ConsensusGuidelines on Antenatal Care- AntenatalScreening for Asymptomatic BacteriuriaClinician information:3 Centre ConsensusGuidelines on Antenatal Care- Antenatalscreening for Hepatitis B virus (HBV)Clinician information:3 Centre ConsensusGuidelines on Antenatal Care- antenatalscreening for SyphilisClinician information: guidelines for thecontrol of infectious diseases –RubellaClinician information: Rubella56

HumanImmunodeficiencyVirus (HIV)Group BStreptococcus (GBS)Handbook-rubellaBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/RubellaThree Centreshttp://3centres.com.au/guidelines/antenatal-screening-for-humanimmunodeficiency-virus-hiv/Three Centreshttp://3centres.com.au/guidelines/prevention-of-early-onset-group-bstreptococcal-disease-gbs/Royal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs19.pdfimmunisationConsumer fact sheet: RubellaClinician information:3 Centre ConsensusGuidelines on Antenatal Care- antenatalscreening for Human ImmunodeficiencyVirus (HIV)Clinician information:3 Centre ConsensusGuidelines on Antenatal Care- preventionof Early Onset Group B StreptococcalDisease (EOGBS)Clinician information: screening andtreatment for Group B Streptococcus inpregnancyInvestigations to ConsiderFerritinHepatitis CVitamin DPap TestVaricella antibodiesChlamydiaRoyal Women’s Hospitalhttp://www.thewomens.org.au/IronpregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/IronDeficiencyinPregnancyThree Centreshttp://3centres.com.au/guidelines/antenatal-screening-for-hepatitis-cvirus-hcv/Better Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Hepatitis_C_the-factsVictorian Department of Healthhttp://www.health.vic.gov.au/chiefhealthofficer/publications/low_vitamin_d_med.htmRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminDandpregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminDAntenatalScreeningPap Screen Victoriahttp://www.papscreen.org.auBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ChickenpoxAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-varicellaBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ChlamydiaVictorian Department of HealthConsumer fact sheet: iron in pregnancyClinician information: Iron deficiency inpregnancy. Includes treatment andinformation on iron supplementsClinician information:3 Centre ConsensusGuidelines on Antenatal Care- antenataltesting for Hepatitis C virus (HBV)Consumer fact sheet: Hepatitis CClinician information: Low Vitamin D inPregnancy- Key Messages for Doctors,Nurses and Allied HealthConsumer fact sheet: vitamin D andpregnancyClinical practice guideline: vitamin Dantenatal screeningConsumer and clinician information onpap screeningConsumer fact sheet: ChickenpoxClinician information: VaricellaimmunisationConsumer fact sheet: ChlamydiaClinician and consumer information:57

Thyroid functionGestational DiabetesGeneticshttp://www.health.vic.gov.au/ideas/diseases/chlam_factsMelbourne Sexual Health Centrehttp://www.mshc.org.au/gpassist/emChlamydiaem/ManagementofChlamydiainPregnancy/tabid/92/Default.aspxMelbourne Sexual Health Centrehttp://www.mshc.org.au/gpassist/Chlamydia/tabid/70/Default.aspxMelbourne Sexual Health Centrehttp://www.mshc.org.au/Portals/1/chlamydia_a4.pdfThe Endocrine Society (USA)http://www.endo-society.org/guidelines/Current-Clinical-Practice-Guidelines.cfmThe Australian Thyroid Foundationhttp://www.thyroidfoundation.com.au/information/information.htmlThree Centreshttp://3centres.com.au/guidelines/screening-for-gestational-diabetesmellitus-gdm/Royal Women’s Hospitalhttp://www.thewomens.org.au/DiabetesMellitusManagementofGestationalDiabetesDiabetes Australiahttp://www.diabetesvic.org.au/LinkClick.aspx?fileticket=hwxCO7vLWuc%3d&tabid=164National Institute for Health and Clinical Excellence (UK)http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdfAustralasian Diabetes in Pregnancy Societyhttp://www.adips.org/images/stories/documents/adips_pregdm_guidelines.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Gestational_diabetes?openRoyal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs7.pdfWorld Health Organisation (WHO)http://www.who.int/genomics/public/geneticdiseases/en/index2.html#tsNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/your_health/egenetics/practitioners/gems.htmGenetic Health Services VictoriaChlamydia- the factsClinician information: management ofChlamydia in pregnancyClinician information: includes letter forpartners, and DHS notificationConsumer fact sheet: ChlamydiaClinical practice guideline: managementof thyroid dysfunction during pregnancyand postpartum.Consumer information: thyroidconditions and iodine deficiencyClinician information:3 Centre ConsensusGuidelines on Antenatal Care- screeningfor Gestational Diabetes MellitusGestational Diabetes Clinical PracticeGuidelineGestational Diabetes Patient Fact sheetClinical guidelines: Management ofDiabetes and it’s complications from preconceptionto the postnatal periodConsensus guidelines for themanagement of patients with of type 1and type 2 diabetes in relation topregnancyPatient information: GestationalDiabetesClinician information: diagnosis ofGestational Diabetes MellitusWHO monogenic diseases information.Includes:ThalassaemiaSickle cell anaemiaHaemophiliaCystic FibrosisTay Sachs diseaseFragile X syndromeHuntington's diseaseClinician information: Genetics in FamilyMedicine - The Australian Handbook forGeneral PractitionersConsumer and health professional58

Thalassaemia andotherhaemoglobinopathiesCystic Fibrosis testingFragile X GeneticScreeningTay Sachswww.genetichealthvic.net.auGenetic Health Services Victoriahttp://www.genetichealthvic.net.au/sections/Patients/?docid=68dcb73b-9469-4db6-9064-9a9300d353aeNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/12%20-%20Haemoglobanopathies%20WEB.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/ThalassaemiaandAbnormalHaemoglobinsinPregnancyWorld Health Organisation (WHO)http://www.who.int/genomics/public/Maphaemoglobin.pdfThalassaemia Australiahttp://www.thalassaemia.org.au/Genetic Health Services Victoriahttp://www.cfscreening.com.au/Genetic Health Services Victoriahttp://www.cfscreening.com.au/Documents/CF_brochure.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/fact_sheets/09%20-%20Cystic%20fibrosis%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/11%20-%20Fragile%20X%20syndrome%20WEB.pdfFragile X Association of Australiahttp://www.fragilex.org.au/http://www.genetichealthvic.net.au/Documents/PDF/TaySachsBrochure.pdfinformationConsumer information: ThalassaemiascreeningClinician information: Genetics in FamilyMedicine - The Australian Handbook forGeneral Practitioners:Haemoglobinopathies chapterClinical practice guideline: Thalassaemiaand abnormal haemoglobins inpregnancy. Covers Thalassaemiascreening, referring for testing andcounselling, investigations and treatmentand specific considerationsGlobal distribution of haemoglobindisordersConsumer fact sheets on: BetaThalassaemia, Alpha Thalassaemia,Haemoglobin E, Sickle Cell Anaemia,family planning.Available in: Arabic, Cantonese, Greek,English, Italian, Mandarin, Nuer,Sinhalese, Tamil and VietnameseConsumer and clinician information:Cystic fibrosis carrier screening program(population carrier screening)Consumer brochure: Cystic Fibrosiscarrier testing (population carrierscreening)Clinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Cystic FibrosisConsumer fact sheet from Genetics inFamily Medicine: The AustralianHandbook for General Practitioners.Cystic FibrosisClinician information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Fragile X syndromeConsumer information: Fragile XConsumer and clinician information:Carrier Testing for Tay Sachs and relatedconditions. For people with AshkenaziJewish ancestry59

TESTING IN PREGNANCY FOR FETAL ABNORMALITIESMost babies are born healthy, but about 4% are born with a birthdefect that may require medical care. There are a number of‘It is important that if a woman or herscreening and diagnostic tests that are available to determine the risk partner has or is a carrier of a geneticof, or to diagnose, certain congenital problems in the fetus. Howevercondition, or there has previously been atests only have the capacity to screen for and diagnose somecongenital abnormality/geneticcongenital problems.condition in another child, the woman isIt is important that if a woman or her partner has or is a carrier of agenetic condition, or there has previously been a congenitalreferred for genetic counselling as earlyabnormality/genetic condition in another child, the woman isas possible, preferably pre-pregnancy.referred for genetic counselling as early as possible, preferably prepregnancy.This is because it can take considerable time to find the time to find the underlying geneThis is because it can take considerableunderlying gene mutations and to determine whether or not amutations and to determine whether orprenatal test is availiable.not a prenatal test is available.’If a test is performed in the community, a copy of the results (ifavailable) should accompany the woman to her first hospital visit.Screening versus Diagnostic TestsScreening tests can be performed to determine who may be at‘If a test is performed in the community,increased risk of having a baby with Down syndrome or some otherchromosome abnormalities and neural tube defects. Low-riska copy of the results (if available) shouldscreening test results do not exclude an abnormality, rather they accompany the woman to her firstindicate that the likelihood of a problem existing is low. If a screening hospital visit.’test gives a comparatively high likelihood of a problem existing, adiagnostic test is offered.Diagnostic tests can diagnose Down syndrome, most chromosomal abnormalities and certain genetic conditions andstructural abnormalities.Early in pregnancy, all women should receive appropriate written information concerning available screening(including potential risks and benefits, the difference between screening and diagnostic testing and possible costs towomen). (Level II & IV evidence) – 3 CentresCounsellingCommunity providers are encouraged to offer early advice and counselling around all tests but this is especiallypertinent for screening and diagnostic tests for fetal abnormalities.All parents should have the opportunity to consider these tests. SMCA should discuss the available routine tests, thenature of the test, the disease/s being tested for, the possibility of false positive and negative results, and theadvantages and disadvantages of testing, taking into account maternal age, medical, family and pregnancy history.Wherever possible, it is important that women are offered written material in their language and have knowledge ofthe local services and their cost.60

Some reasons genetic counselling may be required or recommended are:If a woman wishes to discuss screening and testing furtherIf a woman has a high-risk screening resultIf a woman or her partner has a genetic condition or a family history of a genetic condition that they wishto find out more about (including testing and the possible implications for pregnancy)Couples with a high risk of having a child with a genetic condition; for discussion about prenatal testingIf a healthcare provider requires secondary adviceFurther information and counselling for women, their families, SMCA and other healthcare providers is availablefrom the Genetic Services at the hospitals and Genetic Health Services Victoria.Genetic Services Contact DetailsRWH MHW SH NH Genetic HealthServices VictoriaPh: 8345 2180 Ph: 8458 4250 Ph: 8345 0346 NH does not provide in-house Ph: 8341 6201genetic services. SMCA shouldFax: 8345 2179 Fax: 8458 4254 contact Genetic Services at RWH Fax: 8341 6390for information and adviceMaternal age is an important component of risk calculations in allscreening tests.A low-risk test result does not exclude an abnormality, rather itindicates the low likelihood of a problem existing.Screening tests do not diagnose a condition.Down Syndrome and other ChromosomalAbnormalitiesA woman’s likelihood of having a fetus with Down syndrome andsome other chromosomal abnormalities (such as Edwards (T18),Patau (T13)) increases with the age of the maternal eggs.All women should be offered tests for Down syndrome.The offer of screening for Down syndrome should be made available toall pregnant women, irrespective of age. (Level III & IV evidence)- 3CentresAn 18-20 week fetal morphology ultrasound is a poor screen for Downsyndrome.‘Maternal age is an important componentof risk calculations in all screening testsA low-risk test result does not exclude anabnormality, rather it indicates the lowlikelihood of a problem existing.Screening tests do not diagnose acondition.’‘All women should be offered tests forDown syndrome.’‘An 18-20 week fetal morphologyultrasound is a poor screen for Downsyndrome.’61

Risk by Age of Down Syndrome and other Chromosomal AbnormalitiesMaternal age at delivery*Chance of having a live born babywith Down Syndrome**chance of having a live-born baby witha chromosomal abnormality20-24 years 1 in 1411 1 in 50625 years 1 in 1383 1 in 47626 years 1 in 1187 1 in 47627 years 1 in 1235 1 in 45528 years 1 in 1147 1 in 43529 years 1 in 1002 1 in 41730 years 1 in 959 1 in 38531 years 1 in 837 1 in 38532 years 1 in 695 1 in 32333 years 1 in 589 1 in 28634 years 1 in 430 1 in 24435 years 1 in 338 1 in 17936 years 1 in 259 1 in 14937 years 1in 201 1 in 12438 years 1 in 162 1 in 10539 years 1 in 113 1 in 8140 years 1 in 84 1 in 6441 years 1 in 69 1 in 4942 years 1 in 52 1 in 3943 years 1 in 37 1 in 3144 years 1 in 28 1 in 2445 years 1 in 32 1 in 19* Morris JK, Mutton DE, and Alberman E (2002). Revised estimates of the maternal age specific live birth prevalence ofDown syndrome. J Med Screen, 9, 2-6.** Hook EB (1981) Rates of chromosomal abnormalities. Obs Gyn 58 282-285‘If a women decides toundertake screening forDown syndrome, only do oneof Combined First TrimesterScreening or SecondTrimester Maternal SerumScreening.’‘Combined First TrimesterScreening is not routinelyavailable via the hospitals andneeds to be ordered by the GP.’‘Ideally Combined First TrimesterScreening blood test component isdone in the 10 th week and ultrasounddone in the 12 th week.’62

Screening Tests for Down SyndromeScreeningTest Timing Tests for Detection Rates Costs Results NotesCombinedBlood testScreens for:Down syndromeBlood testResults areOffered to allFirstcomponent:Downdetection ratecomponent:generallywomenTrimesterbetween 9Syndrome(sensitivity) isMedicareavailableOnly do one ofScreeningweeks and 0(Trisomy90.5%rebate iswithin 7Combined Firstdays and 1321)false positiveavailabledays of theTrimester Screeningweeks and 6Edwardsrate is 3.9%however thelaboratoryor Second Trimesterdayssyndrome‘Increased risk’woman isreceivingMaternal Serum(Trisomythreshold is ≥1likely to havethe nuchalScreening18)in 300some out oftranslucencCombined Firstpockety screeningTrimester ScreeningCalculates riskEdwards syndromeexpensesreportis not routinelyUltrasoundby measuringdetection rateUltrasoundavailable via thecomponent:maternal free(sensitivity) iscomponent:hospitals and needsbetween 11beta human67%Medicareto be ordered by theweeks and 3chorionicFalse positiverebate isGPdays and 13gonadotrophinrate is 0.4%availableIdeally Combinedweeks and 6days(free ß-hCG)and pregnancy‘Increased risk’threshold is ≥1however thewoman isFirst TrimesterScreening blood testassociatedin 175likely to havecomponent is doneplasma proteinsome out ofin the 10 th week andA (PAPP-A) andpocketultrasound done incombining withexpensesthe 12 th weekmaternal ageIndividualCombined Firstand nuchalultrasoundTrimester Screeningtranslucencyservices needrequiresmeasurementto becoordination of thecontactedblood testregardingcomponent andcostsultrasoundcomponent.Second15 weeks (canScreens for:Down syndrome:Medicare rebate isResults areUltrasound resultsTrimesterbe done 14-Downdetection rateavailable, howevergenerallyneed to be faxed byMaternal20 weeks)syndrome(sensitivity) isthe woman mayavailablethe ultrasoundSerum(Trisomy85%have some out ofwithin 7service to theScreening21)false positivepocket expensesdays of thematernal serumEdwardsrate is 6.8%laboratoryscreening laboratorysyndrome‘Increased risk’receivingin order for a result63

(Trisomythreshold ≥1 inthe bloodto be generated18)250sampleIn view of this it isNeuralstrongly suggestedtubeEdwards syndrome:women aredefectsdetection ratereviewed by the(sensitivity) isperson who hasCalculates risk44%ordered the test 1by measuringFalse positiveweek after thematernal Alpharate is 0.5%ultrasound to ensurefetoprotein‘Increased risk’a result has been(AFP), free betathreshold ≥1 ingeneratedhuman200For women enrolledchorionicin Shared MaternitygonadotrophinNeural tube defect:Care, SMCA should(free ß-hCG),detection rateindicate that theunconjugated(sensitivity) iswoman is a publicestriol (uE3)93%patient to reduceand Inhibin A.False positiveout of pocket costsrate is 3%for the womanMaternal Serum Screening Laboratory Contact DetailsGenetic Health Services VictoriaPh: 8341 6356Fax: 8341 6389‘Combined First Trimester Screening requirescoordination of the blood test componentand ultrasound component. Ultrasoundresults need to be faxed by the ultrasoundservice to the maternal serum screeninglaboratory in order for a result to begenerated. In view of this it is stronglysuggested women are reviewed by theperson who has ordered the test 1 weekafter the ultrasound to ensure a result hasbeen generated.’64

metabolism diagnosableprenatally by chorionicvillus sampling oramniocentesis, but anexact biochemicaldiagnosis is needed inthe index case beforesuch a prenatal test canbe consideredFISH analysiscostsapproximately$175 and thereis no MedicarerebatePatientsrequesting apreliminaryresult can alsochoose FISHanalysis to getthe quickerresult.available up toapproximately18 weeks)Arranging CVS and AmniocentesisFor follow-up of a high-risk screening test for Down syndrome or Edwards syndrome (Trisomy 18) a woman maychoose to have a diagnostic test (chorionic villus sampling or amniocentesis) or have further counselling (andorganise testing as decided) via genetic services. At RWH, MHW and SH, SMCA are able to arrange a diagnostic testdirectly with a hospital’s ultrasound service as long as the woman has been adequately counselled (includingadvantages and disadvantages of diagnostic testing, the risks involved and implications of possible tests results). Forwomen enrolled in pregnancy care at NH, this should be discussed with a senior obstetrician at the hospital. Awoman’s Rh status should be noted on the referral letter to ultrasound for CVS or amniocentesis.Ultrasound Services Contact Details(to organise CVS/amniocentesis after adequate counselling has been provided)RHW MHW SH NHPh: 8345 2250 Ph: 8458 4300/4328 Ph: 8345 1664 Ph: 8405 8000 (switchboard) and page DrAndrew Ngu. If unavailable then pageObstetric RegistrarFax: 8345 2259 Fax: 8458 4241 Fax: 8345 1665Referrals for amniocentesis and CVS can also be made via genetics services if discussion and further counselling isrequired or if a woman is unsure about whether to undertake diagnostic testing.Genetic Services Contact DetailsRWH MHW SH NH Genetic HealthServices VictoriaPh: 8345 2180 Ph: 8458 4250 Ph: 8345 0346 NH does not provide in-house Ph: 8341 6201Fax: 8345 2179 Fax: 8458 4254genetic services. SMCA shouldcontact Genetic Services at RWHfor information and adviceFax: 8341 639066

Fetal Morphology Ultrasound (18-20 weeks)Test Timing Indication Looks For NotesFetalMorphologyUltrasoundRoutinelyperformedat 18-22weeksAll pregnantwomen shouldbe offered afetalmorphologyultrasoundCan detect somestructuralabnormalitiesincluding someneural tube, cardiac,gastrointestinal,limb, and centralnervous systemdefectsConfirms theaccuracy of theexpected date ofconfinementLooks at the locationof the placentaMay also commenton cervical length(normal length>2.5cm), ovaries andany uterineabnormalitiesIf the placenta is found to be lowlying,a repeat ultrasound should beundertaken at about 32-34 weeks toidentify a placenta praeviaFetal morphology ultrasound is apoor screening test for DownSyndrome, with a sensitivity of onlyabout 50%Due to the limited capacity of thehospitals ultrasound services,preference is given to women withhigh-risk pregnancies. Therefore, acommunity ultrasound may need tobe organised by a woman’s SMCAand a copy of results shouldaccompany the woman to herhospital visitCosts may vary between communityultrasound providers and womenmay incur a cost for this serviceIf an abnormality is found onultrasound in the community,follow-up or advice can be arrangedby contacting the Genetics Service(MHW, RWH, SH) or FetalManagement Unit (RWH)/PerinatalMedicine Unit (MHW) or the SharedCare Coordinator who can facilitatethis. This advice should be sought assoon as an abnormal result isreported67

Access to Fetal Morphology UltrasoundAt NH routine fetal morphology ultrasounds are routinely arranged‘At NH routine fetal morphologyby the hospital Doctor at the first hospital visit.ultrasounds are routinely arranged by theAt RWH, MHW and SH, routine fetal morphology ultrasounds arelimited at the hospitals’ own ultrasound departments. Therefore, athospital Doctor at the first hospital visit.these hospitals, a community ultrasound may need to be organised At RWH, MHW and SH, routine fetalby a woman’s GP. Where a woman does not have a fetal morphology morphology ultrasounds are limited at theultrasound organised either in the community or at the hospital by hospitals’ own ultrasound departments.her first hospital visit, she will be advised to present to her GP toTherefore, at these hospitals, aorganise a community fetal morphology ultrasound referral.community ultrasound may need to beAs with all investigations, the referring practitioner is responsible fororganised by a woman’s GP.’reviewing the result. A copy of results should accompany the womanto her next hospital visit.If advice is required please contact the hospital (see section ‘Management and Referral of Abnormal Findings’).Ultrasound Department Contact Details:For Fetal Morphology UltrasoundRHW MHW SH NHHealth Care ImagingExternal health providers are GPs andThe capacity to perform fetal morphology All women have thisnot able to directly access obstetricians areultrasounds at the hospital is very limited ultrasound organisedfetal morphology ultrasound able to organiseby hospital Doctor atbookingsultrasounds byExternal health providers are not able totheir first hospital visitsending or faxing adirectly access fetal morphologyDepartment ultrasounds are written referral,ultrasound bookingsallocated according to however resourcesDepartment ultrasounds are allocatedclinical and social need. This are limited andaccording to clinical and social need. Thisis based on the information early booking isis based on the information provided inprovided in the GPs initial required.the GPs initial referral for pregnancy carereferral for pregnancy careConsequently, many women will beadvised to present to their GP for referralfor a community ultrasoundPh: 8345 2250 Ph: 8458 4300or 8458 4238Ph: 8345 1664 Ph: 9408 2222Fax: 8345 2259 Fax: 8458 4241 Fax: 8345 1665 Fax: 9408 229968

“Soft Signs” on UltrasoundRecent advances in ultrasound have led to the discovery of a growing number of minor abnormalities or “soft”markers such as choroid plexus cysts. When multiple anomalies are present then karyotyping of the fetus withamniocentesis should be discussed. The role of sonographically isolated “soft” markers on the other hand can becontroversial, especially in younger women who have a low background risk of chromosomal abnormality. Whensuch a “soft” marker is detected, the first priority is to exclude any associated abnormalities with a detailedanatomical survey of the mid-trimester fetus. At the hospitals this can be performed by specialist ObstetricianGynaecologist Sonologist who will also direct any further investigations and follow-up. A Genetic Counselling Serviceis also available to provide the parents with information about the individual risks for that pregnancy, based onmaternal age, other screening tests and the specific ultrasound finding or combination of findings.ResourcesPrenatal screening and testingPrenatalVictorian Clinical Genetics Services Pathologyscreening and http://www.vcgspathology.com.au/downloads/mss/Prenatal_Testing.ptesting- general dfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/sections/03%20-%20Testing%20and%20pregnancy%20WEB.pdfNational Health and Medical Research Councilhttp://www.nhmrc.gov.au/_files_nhmrc/file/your_health/egenetics/practioners/gems/fact_sheets/03%20-%20Testing%20if%20you%20are%20pregnant%20WEB.pdfCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs17.pdf3 Centreshttp://3centres.com.au/guidelines/prenatal-screening-for-downsyndrome/Royal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs35.pdfRoyal Australian and New Zealand College of Obstetricians andGynaecologists (RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs4.pdfConsumer brochure: Prenatal TestingDuring Pregnancy (ultrasound, maternalserum screening, chorionic villus sampling,amniocentesis)Genetics in Family Medicine: The AustralianHandbook for General Practitioners.Chapter 3: Testing and pregnancyConsumer information. Genetics in FamilyMedicine: The Australian Handbook forGeneral Practitioners. Testing if you arepregnant. Includes screening and testing.Consumer fact sheet: Prenatal testing- anoverviewClinician information:3 Centre ConsensusGuidelines on Antenatal Care- PrenatalScreening for Down’s SyndromeClinician information: prenatal screeningfor fetal abnormalitiesClinician information: prenatal screeningtests for trisomy 21 (Down syndrome),trisomy 18 (Edwards syndrome) and neuraltube defectsCombined FirstTrimesterScreeningVictorian Clinical Genetics Services Pathologyhttp://www.vcgspathology.com.au/downloads/CombinedFirstTrimesterScreening.pdfVictorian Clinical Genetics Services Pathologyhttp://www.vcgspathology.com.au/sections/MaternalSerumScreening/?docid=51a81179-f5d3-41ee-8892-992e00efe87dConsumer brochure and pathology requestform: Combined First Trimester ScreeningLinks to consumer brochure and pathologyrequest form: Combined First TrimesterScreening. Available in: Arabic, Chinese,English, Somali, Turkish and Vietnamese69

Second TrimesterMaternal SerumScreeningSecond Trimester Maternal Serum Screening patient information and pathology request forms are available by callingVictorian Clinical Genetic Services PathologyPh: 8341 6303 or 8341 6357Amniocentesis &CVSVictorian Clinical Genetics Services Pathologyhttp://www.vcgspathology.com.au/downloads/YourPregnancy-YourChoice.pdfCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs17c.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/AmniocentesisRoyal Women’s Hospitalhttp://www.thewomens.org.au/ChorionicVillusSamplingCVSConsumer brochure on Second TrimesterMaternal Serum ScreeningConsumer fact sheet: Amniocentesis & CVSConsumer information: amniocentesisCVS patient informationUltrasoundRoyal Women’s Hospitalhttp://www.thewomens.org.au/UltrasoundBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pregnancy_tests_ultrasoundConsumer fact sheet: ultrasound. Availablein: Arabic, Chinese, Croation, English,Khmer, Serbian, Tigrinian, Turkish andVietnameseConsumer information: UltrasoundCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs17a.pdfConsumer information: prenatal ultrasoundChromosomal abnormalitiesTrisomyDisorders(Down syndrome,Edwardsyndrome, Patausyndrome)Neural tube defectsTerminationsBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Birth_defects_trisomy_disordersBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Down_syndrome_explained?openCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs28.pdfCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factSheets/FS30.pdfCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs29.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/BHCV2/bhcArticles.nsf/pages/Birth_defects_central_nervous_system?OpenDocumentCentre for Genetics Education (NSW Health)http://www.genetics.com.au/pdf/factsheets/fs59.pdfVictorian Legislationhttp://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/f932b66241ecf1b7ca256e92000e23be/BB2C8223617EB6A8CA2574EA001C130A/$FILE/08-58a.pdfConsumer fact sheet: Trisomy disordersConsumer fact sheet: Down syndromeConsumer fact sheet: Down syndromeConsumer fact sheet: Edwards syndromeConsumer fact sheet: Patau syndromeConsumer fact sheet: Birth defects -central nervous systemIncludes information on spina bifida,anencephaly and encephaloceleConsumer fact sheet: Neural tube defectsspinabifida and anencephalyAbortion Law Reform Act 200870

MANAGEMENT AND REFERRAL OF ABNORMAL FINDINGSIt is the primary responsibility of the provider ordering a test or noting any abnormal finding to ensure appropriatefollow-up, communication and management. However, all providers should check that follow-up of any incompleteor abnormal investigation results or findings have occurred.Community and hospital providers need to clearly document, date and sign, the following information in the handheld pregnancy record:investigations ordered‘It is the primary responsibility of theresults of investigationsprovider ordering a test or noting anyabnormal findingsabnormal finding to ensureaction takenappropriate follow-up, communicationand management. However, allAll providers must record routine examination findings in the hand heldproviders should check that follow-uppregnancy record. This includes:blood pressure readingof any incomplete or abnormalmeasurement of fundal height in centimetresinvestigation results or findings havefetal movements from 20 weeksoccurred.fetal auscultation from 20 weeksCommunity and hospital providerschecking fetal presentation from 30 weeksneed to clearly document, date andleg oedema if presentsign, the following information in theconsider urine testing for proteinuriahand held pregnancy record:Referral of Problemsinvestigations orderedAll providers of Shared Maternity Care have a responsibility toresults of investigationsappropriately assess, document and respond to problems that ariseabnormal findingsduring a woman’s pregnancy. In general, the community provideraction taken’should consider referring the woman for hospital assessment at theEmergency Department or Pregnancy Assessment Service or foradditional clinical consultation if the pregnancy deviates from normal.This should be based on individual clinical assessment by the SMCA.The Shared Maternity Care CoordinatorThe Shared Maternity Care Coordinator can assist in obtaining results, informing SMCA of management that hastaken place and facilitating assistance for SMCA. This is appropriate for non-urgent situations.The Shared Maternity Care Coordinator role varies between health services and, depending on the hospital, theShared Maternity Care Coordinator may be able to assist with the following:organising extra appointments for additional clinical consultation with obstetric Doctors, allied health,psychiatry, genetics and physiciansnon-urgent reassessment of community ultrasound and other pathology results by the relevant department71

Shared Maternity Care Coordinator Contact DetailsRWH MHW SH NHPh: 8345 2129 Ph: 8458 4120 Ph: 8345 1616Ph: 8405 8772Mob: 0466 130 457Fax: 8345 2130 Fax: 8458 4205 Fax: 8345 1691 Fax: 8405 8766Email:sharedcare@thewomens.org.auEmail:sharedcare@mercy.com.auEmail:maternitysharedcare@wh.org.auEmail:maternitysharedcare@nh.org.auFor more immediate clinical advice or review, refer to the Emergency Department, Pregnancy Day AssessmentService or contact the Registrar of the team/day via the hospital switchboard.Emergency Department Assessment (24 hours/day)Each participating hospital’s Emergency Department is available 24 hours a day for assessment of urgent antenatalor postnatal problems. Referral by phone or letter is expected and appreciated. SMCA will receive aletter/communication in the hand held pregnancy record within 48 hours of the woman’s attendance at a hospitalEmergency Department.Referral to the hospital Emergency Department is recommended if the woman has:• first trimester bleeding or pain that cannot be appropriately diagnosed and managed in the community• threatened preterm labour (≤37 weeks)• undiagnosed abdominal pain• preterm rupture of membranes• antepartum haemorrhage• unusual migraines, visual disturbances• seizures• problems usually seen in Pregnancy Assessment Services, out of hours• a requirement for anti-D immunoglobulin following a sensitising eventThe above list is not exhaustive.Emergency Department Contact DetailsTelephone advice is also available 24 hours a day for SMCA, GPs and womenRWH MHW SH NHPh: 8345 3636or 8345 3637Ph: 8458 4000or 8458 4005Ph: 8345 1596(For GP/SMCA use only)Ph: 8405 2610(For GP/SMCA use only)Fax: 8345 3645 Fax: 8458 4205 Fax: 8345 1607 Fax: 8405 894472

Pregnancy Assessment Services (business hours)Each hospital has a Pregnancy Assessment Services that provides maternal and‘Each hospital has a Pregnancyfetal assessment including:blood pressure monitoring and pathologyAssessment Services thatcardiotocograph (CTG)provides maternal and fetalultrasound. May be to check:assessment. Hours varyo amniotic fluid index (AFI) for assessment of placental function between services but areo systolic/diastolic ratio (SDR) for assessment of possible growth generally within business hours.’restrictiono fetal presentation if non-cephalic presentation at ≥ 36 weeksexternal cephalic version (ECV) for management of breech presentation at ≥36 weeksobstetric assessmentarrangement of ultrasound for fetal growth and wellbeing if indicatedReferral to the Pregnancy Assessment Service is recommended if the woman has:hypertension (when systolic BP is 140 mmHg and/or diastolic BP is 90 mmHg or there is an incremental riseof ≥ 30 mmHg systolic or 15 mmHg diastolic – 3 Centres)fundal height unusually large or small (2 cm more or less than for dates or significant deviation from growthpattern)intractable vomitingdecrease in fetal movementsjaundice or severe pruritisnon-cephalic presentation ≥ 36 weeks gestationThe above list is not exhaustive and this service does not replace referral to the hospital Emergency Department forurgent problems. SMCA are encouraged to phone the service to discuss with a senior Midwife any concerns and howthey are best managed. The outcome of each visit will be documented in a woman’s hand held pregnancy record.Pregnancy Assessment Services Contact DetailsHours vary between services but are generally within business hoursOutside of these times, women should be referred to the Emergency DepartmentRWHPregnancy Day CareCentreMHWMercy Perinatal CentreSHPregnancy DayStay UnitNHPregnancy Assessment and ReviewDay StayPh: 8345 2184 Ph: 8458 4267 Ph: 8345 1029 Ph: 8405 8205Hours ofMon-Fri: 9am-5pmMon-Fri: 9am-5.30 pmMon-Fri: 8am-5pmMon, Tues, Thurs: 8am-4pmoperationSat: 8am-12pmSat: 8am-4.30 pm (byappointment only on Sat)How toPh: 8405 8000 (switchboard) andreferSMCA are advised to refer via phoneask for Labour Ward Registrar73

The Registrar (24 hours/day)The Registrar of the team caring for the woman, or the on-call Obstetric Registrar, can be contacted directly todiscuss urgent or complex clinical issues. To contact the Registrar, phone the hospital switchboard and ask for theObstetric Registrar. Alternatively, for non-urgent queries during business hours, SMCA can contact the SharedMaternity Care Coordinator.Hospital Switchboard Contact DetailsRWH MHW SH NHPh: 8345 2000 Ph: 8458 4444 Ph: 8345 6666 Ph: 8405 8000Abnormal Results: Test for Fetal AbnormalitiesManagement of screening tests (e.g. Combined First Trimester Screening, Second Trimester Maternal SerumScreening) requires great vigilance from both community and hospital providers. It is important that women arecounselled and the results are documented, communicated and followed up adequately. The Combined FirstTrimester Screen requires coordination of the blood component and ultrasound component of the investigation. Togenerate a result, ultrasound findings need to be faxed by the ultrasound service to Genetic Health ServicesVictoria’s maternal serum screening laboratory. In the event of any concerns or abnormal results, Genetics Servicesat the hospital can be contacted to facilitate further adviceIt is strongly suggested that women are reviewed by the person who has ordered the Combined First TrimesterScreen one week after the ultrasound to ensure a result has beengenerated.‘It is strongly suggested that womenFor follow-up of a high-risk screening test for Down syndrome or are reviewed by the person who hasEdwards syndrome (Trisomy 18) a woman may choose to have a ordered the Combined First Trimesterdiagnostic test (chorionic villus sampling (CVS) or amniocentesis) and Screen one week after the ultrasoundor have further counselling via genetic services. At RWH, MHW and SH,to ensure a result has been generated’SMCA are able to arrange a diagnostic test directly with a hospital’sultrasound service as long as the woman has been adequatelycounselled. For women enrolled in pregnancy care at NH, this should be discussed with a senior obstetrician at thehospital. A woman’s Rh status should be noted on the referral letter to ultrasound for CVS or amniocentesis.For follow up of a high risk result for neural tube defects a tertiary centre ultrasound is required for diagnosis.Tertiary ultrasounds can be facilitated by contacting the Shared Maternity Care Coordinator, the Obstetric Registraror the ultrasound department.For more information, refer to the TESTING IN PREGNANCY FOR FETAL ABNORMALITIES section of these Guidelines.74

Ultrasound Services Contact Details(to organise CVS/amniocentesis or tertiary ultrasound after adequate counselling has been provided)RHW MHW SH NHPh: 8345 2250 Ph: 8458 4300/4328 Ph: 8345 1664 Ph: 8405 8000 (switchboard) and page DrAndrew Ngu. If unavailable then page ObstetricRegistrarFax: 8345 2259 Fax: 8458 4241 Fax: 8345 1665Genetics ServicesGenetics services are available at RWH and MHW with a limited service at SH. NH does not provide in-house geneticsservices. For women enrolled in pregnancy care at NH, SMCA should contact Genetic Services at RWH. These servicescan be contacted during business hours to facilitate advice, counselling, referral or management of abnormal testresults. At SH, the Shared Maternity Care Coordinator can assist in organising a genetic counselling appointment.SMCA will be informed regarding the outcome of a woman’s appointment.Genetic Health Services Victoria also has genetic counselling/advice service for both families and healthprofessionals.Genetic Services Contact DetailsRWH MHW SH NH Genetic HealthServices VictoriaPh: 8345 2180 Ph: 8458 4250 Ph: 8345 NH does not provide in-house genetic Ph: 8341 62010346services. SMCA should contact GeneticFax: 8345 2179 Fax: 8458 4254 Services at RWH for information and advice Fax: 8341 6390Abnormality on UltrasoundIn non-urgent situations, appropriate follow-up for an abnormality found on an ultrasound organised by a SMCA canbe facilitated by the Shared Maternity Care Coordinator. This includes when a SMCA is unsure of the interpretationof findings on an ultrasound they have ordered, if a tertiary ultrasound is required or if further counselling orconsultation is required.Please contact the Shared Maternity Care Coordinator with the appropriate patient and ultrasound information tofacilitate follow-up. The Registrar, Genetics Service or hospital ultrasound department can also be contacted foradvice (contact details above).75

High-Risk PregnanciesAs tertiary maternity centres, RWH and MHW have units that manage pregnancies involving significant fetalabnormalities or women with complicated pregnancies due to high-risk conditions (eg. significant heart disease). If afetal abnormality has been detected on ultrasound, these units can be contacted for advice.High-Risk Pregnancy Units Contact DetailsRWHMHWFetal Management UnitPerinatal Medicine UnitPh: 8345 2158 Ph: 8458 4248Fax: 8345 2139 Fax: 8458 4504Termination of PregnancyWhen termination of pregnancy is to be considered for any reason, referral should be made as early as possible,even if the diagnosis is uncertain and/or the woman is not yet sure of her decision. This allows for completing anydiagnostic work-up and specialist advice as soon as possible, so that if termination of pregnancy is the eventualdecision it may be done as early as possible, to maximise treatment options. When antenatal diagnosis is indicated,some women may prefer CVS to amniocentesis, so that an earlier result may be obtained and abortion undertakenearlier if warranted.RWH, SH and NH provide termination services; they are not available at‘The Abortion Law Reform Act 2008MHW. MHW provides the full range of screening and investigations forprovides that termination offetal abnormality, but refer women elsewhere for advice andpregnancy may be performed after 24counselling if they wish to consider pregnancy termination for anyreason.weeks under certain conditions,including the need for a secondIn the public system, surgical abortion and abortion for “psychosocial” opinion and the woman’sindications is available only prior to 18 weeks gestation. Abortion maycircumstances to be taken intobe performed after this gestation and even after 24 weeks if a fetalaccount. The Act also describes aabnormality or other serious condition is diagnosed; in these casesDoctor's statutory duties relating toreferral should be made via the relevant hospital’s antenatal or geneticsreferral in instances where they mayservice.hold a conscientious objection.’The Abortion Law Reform Act 2008 provides that termination ofpregnancy may be performed after 24 weeks under certain conditions,including the need for a second opinion and the woman’s circumstances to be taken into account. The Act alsodescribes a Doctor's statutory duties relating to referral in instances where they may hold a conscientious objection.76

Other Abnormal FindingsGestational DiabetesIf a Glucose Challenge Test (GCT) result is positive, a Glucose ToleranceTest (GTT) is usually required to diagnose Gestational Diabetes. If a SMCAdiagnoses Gestational Diabetes, the Shared Maternity Care Coordinatorneeds to be informed in order to make appropriate hospitalappointments with Diabetes Educators and an Obstetrician. If GestationalDiabetes develops, Shared Maternity Care is usually ceased (unlessindividual arrangement is made between SMCA and the hospital).‘If a Glucose Challenge Test (GCT)result is positive, a Glucose ToleranceTest (GTT) is usually required todiagnose Gestational Diabetes’.Group B Streptococcus (GBS)If the GBS swab result is positive and the woman is asymptomatic, antenatal treatment is not required and thehospital will administer intravenous antibiotic treatment (usually Penicillin) at the onset of labour. SMCA shouldremind women with a positive GBS screen result to present to hospital early in labour.Infectious Diseases in PregnancyEach hospital has access to infectious disease physician advice. For urgent assessment of an infectious illness orexposure to an infectious disease, women should be referred to the Emergency Department or the Registrar of theday should be contacted for advice. If a non-urgent infectious disease appointment is required, contact the SharedMaternity Care Coordinator to arrange.Varicella exposure and infectionFetal effects: “Varicella infection during the first trimester of pregnancy confers a small risk of miscarriage. Maternalinfection before 20 weeks may rarely result in the fetal varicella zoster syndrome, with the highest risk (2%)occurring at 13–20 weeks. Clinical manifestations include growth retardation, cutaneous scarring, limb hypoplasiaand cortical atrophy of the brain. Intrauterine infection can also result in herpes zoster in infancy. This occurs in lessthan 2% of infants. The highest risk is associated with infection in late pregnancy. In the third trimester, maternalvaricella may precipitate the onset of premature labour. Severe maternal varicella and pneumonia at any stage ofpregnancy can cause fetal death. ” (1)Maternal effects: Pregnant women who are not immune are at high-risk of severe disease and complicationsSMCA should refer susceptible pregnant women who have been exposed to varicella during pregnancy for specialistobstetric advice by referring the women to the Emergency Department. Women may be offered zoster immuneglobulin (VZIG) and antivirals (famciclovir, valaciclovir or aciclovir), especially where delivery is imminent. Wherevaricella develops in pregnancy, early medical review within 24 hours of rash onset is indicated via the EmergencyDepartment.77

Human Parvovirus B19 (Slapped Cheek) exposure and infectionParvovirus infection in the first 20 weeks of pregnancy can cause fetal anaemia with hydrops fetalis. Fetal deathoccurs in less than ten per cent of these cases. (2)“Pregnant women who have been exposed to parvovirus infection should be offered serological testing forparvovirus-specific IgG to determine their susceptibility. The diagnosis of parvovirus infection is usually made,serologically, by demonstration of IgG seroconversion and/or the presence of parvovirus IgM. IgM is usuallydetectable within 1-3 weeks of exposure and lasts for2-3 months.” (3) Repeat testing in 10-14 days may be required.If diagnosed with Parvovirus, women should be referred for prompt ultrasound and obstetric review. This may befacilitated by the Shared Maternity Care Coordinator. If further management is required, including serial ultrasound,this will be arranged by the hospital and Shared Maternity Care would usually be ceased (unless an individualarrangement is made between SMCA and the hospital).References:1 The blue book: guidelines for the control of infectious diseases Communicable Diseases Section, Victorian Department of HumanServices, 2005. P. 252 The blue book: guidelines for the control of infectious diseases Communicable Diseases Section, Victorian Department of HumanServices, 2005. P. 533 Gilbert, GL. Parvovirus B19 infection and its significance in pregnancy. Communicable Diseases Intelligence. 24, 2000.ResourcesThe resources section below includes clinical practice guidelines for a range of other abnormal findings duringpregnancy such as red cell antibodies in pregnancy, iron deficiency and vitamin D deficiency.Medicines inPregnancyMercy Hospital for Womenhttp://www.mercy.com.au/files/NRR6CEQQCO/Psychotropic%20drugs%20%20pregnancy%202nd%20Edn.pdfPsychotropic Medication inPregnancy/LactationRoyal Women’s HospitalPregnancy and Breastfeeding Medicines GuideAvailable from Pharmacy DepartmentPh: 9345 3190E: rwh.pharmacy@thewomens.org.auNote: In 2011, a Psychotropic Medicines resources website and phone line will be introduced at RWH as a statewide serviceGestationalDiabetesTherapeutic Goods Administration http://www.tga.gov.au/docs/pdf/medpreg.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/DiabetesMellitusManagementofGestationalDiabetesClinician information: Prescribingmedicines in pregnancy. AnAustralian categorisation of riskof drug use in pregnancyGestational Diabetes ClinicalPractice GuidelineDiabetes Australiahttp://www.diabetesvic.org.au/LinkClick.aspx?fileticket=hwxCO7vLWuc%3d&tabid=164Gestational Diabetes Patient Factsheet78

Group BStreptococcus (GBS)VaricellaNational Institute for Health and Clinical Excellence (UK)http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdfAustralasian Diabetes in Pregnancy Societyhttp://www.adips.org/images/stories/documents/adips_pregdm_guidelines.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Gestational_diabetes?openRoyal Australian and New Zealand College of Obstetricians and Gynaecologists(RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs7.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/GBSColonisationAntenatalIntrapartumStrategiestoPreventEarlyOnsetNeonatalSepsisRoyal Australian and New Zealand College of Obstetricians and Gynaecologists(RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs19.pdfVictorian Department of Healthhttp://www.health.vic.gov.au/ideas/bluebook/chicken_poxBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Chickenpox?openClinical guidelines: Managementof Diabetes and it’s complicationsfrom pre-conception to thepostnatal periodConsensus guidelines for themanagement of patients with oftype 1 and type 2 diabetes inrelation to pregnancyPatient information: GestationalDiabetesClinician information: diagnosis ofGestational Diabetes MellitusGBS Clinical Practice GuidelineClinician information: screeningand treatment for Group BStreptococcus in pregnancyGuidelines for the control ofinfectious diseases (Blue Book)-VaricellaConsumer information: VaricellaParvovirusAustralian Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2000-cdi2403s-cdi24msa.htmVictorian Department of Health and Ageinghttp://www.health.vic.gov.au/ideas/bluebook/erythemaClinician information: ParvovirusB19 infection and its significancein pregnancyGuidelines for the control ofinfectious diseases (Blue Book)-ParvovirusVictorian Department of Health and Ageinghttp://www.health.vic.gov.au/ideas/bluebook/erythema/erythema_pregnant_infoBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Slapped_face_disease?openConsumer information: Slappedcheek infection information sheetfor pregnant womenConsumer fact sheet: Slappedcheek infectionRed Cellantibodiesand Rh Dimmunoglobulin (anti-D)Royal Women’s Hospitalhttp://www.thewomens.org.au/RedCellAntibodyTestingInPregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/RhDImmunoglobulininObstetricsRed Cross Blood ServiceClinician information: A guide tored cell antibody screeningGuides the administration of anti-D to Rh D negative pregnantwomen including antenataladministration for sensitisingevents and antenatal prophylaxisTransfusion medicine manual-Pregnancy and Anti-D. Includes:79

http://manualtransfusioncomau.ozstaging.com/Pregnancy-and-Anti-D.aspxAustralian Red Cross Blood Servicehttp://manualtransfusioncomau.ozstaging.com/admin/file/content2/c7/You%20and%20Your%20Baby%20brochure.pdfAustralian Red Cross Blood Servicehttp://manualtransfusioncomau.ozstaging.com/admin/file/content2/c7/HDN%20brochure.pdfNational Blood Authorityhttp://www.nba.gov.au/pubs/pdf/glines-anti-d.pdfGuidelines for the use of RhImmunoglobulin, Anti-D testing inpregnancy, frequently askedquestions and educationalsupport materialConsumer information. You andyour baby: important informationfor Rh (D) negative womenConsumer information:Important information for Rh (D)Negative Women: Prevention ofHaemolytic Disease of theNewborn. For women whoexperience early fetal lossClinician information: Guidelineson the prophylacticuse of Rh D immunoglobulin(anti-D) in obstetricsIrondeficiencyVitamin B12Vitamin DTerminationsRoyal Australian and New Zealand College of Obstetricians and Gynaecologists(RANZCOG)http://www.ranzcog.edu.au/publications/statements/C-obs6.pdfRoyal Women’s Hospitalhttp://www.thewomens.org.au/IronDeficiencyinPregnancyRoyal Women’s Hospital http://www.thewomens.org.au/IronpregnancyRoyal Women’s Hospitalhttp://www.thewomens.org.au/VitaminB12inPregnancyVictorian Department of Healthhttp://www.health.vic.gov.au/chiefhealthofficer/publications/low_vitamin_d_med.htmVitamin D - antenatal screeninghttp://www.thewomens.org.au/VitaminDAntenatalScreeningRoyal Women’s Hospital http://www.thewomens.org.au/VitaminDandpregnancyVictorian Legislationhttp://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/f932b66241ecf1b7ca256e92000e23be/BB2C8223617EB6A8CA2574EA001C130A/$FILE/08-58a.pdfClinician information: guidelinesfor the use of Rh DImmunoglobulin (anti-D)inobstetrics in AustraliaClinical Practice Guideline:Information on when to treat andsupplementation informationConsumer fact sheet: Iron inpregnancyClinical Practice Guideline:Includes when to check VitaminB12 levels and algorithm formanagement of low orindeterminate vitamin B12 levelsClinician information: LowVitamin D in Pregnancy- KeyMessages for Doctors, Nursesand Allied HealthInformation on Vitamin Ddeficiency, screening andtreatmentConsumer fact sheet: Vitamin Dand pregnancyAbortion Law Reform Act 200880

MENTAL HEALTH AND WELLBEINGFor mental health issues, there are a number of pathways and services that can be accessed to support SMCA andwomen depending on urgency. For women who require psychiatric care during pregnancy (for example, women withbipolar disorder, schizophrenia, severe depression or currently taking antipsychotic medication or mood stabilisers),referral pre-pregnancy or early in pregnancy is recommended, noting current and past psychiatric history.Adult mental health services operate a range of services, both urgent and non-urgent, including Crisis Assessmentand Treatment (CAT) Teams and Primary Mental Health Teams. Most services are delivered on an area basis,depending on where a patient lives.Crisis Assessment and Treatment (CAT) Teams (urgent)CAT teams operate 24 hours a day and provide urgent community-basedassessment and short-term treatment interventions to people in psychiatriccrisis. CAT services have a key role in deciding the most appropriate treatmentoption and in screening all potential inpatient admissions.CAT teams are a component of adult mental health services and can byaccessed by anyone (contact details below). CAT teams are also attached tomost Emergency Departments.Primary Mental Health Teams (non urgent)In non urgent situations, Primary Mental Health Teams provide consultationfor women (including psychiatric assessment, feedback and development of atreatment plan) and advice to primary health services such as GPs andcommunity health centres. They do not provide case management. PrimaryMental Health Services are a component of adult mental health services(contact details on following page).‘Adult mental health servicesoperate a range of services, bothurgent and non-urgent, includingCrisis Assessment and Treatment(CAT) Teams and Primary MentalHealth Teams. CAT teams operate24 hours a day and provide urgentcommunity-based assessment andshort-term treatment interventionsto people in psychiatric crisis.’81

Mental HealthServiceLocal GovernmentAreasAdult Mental Health Service Areas and Local Government Areas24 hour psychiatric triage information, assessment and referralIncludes CAT Teams and Primary Mental Health TeamsPh:WebsiteNorthernWhittleseaDarebinhttp://www.health.vic.gov.au/mentalhealth/services/adult/northern-a.htmNorth WestMid WestHumeMorelandMeltonBrimbank1300 874 243(1300 TRIAGE)http://www.health.vic.gov.au/mentalhealth/services/adult/northwest-a.htmhttp://www.health.vic.gov.au/mentalhealth/services/adult/midwest-a.htmInner WestMoonee ValleyMelbournehttp://www.health.vic.gov.au/mentalhealth/services/adult/inwest-a.htmInner Urban EastSouth WestNorth EastYarraBoroondaraWyndhamHobsons BayMaribyrnongNillumbikBanyule1300 558 862 http://www.health.vic.gov.au/mentalhealth/services/adult/inurbaneasta.htm1300 657 259 http://www.health.vic.gov.au/mentalhealth/services/adult/southwest-a.htm1300 859 789 http://www.health.vic.gov.au/mentalhealth/services/adult/northeast-a.htmThis table does not include all adult mental health service areas in Victoria. For more services, access Victoria’s adult specialist mentalhealth services website which includes maps of each region: http://www.health.vic.gov.au/mentalhealth/services/adult/index.htmInpatient Psychiatric ServicesShould a woman require inpatient admission for a psychiatric illness during pregnancy, this is usually arranged atother hospitals (e.g. Melbourne Health, Austin Health, St Vincent’s Health and Werribee Mercy Hospital) by thereferring hospitals’ psychiatric teams or crisis assessment and treatment (CAT) teams. Please note: there areinpatient beds onsite at NH however they are managed by Melbourne Health. Similarly, inpatient beds at SH aremanaged by Mid West Mental Health Service.Hospital Mental Health Services (non-urgent)RWH and MHW have mental health services that can assess and manage women undertaking pregnancy care atthose hospitals in non-urgent situations. To access these:The Shared Maternity Care Coordinator can facilitate an appointment for non-urgent psychiatricconsultation for women enrolled in Shared Maternity Care.For advice during business hours, GPs and SMCA are encouraged to contact the psychiatric team via thehospital switchboard or the relevant hospital psychiatric service directly (contact details below)82

Mental Health/Psychiatry Contact DetailsRWH MHW SH NHPh: 8345 2000 (switchboard)Ph: 8458 4444While psychiatric servicesWhile psychiatric servicesand ask for the(switchboard) and ask forexist at SH, they are usuallyexist at NH, they are usuallyPsychiatric Consultationthe Psychiatry Registraronly accessible for inpatientonly accessible for inpatientLiaison NurseOrliaison consultationsliaison consultationsOrContact Perinatal MentalPsychiatry RegistrarHealthFor urgent care orFor urgent care orPh: 8458 4843assessment contact CATassessment contact CATteamteamReferring a woman directly to a private provider (psychiatrist or psychologist) is also an option that SMCA mayconsider when caring for a pregnant woman with mental health issues.In the postnatal period both public and private mother and baby services and early parenting centres provide clinicaland support services for parents experiencing difficulties (including mental health problems). Where there areconcerns about the wellbeing of a child or family, Child FIRST is the referral point for family services in Victoria.Please see the POSTNATAL CARE section of these Guidelines for more information and contact details.Alcohol and Drug ServicesEach hospital has services to support women with alcohol and drug issues during pregnancy and postpartum and toprovide advice to GPs and SMCA. They work closely with the hospital’s social work and mental health services.Alcohol and Drug Service Contact DetailsRWH MHW SH NHWomen’s Alcohol & DrugTransitions ClinicMaternity Outreach andSMCA are advised toServicePh: 8458 4100 (GPSupport Service Clinicdiscuss management ofPh: 8345 3931Hotline)Ph: 8345 1727individual cases withFax: 9344 2719OrFax 8345 1691the hospital obstetricemail:Ph: 8458 4201team.wads@thewomens.org.au(coordinating midwife)This can be done byWomen are able to self refer toFax: 8458 4206contacting the Sharedthis serviceWomen are able to selfMaternity Carerefer to this serviceCoordinator.Intimate Partner ViolenceSadly, intimate partner violence is responsible for more ill-health and premature death in Victorian women underthe age of 45 than any other of the well-known preventable risk factors, including high blood pressure, obesity andsmoking. Findings from VicHealth’s 2004 study “The Health Costs of Violence: Measuring the burden of diseasecaused by intimate partner violence” demonstrate the seriousness and prevalence of intimate partner violence.83

Intimate partner violence has wide ranging and persistent effects on women’s physical and mental health andcontributes 8.8% to the total disease burden in Victorian women aged 15 to 44. Direct health consequences forwomen exposed to violence include depression, anxiety and phobias, suicide attempts, chronic pain syndromes,psychosomatic disorders, physical injury, gastrointestinal disorders, irritable bowel syndrome and a variety ofreproductive consequences. The influence of the abuse can persist long after the abuse has stopped and the moresevere it is, the greater its impact on a woman’s physical and mental health.One in five Australian women report being subjected to violence atsome stage in their adult lives, increasing their risk of mental healthproblems, behavioural and learning difficulties. The risk is higher inpregnant women and in the period following the birth of a child. Youngwomen who have been exposed to this type of violence are more likelyto have an unplanned pregnancy, a termination or a miscarriage. Theyare slower to make contact with medical services for antenatal carethan women who are not exposed to violence and their babies aremore likely to have a problem diagnosed after birth. In addition, it isestimated that one in four Victorian children has witnessed intimatepartner violence, increasing their risk of mental health problems,behavioural and learning difficulties. (7)‘One in five Australian women reportbeing subjected to violence at somestage in their adult lives, increasing theirrisk of mental health problems,behavioural and learning difficulties. Therisk is higher in pregnancy women and inthe period following the birth of a child.’Intimate Partner Violence Crisis Service Contact DetailsWomen’s Domestic Violence Crisis ServicePh: 9373 0123 or 1800 015 188Statewide 24 hour crisis support and safeaccommodation (refuges) for women and their childrenImmigrant Women’s Domestic Violence ServicePh: 8413 6800Support to women from culturally and linguisticallydiverse (CALD) backgrounds in their primary languageMentalHealthResourcesBeyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload&fid=1279Beyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=94.751&tmp=FileDownload&fid=1334Post and Antenatal Depression Association (PANDA)http://www.panda.org.au/images/stories/PDFs/Antenatal_Depression.pdfAustralian Government Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/mentalpubs-m-mangp-toc~mental-pubs-m-mangp-app~mental-pubs-m-mangpapp-12Victorian Department of Healthhttp://www.health.vic.gov.au/mentalhealth/services/adult/index.htmAntenatal and Postnatal Depression - AGuide to management for healthprofessionalsEmotional Health During Pregnancy andEarly Parenthood bookletConsumer fact sheet: Antenatal DepressionEdinburgh Perinatal depression scaleAdult Mental Health Service Areas and LocalGovernment Areas.24 hour psychiatric triage information,assessment and referral (including CATteams)84

Medicines inPregnancyMercy Hospital for Womenhttp://www.mercy.com.au/files/NRR6CEQQCO/Psychotropic%20drugs%20%20pregnancy%202nd%20Edn.pdfRoyal Women’s HospitalPregnancy and Breastfeeding Medicines GuideAvailable from Pharmacy DepartmentPh: 9345 3190E: rwh.pharmacy@thewomens.org.auPsychotropic Medication inPregnancy/LactationNote: In 2011, a Psychotropic Medicines resources website and phone line will be introduced at RWH as a statewide serviceTherapeutic Goods Administrationhttp://www.tga.gov.au/docs/pdf/medpreg.pdfClinician information: Prescribing medicinesin pregnancy. An Australian categorisation ofrisk of drug use in pregnancy85

POSTNATAL CAREImmediate Postnatal CareThe average hospital stay after the birth of a baby is 1-2 days for a vaginal birth and 3 days for a caesarean section. Ahospital discharge summary is sent to the SMCA and nominated GP within 48 hours of discharge. In the case of afetal or neonatal death or significant complications or problems, the GP and SMCA will be contacted by the Registraror Consultant.Hospitals should ensure that consistent information is given to women (regarding care after hospital stay) and thatshared care providers are included in planning (Level IV evidence) – 3 CentresImmediate postnatal care is undertaken at the hospital. This includes:- physical assessment of mother and baby- wound/perineal/breast care- emotional wellbeing and parenting- supporting parents in caring for their baby- breastfeeding/infant feeding: initiation and support- contraception education- routine newborn screening test for Hypothyroidism, PKU, Cystic Fibrosis, some metabolic disorders(Guthrie test)- routine newborn Hearing ScreeningNewborn Screening Test (Guthrie Test)The newborn screening test is carried out on a blood sample obtained by aheel prick and placed on pre-printed filter paper (Guthrie cards). All tests ‘Newborn screening identifies babiesare processed at Genetic Health Services Victoria’s Newborn Screening with an increased risk of havingLaboratory located at The Royal Children’s Hospital. Newborn screeningHypothyroidism, PKU, Cystic Fibrosis,identifies babies with an increased risk of having Hypothyroidism, PKU,and over 20 additional metabolicCystic Fibrosis, and over 20 additional metabolic disorders.disorders.’The newborn screening test is performed when the baby is between 48 and72 hours of age. More false positives and negatives occur when thescreening is done before 48 hours. As the period of hospitalisation provides the only certain opportunity for testing,if a baby is discharged before 48 hours, the newborn screening test is carried out before the baby leaves hospital,and then again in the community as soon after 48 hours as possible (by the domiciliary midwife). The hospital ofbirth is responsible for ensuring all babies have the newborn screening test. This includes babies who are transferredto other hospitals or domiciliary midwifery programs.About 0.1% of babies tested will be diagnosed with a condition as a result of newborn screening. All hospitals receivea weekly report of results, and parents of babies whose test results indicate an increased risk of any of the disordersare contacted and confirmatory diagnostic testing organised. Notification is also made to the paediatrician/GP orhospital shown on the newborn screening test.86

Newborn Screening Test Contact Details – Victorian Clinical Genetics ServicesLaboratoryPh: 8341 6272Fax: 8341 6339Email: screeninglab@ghsv.org.auNewborn Screening CounsellingPh: 8341 6201Newborn Hearing ScreeningAs part of the Victorian Infant Hearing Screening Program (VIHSP), allbabies born at RWH, MHW, SH and NH undergo a routine hearing screen ‘All babies born at RWH, MHW, SH andand risk factor assessment, prior to discharge. Any baby who has not beenNH undergo a routine hearing screenscreened prior to discharge is called back by VIHSP for an outpatientand risk factor assessment, prior toscreen.discharge.’Screening results are documented in the baby’s Child Health Record (‘BlueBook’) and where a pass result is not obtained, VIHSP organises adiagnostic audiology referral which is followed up by both VIHSP and the Maternal Child Health Nurse.If a pass result is obtained but risk factor/s have been identified, this is documented in the Child Health Record andflagged for follow-up by the Maternal Child Health Nurse who will refer for diagnostic audiology if required at the 2week and/or 6-8 month check, or in response to parental concern.If a GP identifies risk factors not already identified and followed up by Maternal Child Health Service or there isconcern about a baby’s hearing, a GP can also refer for diagnostic audiology.Hearing loss risk factors include:family history of congenital hearing impairment‘If a GP identifies risk factors notrubella, cytomegalovirus, or toxoplasmosis during pregnancy already identified and followed up byadmitted to neonatal intensive care or admitted to special care Maternal Child Health Service or therenursery for 2 or more daysis concern about a baby’s hearing, aApgar score of less than 4 at five minutes of ageGP can also refer for diagnosticbirth weight

Domiciliary CareIn addition to immediate postnatal care in hospital, the hospitals offer at least one domiciliaryMidwife visit for all women in the first week after discharge. In addition, the hospital notifiesthe local Maternal Child Health Service of the woman’s discharge and a home visit by aMaternal Child Health Nurse within the first few weeks of a woman’s discharge is arranged. Inaddition, there is capacity for enhanced services if required, see ‘Maternal Child HealthServices’ under Community Postnatal Care below.‘The hospitals offerat least onedomiciliary Midwifevisit for all womenin the first weekafter discharge.’The Child Health Record (“Blue Book”)All parents are given a Child Health Record for their baby in hospital. It is used by Maternal Child Health Nurse andGPs as a record of a child’s health and development including growth immunisations and development milestones. Itis the main communication tool between parents, the Maternal Child Health Nurse, GPs and other healthprofessionals and is a record of all Maternal Child Health Nurse visits.Community Postnatal CareMost postnatal care is undertaken in the community by GPs in conjunction with MaternalChild Health Services. Infants in Australia have a higher percentage of GP visits during the firstyear of life than in any other year of life. (4) Unfortunately, there are high levels of postnatalmorbidity at 6 months postpartum (see table below) and low levels of maternal satisfactionwith hospital postnatal care in Victoria. (5)The hospitals encourage all women and their babies to attend their GP for a postnatal checkat 6 weeks, or earlier if needed. If a woman does not have GP, the hospitals will assist her tofind one prior to discharge from hospital.‘....there are highlevels of postnatalmorbidity at 6months postpartum’Common Postnatal problems in the 6-7 months after childbirth*PROBLEM PRIMIPARAS (%) MULTIPARAS (%)Backache 44 43Bowel problems 10 11Constantly reliving baby’s birth 7 5Contraception 8 9Depression 19 20Haemorrhoids 26 24Mastitis (if breastfeeding) 16 18More coughs and colds than usual 9 13No health problems 5 6Other 7 8Pain from a caesarean wound 63+ 60Painful perineum 31 15Relationship with partner 19 18Sex 31 24Tiredness/exhaustion 68 70+Includes only women who had a caesarean section (n+1336) *Adapted from (6)88

In light of the above, the following is recommended:that every woman has postnatal care provided by her GPthe timing of visits should be individualised and reflect awoman’s needsat the postnatal check-up, both the mother and child should beassesseda woman-centred approach should be taken so that a woman isable to direct the GP to areas of most relevance to herAreas to address as part of a postnatal check include:physical assessment of mother and baby, including feeding andsettlingdevelopmental assessment of the babyemotional wellbeing of mother and babyrelationship and social supportshealth promotionopportunity for parents to express concerns‘Areas to address as part of apostnatal check include:physical assessment of mother andbaby, including feeding andsettlingdevelopmental assessment of thebabyemotional wellbeing of motherand babyrelationship and social supportshealth promotionopportunity for parents to expressconcerns’Postnatal GP Visit Guide: MotherAim of Visit Physical Investigationsand ImmunisationsIssues for Discussion / Health Promotionphysicalfollow-up complications ofconsider haemoglobin ifphysical wellbeingassessmentpregnancy (eg. hypertension,previous anaemia orbreastfeeding/infant feedingemotionalpre-eclampsia, gestationalpostpartum haemorrhageemotional wellbeing and parentingassessmentdiabetes)If gestational diabetes, confirmpostnatal depression/adjustmentparentingcheck woundspostnatal GTT has beenparenting supportsassessmentcheck for fever, anaemia andarrangedrelationship and social wellbeingpromotebreastfeedingvaginal lossassess for breastfeedingIf gestational diabetes, discussand establish ongoingcontraception, sexuality andrelationship issuesrelationshipand socialassessmentopportunityto expressconcernsdifficultiesask about urinary and faecalcontinenceask about perineal symptomsand intercoursemaintain awareness ofpostnatal depressionmaintain awareness ofintimate partner violencemaintain awareness ofparenting, including childmistreatmentscreening and recall systems(generally 2 yearly GTT ifnormal GTT and yearly GTT ifimpaired GTT)Pap smear if dueMMR immunisation if rubellaantibody titre low (and notgiven in hospital prior todischarge)Varicella immunisation if nonimmune(2 doses required)Pertussis (‘Boostrix’)exercise including pelvic floormaternal nutritionsleep and restsmoking, drugs and alcoholvitamin D supplementation if motherwas vitamin D deficient duringpregnancy (baby and mother and otherfamily members)liaison with other community services(in particular recent migrants, mothersfrom Aboriginal and Torres StraitIslander background, adolescent89

immunisation of mother andother close family contacts ifnot undertaken prior topregnancymothers, mothers with alcohol anddrug problems)Postnatal GP Visit Guide: BabyAim of visit Physical Investigationsand ImmunisationsIssues for discussion / Health Promotionphysicalfollow-up on anyfollow-up on investigationappropriate feeding and weight gainassessmentcomplications, or parentalresults (e.g. fetalimmunisationdevelopmentalconcernshydronephrosis)vitamin D supplementation if motherassessmentfollow-up on any relevantfollow up abnormal clinicalwas vitamin D deficient duringhealthtestsfindings (e.g. prolongedpregnancy (eg. ‘Pentavite’) at leastpromotionassessment of growth –jaundice, heart murmurs)while exclusively breastfeedingopportunity forheight, weight and headscreening hip ultrasound forsettling and sleepparents tocircumferencebabies at risk of hip dysplasiaSudden Infant Death Syndrome (SIDS)expresscheck if smiling and(breech, talipes, family history)preventionconcernsfollowingconfirm baby born to a motherdangers of passive smokinggeneral physicalwho is a Hepatitis B carrier hascar safety and other injury preventionexamination especially:received 2 injections post birthsun protectionassess for jaundice, toneassessment, heart, testes,hips, squint, eyes (redreflex)(Hepatitis B Immunoglobulinand Hepatitis B paediatricformulation (Engerix-Bpaediatric or H-B-VAX IIdental healthcommunity and other support andresourcesidentify risk of hearing(paediatric)) and reinforce needproblemsfor full immunisation andtesting between 9-15 monthsof ageMaternal Child Health ServicesThere is a capacity for an enhanced Maternal Child Health service if needed. This may include additional homesupport and Maternal Child Health Nurse visits. GPs, the hospital, and women can contact the woman’s localMaternal Child Health service to discuss this.Maternal Child Health Services Contact DetailsDirectory of Maternal Child Health services withpostcode search function:http://www.eduweb.vic.gov.au/mch/t_centrelist.aspMaternal Child Health Line - 24 hoursPh: 13 22 29Both GPs and families can use this service90

Enhanced Maternal Child Health Services: a component of Child and Family Information, Referraland Support Teams (Child FIRST)Child FIRST includes enhanced Maternal Child Health services and other support services (e.g. social work, housing,legal, drug and alcohol services) and can be contacted when a health professional feels a family requires additionalsupport. This may be for issues including:young womenisolation and/or unsupported familiesparenting problems that may affect the child's developmentsocial or economic disadvantage that may adversely impacton a child’s care or development‘Child FIRST includes enhanced MaternalChild Health services and other supportservices (e.g. social work, housing, legal,drug and alcohol services) and can becontacted when a health professionalfamily conflict, including family breakdownfamilies under pressure due to a family member’s physicalor mental illness, substance abuse, disability orfeels a family requires additionalsupport.’bereavementReferral to Child FIRST services does not replace mandatory reporting of child of abuse to Child Protection Services.Child FIRST Contact DetailsMonashWhitehorseManninghamBoroondaraNillumbikWhittleseaBanyuleYarraDarebinBrimbankMeltonHumeMorelandHobson’s BayMaribyrnongMelbourneMoonee ValleyWyndhamKingstonBaysideGlen EiraStonningtonPort PhillipPh: 1300762 125 Ph: 9450 0955 Ph: 1300 138Ph: 1300 786Ph 1300 775Ph: 1300 367 441180433160Services are delivered on an area basis depending on where a family lives. This table does not include all Child FIRSTareas in Victoria. For the full list of referral numbers, access the Child FIRST website:http://www.cyf.vic.gov.au/quick-help/first-child-and-family-information-referral-and-support-teamsAccess to enhanced MCHS often occurs via the woman’s usual Maternal Child Health service. GPs are encouraged tocontact the Maternal Child Health service if they feel additional support may be beneficialMandatory Reporting Requirements for Health ProfessionalsThe Children and Young Persons Act 1989 Section 64 (1C) states that certainprofessionals (including GPs, obstetricians and midwives) must report to ChildProtection Services, when, in the course of their professional duty:“*they+ form the belief on reasonable grounds that a child is in needof protection[because] the child has suffered, or is likely to suffersignificant harm as a result of physical injury and the child’s parentshave not protected or are unlikely to protect, the child from harm ofthat typeOr‘The Children and Young Persons Act1989 Section 64 (1C) states thatcertain professionals (including GPs,obstetricians and midwives) mustreport to Child Protection Servicesunder certain circumstances.’91

the child has suffered, or is likely to suffer, significant harm as a result of sexual abuse and the child’sparents have not or are unlikely to protect, the child from harm of that type”To make a notification of child abuse, contact the regional Child Protection Service.Child Protection Services Contact DetailsFor reporting of suspected child abuseEastern Southern Western and Northern Child Protection Crisis LinePh: 1300 360 391 Ph: 1300 655 795 Ph:1300 664 977 Ph: 131 278(for emergency child protectionmatters outside of normal businesshours)Mental Health and Wellbeing in the Postnatal PeriodIn the postnatal period, there are a number of services women can access for mental health issues. Adult mentalhealth services operate a range of services, both urgent and non-urgent including Crisis Assessment and Treatment(CAT) Teams and Primary Mental Health Teams. Most services are delivered on an area basis, depending on where apatient lives.In addition, for non-urgent assessment, parents experiencing difficulties (including mental health problems, settlingissues) support services are available via early parenting centres.Referring a woman directly to a private provider (psychiatrist or psychologist) is also an option that GPs may considerwhen caring for a woman with mental health issues in the postnatal period.Crisis Assessment and Treatment (CAT) Teams (urgent)CAT teams operate 24 hours a day and provide urgent communitybasedassessment and short-term treatment interventions to people inpsychiatric crisis. CAT services have a key role in deciding the mostappropriate treatment option and in screening all potential inpatientadmissions (includes access to inpatient mother and baby units).CAT teams are a component of adult mental health services and can byaccessed by anyone (contact details below). CAT teams are alsoattached to most Emergency Departments.‘In the postnatal period, there are anumber of services women can access formental health issues. Adult mentalhealth services operate a range ofservices, both urgent and non-urgentincluding Crisis Assessment andTreatment (CAT) Teams and PrimaryMental Health Teams.’Primary Mental Health Teams (non-urgent)In non urgent situations, Primary Mental Health Teams provide consultation for women (including psychiatricassessment, feedback and development of a treatment plan) and advice to primary health services such as GPs andcommunity health centres. They do not provide case management. Primary Mental Health Services are a componentof adult mental health services (contact details on next page).92

Mental HealthServiceNorthernLocal GovernmentAreasWhittleseaDarebinAdult Mental Health Service Areas and Local Government Areas24 hour psychiatric triage information, assessment and referralIncludes CAT Teams and Primary Mental Health TeamsPh:Websitehttp://www.health.vic.gov.au/mentalhealth/services/adult/northern-a.htmNorth WestMid WestHumeMorelandMeltonBrimbank1300 874 243(1300 TRIAGE)http://www.health.vic.gov.au/mentalhealth/services/adult/northwest-a.htmhttp://www.health.vic.gov.au/mentalhealth/services/adult/midwest-a.htmInner WestMoonee ValleyMelbournehttp://www.health.vic.gov.au/mentalhealth/services/adult/inwest-a.htmInner Urban EastSouth WestNorth EastYarraBoroondaraWyndhamHobsons BayMaribyrnongNillumbikBanyule1300 558 862 http://www.health.vic.gov.au/mentalhealth/services/adult/inurbaneast-a.htm1300 657 259 http://www.health.vic.gov.au/mentalhealth/services/adult/southwest-a.htm1300 859 789 http://www.health.vic.gov.au/mentalhealth/services/adult/northeast-a.htmThis table does not include all adult mental health service areas in Victoria. For more services, access Victoria’s adult specialist mental healthservices website which includes maps of each region: http://www.health.vic.gov.au/mentalhealth/services/adult/index.htmMother and Baby ServicesThe three public mother and baby inpatient services in Victoria are located at the Austin Hospital, Werribee MercyHospital and Monash Medical Centre. These mother and baby services provide specialist assessment andmanagement of women with mental illness in the postnatal period. Generally, infants up to 12 months of age areadmitted with their mothers.SMCA can refer a woman via the woman’s local adult mental health service (above) and an intake worker will assessthe woman and arrange admission to the appropriate service.Public Mother and Baby Units in Victoria Contact DetailsInpatient ServicesAustin Health - Heidelberg Monash Medical Centre - Clayton Werribee Mercy Hospital - WerribeePh: 9496 6406Fax: 9496 4366AH: 9496 5000Ph: 9594 1414Fax: 9594 6615Ph: 9216 8465Fax: 9216 8470Early Parenting CentresEarly Parenting Centres provide help and support for families with children 0 to 3 years who have difficultiesadjusting to, or establishing, feeding, sleeping and other early childhood routines. Families can stay at the centres orattend day stay programs. SMCA are able to refer directly to these services, and women are also able to self-refer.93

Early Parenting Centres in Melbourne Contact DetailsTweddle Child and Family HealthService - FootscrayPh: 9689 1577Fax: 9689 1922http://www.tweddle.org.au/O'Connell Family Centre - CanterburyPh: 8416 7600Fax: 9816 9729http://www.mercy.com.au/html/s02_article/article_view.asp?id=200&nav_cat_id=215&nav_top_id=84Queen Elizabeth Centre, NobleParkPh: 9549 2777Fax: 9549 2779http://www.qec.org.au/Private facilities with both mother and baby units and parenting centres are also available. To refer, SMCA shouldcontact the facilities directly.Private Hospitals with Mother and Baby Units in Melbourne Contact DetailsAll provide both day and inpatient programsNorth Park –BundooraMitcham Private - Mitcham Albert Road Clinic - Melbourne Masada - St Kilda EastPh: 9467 6022Ph: 92103134Ph: 9256 8322Ph: 9038 1413http://www.healthscohttp://www.mitchamprivathttp://www.albertroadclinic.com.http://www.masadaprivatpehospitals.com.au/ine.com.au/mbu/introductioau/services/parent_infant.aspe.com.au/mbu/Baby_Unitfo/general/Hospital/gn.asp.aspet/1565/itemId/BreastfeedingThe World Health Organisation states that: ‘exclusive breastfeeding is recommended up to 6 months of age, withcontinued breastfeeding along with appropriate complementary foods up to two years of age or beyond’ (WHO). InVictoria, exclusive breastfeeding rates have not increased in the last seven years and the percentage of infants fullybreastfed remain at approximately 50% at 3 months and 38% at 6 months (8).It is widely accepted that breastfeeding positively influences the physical and emotional health of both mother andinfant. It provides nutrition for normal growth and development of infant and provides protection against manydiseases and infections for both mother and baby.The hospitals strongly encourage breastfeeding with support and education available at each hospital for all womenin the antenatal and postnatal period. Breastfeeding is discussed and encouraged by hospital staff at both antenatalvisits and childbirth education sessions. In the immediate postnatal period, Lactation Consultants are available toinpatients.Outpatient hospital assistance is available:for women experiencing breastfeeding problems up to 3 months postpartum94

antenatally for women who have risk factors for breastfeeding difficulties (e.g. have had poor breastfeedingexperiences, breast surgery, multiple pregnancies)for women who require additional supportGPs and SMCA are able to contact breastfeeding support services at the hospitals for advice or referral. Women arealso able to contact the hospital breastfeeding services directly.In addition to hospital breastfeeding services, many MCH Services provide assessment and support, as do earlyparenting centres and organisations such as the Australian Breastfeeding Association.A range of clinical practice guidelines relating to breastfeeding can be found in the resource section.Hospital Breastfeeding Support Contact DetailsWomen are able to self-refer to the hospital they are booked into or have given birth inRWHBreastfeeding Education andSupport Services (BESS)MHWBreastfeedingSupport CentreSHBreastfeeding CentreNHSpecialist BreastfeedingServicePh: 8345 2000 (switchboard) andask to have the lactationconsultant paged orPh: 8345 2496 and leave amessagePh: 8458 4677 or8458 4676Ph: 8345 1049 to leave a messageService only available Monday andThursday at this time.Contact the maternity ward if thematter is urgentPh: 8345 1727Ph: 8405 8000(switchboard) and ask tohave the lactationconsultant paged orPh: 8405 8202Day stay program alsoavailableGestational DiabetesFor women who have had Gestational Diabetes, the hospital will arrange for the woman to have a GTT performedaround six weeks after the birth. GPs are encouraged to ensure this has been done. Even if the result of this initialpostnatal GTT is normal, women are at increased risk of developing diabetes later in life with a 30 to 50% chance ofdevelopment within 15 years after a pregnancy with Gestational Diabetes. Therefore these women requirecounselling and minimisation of risk factors for diabetes and vascular disease and regular retesting (e.g. 2 yearly GTTif normal GTT and yearly GTT if impaired GTT).Hepatitis B CarriersFor babies born to mothers who are Hepatitis B carriers, GPs are encouraged to confirm that the baby has receivedtwo injections post birth (both Hepatitis B Immunoglobulin and Hepatitis B paediatric formulation (Engerix-Bpaediatric or H-B-VAX II (paediatric)). The baby requires full Hepatitis B immunisation and testing for carrier statusbetween 9 and 15 months. In addition, as in the usual management of people who are Hepatitis B carriers, otherfamily contacts should be immunised and their immunity confirmed and Hepatitis B surveillance for the motherundertaken (9).95

References4 Gold Field SR, Wright M, Oberklaid F. Parents, infants and health care: utilization of health services in the first 12 months of life.Journal of Paediatric Child Health 32: 249-253, 2003.5 Brown S, Davey M, Bruinsma F. Women’s views and experiences pf postnatal hospital care in the Victorian Survey of Recent Mothers2000. Midwifery; 21, 109-126, 20056 Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. British Journal of Obstetrics andGynaecology; 105: 156-161, 19987 VicHealth. The Health Costs of Violence: Measuring the burden of disease caused by intimate partner violence. VicHealth, 20048 Victorian Department of Education and Early Childhood Development.http://www.education.vic.gov.au/researchinnovation/vcams/children/2-1breastfed.htm Accessed12/8/20109 The Australian Immunisation Handbook, 9 th Ed. Australian Department of Health and Ageing, 2008.ResourcesPostnatal Care– GeneralHaving a baby in Victoria- Ongoing care after you have your babyhttp://www.health.vic.gov.au/maternity/yourpregnancy/ongoingcare.htmRaising Children Networkhttp://raisingchildren.net.au/Children, Youth and Child Health Service (South Australia)http://www.cyh.com/SubDefault.aspx?p=98Child Health Record “The Blue Book”Victorian Department of Education and Early Childhood Developmenthttp://www.education.vic.gov.au/ecsmanagement/mch/childhealthrecord/default.htmVictorian Department of Education and Early Childhood Developmenthttp://www.education.vic.gov.au/ecsmanagement/mch/childhealthrecord/language.htmNewborn ScreeningNewborn Victorian Department of HealthScreening Test http://www.health.vic.gov.au/nbs/Better Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Newborn_scrConsumer information including:Postnatal domiciliary careVictorian Child Health RecordMaternal and child health servicesSix-week postnatal check formother and babyContraceptionSex after pregnancyBirth RegistrationInfant car restraintsCrying babySleep baby sleepImmunisation programSudden infant death syndromeConsumer information: comprehensivewebsite with large range ofinformation about babies, children,families and parenting includinghealth, development and safetyParenting and Child Health websiteInformation about the child healthrecord including child health anddevelopment, growth charts,immunisation and useful contactsBasic information on how to use thechild health record. Available in Arabic,Chinese, English, Polish, Spanish,Turkish and VietnameseConsumer information on NewbornScreening TestConsumer information on NewbornScreening Test96

eening?openVictorian InfantHearingScreeningVictoria Clinical Genetics Servicehttp://www.genetichealthvic.net.au/Documents/PDF/Newborn_Screening_Brochure.pdfRoyal Children’s Hospitalhttp://www.rch.org.au/vihsp/index.cfm?doc_id=7461Community services and supportsMaternal Child Victorian Department of Education and Early Childhood DevelopmentHealth Services http://www.eduweb.vic.gov.au/mch/t_centrelist.aspConsumer fact sheet on NewbornScreening TestFrequently asked questions aboutInfant Hearing Screening in VictoriaDirectory of Maternal and Child HealthCentre with postcode search functionChild protectionBreastfeedingBreastfeeding(General)BreastfeedingClinical PracticeGuidelinesVictorian Department of Human Services- Children, Youth and Familieshttp://www.cyf.vic.gov.au/quick-help/first-child-and-family-informationreferral-and-support-teamsVictorian Department of Human Services- Children, Youth and Familieshttp://www.cyf.vic.gov.au/__data/assets/pdf_file/0010/334963/respondingto-child-abuse.pdfAustralian Breastfeeding Associationhttp://www.breastfeeding.asn.au/bfinfo/index.htmlWorld Health Organisationhttp://www.who.int/topics/breastfeeding/enRoyal Women’s Hospitalhttp://www.thewomens.org.au/BreastfeedingBestPracticeGuidelinesRoyal Women’s Hospitalhttp://www.thewomens.org.au/LowBreastmilkSupplyRoyal Women’s Hospitalhttp://www.thewomens.org.au/MedicationsandHerbalPreparationstoIncreaseBreastmilkProductionGalactagoguesRoyal Women’s Hospitalhttp://www.thewomens.org.au/MastitisLactationalRoyal Women’s Hospitalhttp://www.thewomens.org.au/NippleEczemaDermatitisRoyal Women’s Hospitalhttp://www.thewomens.org.au/NippleorBreastPainLactationAlgorithmReferral and support teams directoryResponding to Child Abuse. Forprofessionals working with childrenincludes information on mandatoryreportingLarge variety of consumer informationon breastfeeding including supportand adviceGeneral breastfeeding informationClinician information: breastfeedingbest practice guidelinesClinical Practice Guideline: low breastmilk supply.Includes: assessment, signs andmanagement of low milk supplyClinical Practice Guideline: medicationsand herbal preparations to increasebreast milk production(galactagogues). Includes: commonlyavailable galactagogues (Domperidoneand Metoclopramide) and herbalpreparationsClinical Practice Guideline: mastitis.Includes: signs, symptoms,investigations and management andmastitis clinical algorithmClinical Practice Guideline: nippleeczema dermatitis. Includes:assessment, managment andtreatmentClinical Practice Guideline: nipple orbreast pain (lactation) algorithm. Toassess for possible mastitis, nippleeczema dermatitis, bacterial infectionand thrush97

Other infantfeedingRoyal Women’s Hospital http://www.thewomens.org.au/ThrushinLactationRoyal Women’s Hospitalhttp://www.thewomens.org.au/TongueTieManagementRaising Children Networkhttp://raisingchildren.net.au/articles/how_to_bottle-feed.html/context/203Clinical Practice Guideline: thrush inlactationIncludes: signs, symptoms andtreatment of both nipple and breastthrushClinical Practice Guideline: tongue-tiemanagementConsumer information on how tobottle feed safelyMedicalGestationalDiabetesHepatitis BPostnatalmedical caremotherDiabetes Australiahttp://www.diabetesvic.org.au/LinkClick.aspx?fileticket=hwxCO7vLWuc%3d&tabid=164Australian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-hepatitisbRoyal Children’s Hospitalhttp://www.rch.org.au/intranet/fracp_resources/?doc_id=1338Royal Women’s Hospitalhttp://www.thewomens.org.au/PostpartumCareObstetricbasedCareRoyal Women’s Hospitalhttp://www.thewomens.org.au/ThirdandFourthDegreeTearsManagementRoyal Women’s Hospitalhttp://www.thewomens.org.au/ImprovingyourrecoveryafterbirthPhysiotherapyadviceRoyal Women’s Hospitalhttp://www.thewomens.org.au/GoinghomeafterhavinganEpiduralSpinalContinence Foundation of Australiahttp://www.continence.org.au/resources.php?keyword=&topic%5B%5D=Pregnancy&language=English&type=&submitted=SearchFamily Planning VictoriaConsumer fact sheet on GestationalDiabetesClinician information: Hepatitis BHepatitis immunisation for babies.Information including if mother is aHepatitis B carrierPost partum assessment clinicalpractice guideline. Includes: febrileillness, secondary post partumhaemorrhage, mastitis, anaemia,perineum, urinary problems,constipation and haemorrhoids,thyroid, pap smear, vitaminsupplementationPost partum counselling including:physiological changes, contraception,post delivery discussion and postnataldepressionThird and fourth degree tears clinicalpractice guidelineDefinition, associated risk factors,repair techniques, post repairmanagement and follow-upConsumer fact sheet: improving yourrecovery after birth. Includes: after acaesarean birth, pelvic floor exercises,healthy bladder and bowel habits, backcare and correct lifting techniques.Available in: Arabic, Chinese, Hindi,Somali, Turkish, VietnameseConsumer fact sheet: Going homeafter having an epidural/spinalConsumer brochure: 1in 3 WomenWho Have Ever Had a Baby WetThemselvesConsumer information: postnatal98

http://www.fpv.org.au/pdfs/PostNatalContraceptionAugust05%20.pdfBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pelvic_floor?opencontraceptionConsumer fact sheet: pelvic floorVaccinationsMeasles, mumps& rubellaVaricellaInfluenzaPertussisMental HealthPostnataldepressionAustralian Immunisation Handbookhttp://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-homeVictorian Department of Health http://www.health.vic.gov.au/immunisationVictorian Department of Healthhttp://www.health.vic.gov.au/immunisation/fact-sheets/languageAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-measlesAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-mumpsAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-rubellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-varicellaAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-influenzaAustralian & State and Territory Governmentshttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/IMM123-cnt/$File/imm123-fs-2010.pdfAustralian Immunisation Handbookhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-pertussisBeyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=7.102&tmp=FileDownload9th Edition Australian ImmunisationHandbook, 2008Clinical guidelines for healthprofessionals on the safest and mosteffective use of vaccines in theirpractice. These recommendations aredeveloped by the Australian TechnicalAdvisory Group on Immunisation(ATAGI) and endorsed by the NationalHealth and Medical Research Council(NHMRC)Victorian Government Immunisationfact sheetsImmunisation fact sheets in:Arabic, Bosnian, Chinese, Croatian,Dari, Greek, Indonesian, Italian, Karen,Khmer/Cambodian, Macedonian,Maltese, Polish, Russian, Serbian,Sinhalese, Somali, Spanish, Turkish,VietnameseClinician information: MeaslesimmunisationClinician information: MumpsimmunisationClinician information: RubellaimmunisationClinician information: VaricellaimmunisationClinician information: InfluenzaimmunisationClinician fact sheet: influenzavaccination 2010Clinician information: PertussisimmunisationAntenatal and Postnatal Depression - AGuide to management for health99

&fid=1279Beyond Bluehttp://www.beyondblue.org.au/index.aspx?link_id=94.751&tmp=FileDownload&fid=1334Post and Antenatal Depression Association (PANDA)http://www.panda.org.au/index.php?option=com_content&view=article&id=11&Itemid=31Australian Government Department of Health and Ageinghttp://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubsm-mangp-toc~mental-pubs-m-mangp-app~mental-pubs-m-mangp-app-12Victorian Department of Healthhttp://www.health.vic.gov.au/mentalhealth/services/adult/index.htmprofessionalsEmotional Health During Pregnancyand Early Parenthood bookletRange of consumer fact sheets onantenatal and postnatal depressionEdinburgh Perinatal depression scaleAdult Mental Health Service Areas andLocal Government Areas.24 hour psychiatric triage information,assessment and referral (including CATteams)Early parentingcentresTweddlehttp://www.tweddle.org.au/O’Connell Family Centrehttp://www.mercy.com.au/html/s02_article/article_view.asp?id=200&nav_cat_id=215&nav_top_id=84Queen Elizabeth Centrehttp://www.qec.org.au/Private Hospitalswith Mother &Baby Units inMelbourneNorthpark Private Hospitalhttp://www.healthscopehospitals.com.au/info/general/Hospital/get/1565/itemId/Mitcham Private Hospitalhttp://www.mitchamprivate.com.au/mbu/introduction.aspAlbert Road Clinichttp://www.albertroadclinic.com.au/services/parent_infant.aspMasada Private Hospitalhttp://www.masadaprivate.com.au/mbu/Baby_Unit.aspIntimate partner violenceDomestic Violence and Incest Resource centrehttp://www.dvirc.org.au/Women’s Domestic Violence Crisis ServicePh: 9373 0123 or 1800 015 188Immigrant Women’s Domestic Violence ServicePh: 8413 6800www.iwdvs.org.auVicHealthhttp://www.vichealth.vic.gov.au/en/Programs-and-Projects/Freedom-fromviolence/Intimate-Partner-Violence.aspxBaby health, growth and developmentGeneralRoyal children’s Hospitalhttp://www.rch.org.au/kidsinfo/index.cfm?doc_id=3665Information and referral tospecialist support services helpfulpamphlets and websitesStatewide 24 hour crisis supportand safe accommodation (refuges)for women and their childrenSupport to CALD women in theirprimary languageThe Health Costs of Violence’ VICHealth burden of disease report onintimate partner violenceConsumer information: ‘KidsHealth Info’- medical information100

written for parents. A-Z searchfunctionSleepGrowth chartsVitamin DBirthmarksHip dysplasiaJaundiceSudden InfantDeath Syndrome(SIDS)Raising Children Networkhttp://raisingchildren.net.au/Raising children Networkhttp://raisingchildren.net.au/articles/newborn_sleep_nutshell.html/context/13World Health Organisationhttp://www.who.int/childgrowth/standards/en/Raising Children Networkhttp://raisingchildren.net.au/articles/what_is_growth.html/context/745Victorian Department of Healthhttp://www.health.vic.gov.au/chiefhealthofficer/publications/low_vitamin_d_med.htmBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/BirthmarksBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcArticles.nsf/pages/Developmental_hip_dysplasia_explained?openRoyal Women’s Hospitalhttp://www.thewomens.org.au/JaundicehyperbilirubinaemiainthehealthyterminfantonthepostnatalwardorinthecommunityBetter Health Channelhttp://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Sudden_infant_death_syndrome_(SIDS)_explained?openConsumer information:comprehensive website with largerange of information about babies,children, families and parentingincluding health, development andsafetyConsumer information ‘Newbornsleep in a nutshell’Clinician information: WHO childgrowth standardsConsumer information: growthchartsClinician information: low vitaminD in pregnancy- key messages fordoctors, nurses and allied healthConsumer information: birthmarksConsumer information:developmental hip dysplasiaexplainedJaundice in the healthy term infantclinical practice guideline.Assessment, investigations,management and algorithmsConsumer information: SIDSexplainedSafetySIDS and Kidshttp://www.sidsandkids.org/safe-sleeping/health-professionals/SIDS and Kidshttp://www.sidsandkids.org/safe-sleeping/other-languages/Raising children Networkhttp://raisingchildren.net.au/safety/babies_safety.htmlVicRoadshttp://www.vicroads.vic.gov.au/Home/SafetyAndRules/SaferVehicles/ChildRestraints/Health Professionals Information.Includes: babies head shape, homemonitoring, pacifier dummy use,room sharing, room temperature,second hand mattress use,sleeping with baby, smoking, toxicgas, wrappingConsumer information: safesleeping fact sheet in English andmany other languagesConsumer information: includesfirst aid, equipment safety, caresafety, indoors and outdoorssafetyConsumer information onchoosing the correct child safetyrestraint101

APPENDIX 1: LEVELS OF EVIDENCEThe evidence for intervention questions presented in ‘The 3 Centres Consensus Guidelines on Antenatal Care’ wassystematically assessed and classified according to the NHMRC’s ‘A Guide to the Development, Implementation andEvaluation of Clinical Practice Guidelines (1998)’. Evidence for other questions was generally given the equivalent ofLevel IV status by consensus of the steering group and clinical epidemiologist.Level I Evidence is obtained from systematic review of all relevant randomised controlled trialsLevel II Evidence is obtained from at least one properly designed randomised controlled trialLevel III-1 Evidence is obtained from well-designed pseudo-randomised controlled trials (with alternate allocation orsome other method)Level III-2 Evidence is obtained from comparative studies with concurrent controls and allocation not randomised(cohort studies), case control studies or interrupted time series with a control groupLevel III-3 Evidence is obtained from comparative studies with historical controls, two or more single arm studies orinterrupted time series without a parallel control groupLevel IV Evidence is obtained from case series, opinions of respected authorities, descriptive studies, reports ofexpert committees and case studies102

Women’s Voices“Shared Care is the best kept secret”“It’s been great bringing my baby back to the doctor who looked afterme when I was pregnant”“My doctor was there throughout the hole (sic) thing which will bemy baby’s doctor”“We speak same language”“If my GP wasn’t able to assist, she sourced the necessary person at thehospital to guide and assist me”“Was great for my GP (and I felt comfortable) to see my progress and if Ineeded medical attention she was just a phone call away”“Had a good long term relationship with GP…will be baby’s doctor”“…convenient for my lifestyle”“I have 3 children so not having to go to the hospital all the time was great”“Helped set up a great relationship for my whole family with our local GP”“….I could see a doctor I knew, liked and trusted”“Shared care was a brilliant process and I would recommend it”103