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Guide: Shared antenatal care

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  • Background
  • Definitions
  • RANZOG Policy Statement on Shared Care
  • Sample exclusion list for shared care
  • Safety mechanisms
  • Sample Shared Antenatal Care Protocols and Guidelines
  • Benefits and potential pitfalls of a shared antenatal care program
  • References

  • Background

    Recent Australian guidelines promote collaboration, evidence-based practice and a greater role for primary health providers in maternity care.

    • The NHRMC’s National Guidance on Collaborative Maternity Care, 2010 defines maternity care collaboration thus:
      In maternity care, collaboration is a dynamic process of facilitating communication, trust and pathways that enable health professionals to provide safe, woman-centred care. Collaborative maternity care enables women to be active participants in their care.
      The Guidance notes:
      Primary care is the preferred approach to providing pregnancy and birthing services to women with uncomplicated pregnancies.
    • The Australian Health Ministers’ Advisory Council (AHMOC), Primary Maternity Services in Australia: A Framework for Implementation, 2008 notes that:
      The main aim of primary maternity models is to offer improved continuity of primary carer for women with normal pregnancy risk, with a midwife or GP, who works in collaboration with an obstetric specialist to refer or consult with as required.
    • AHMOC, Clinical Practice Guidelines: Antenatal Care, 2012. These new national evidence-based guidelines cover the antenatal care of healthy pregnant women (i.e. those who do not have known pre-existing conditions or complications).They are intended for use in all settings where antenatal care is provided, including shared care, which is defined as:
      ...several health professionals...involved in the care of a woman during pregnancy, often in the context of a formal arrangement; health professionals involved may include GPs, midwives, other primary care health professionals, specialist obstetricians and hospital practitioners.

    • Definitions

      The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Policy Statement on Shared Maternity Care Obstetric Patients in Australia, 2011 provides the following definitions of key terms:

      Shared Care

      A cooperative arrangement whereby antenatal and postnatal care of the pregnant woman is shared between a Shared Care Provider and a specialist obstetrician, GP obstetrician or hospital-based obstetric unit.

      Shared Care Provider

      A registered health medical practitioner or registered midwife engaging in shared care with a specialist obstetrician, GP obstetrician or hospital-based obstetric unit.

      Shared Care Program

      A program set up with appropriate structures and guidelines by a local hospital unit, a specialist obstetrician or a GP obstetrician in conjunction with shared care providers to facilitate shared antenatal and postnatal care in a safe and acceptable manner.

      Coordinating Body

      An entity with representation from both the hospital/ health facility where intrapartum care of women in a shared care program occurs and shared care providers, which is responsible for maintaining the coordination, standards and evaluation of the program e.g. a hospital credentialing committee or equivalent.


      RANZOG Policy Statement on Shared Care

      RANZOG recognises that shared care programs are ‘local entities and their form, structure, guidelines and management are at a local level.’ e.g. area health service. However, the RANZOG Policy Statement provides overarching guidance on key areas of practice:

      1. Credentialing

      The coordinating body must ensure shared care providers:

      • are registered practitioners within their professional organisation
      • are covered by professional indemnity
      • are of good character
      • have adequate maternity care training, experience or supervision.

      Time to re-credentialing of shared care providers must not exceed 3 years.

      2. Re-credentialing

      The coordinating body shall ensure that shared care providers undertake appropriate education to aid compliance with policies and guidelines of the shared care program and establish criteria for re-credentialing based on compliance with these policies and guidelines and continuing professional development (CPD).

      3. Shared Care in Practice

      • Most pregnant women are suitable for a degree of shared care.
      • The coordinating body shall develop policies and guidelines pertaining to the shared care program, including inclusion criteria (for sample exclusion criteria see Table 1). These should reflect local, cultural and geographical needs of the community, as well as provide evidence-based principles of good obstetric care.
      • The degree of complexity of care undertaken by a shared care provider will vary between intrapartum care providers (hospitals, specialist obstetricians and GP obstetricians) and reflect the obstetric competence of the shared care provider, practice location and patient demographics.
      • The complexity of maternity care undertaken by an individual shared care provider should be determined by that doctor in conjunction with the coordinating body, in accordance with their clinical skills, practice location and patient demographics.
      • All practitioners involved in shared care should recognise that the timely referral for support and assistance in the management of complex maternity care and psychosocial problems is entirely appropriate.
      • If the intrapartum care provider considers a pregnant woman is no longer suitable for shared maternity care, the intrapartum care provider has a responsibility to notify the shared care provider prior to the next maternity visit falling due.

      Shared care protocols should include:

      • Clear delineation of roles and responsibilities
      • Timelines for hospital registration
      • Timelines for visits
      • Timelines for investigations, discussions and procedures
      • Eligibility criteria
      • Record keeping and ownership of the records
      • Transfer of records
      • The ability for urgent referral for assessment if and when required


      Sample exclusion list for shared care

      Pre-existing maternal disease:

      • Cardiovascular — established heart disease, pulmonary embolism or DVT, chronic hypertension requiring treatment
      • Urinary system — established renal disease
      • Psychoneurological — established mental disorder, adjudged by medical professionals to be at risk psychologically
      • Endocrine — diabetes mellitus, unstable gestational diabetes, thyroid disease requiring medication
      • Respiratory — acute asthmatic condition, major respiratory disorders
      • Other systems — active malignancy, haemolytic disease, proven syphilis
      • Maternal physical findings — multiple pregnancy
      • Abnormal conditions developing during pregnancy

      Adapted from Lombardo & Golding, Aust Fam Physician 2003


      4. Postnatal care

      • The shared care provider or intrapartum care provider, as appropriate, should conduct a postnatal check at an appropriate time to determine the well-being of both mother and baby and to carry out a postnatal review.
      • Postnatal care education, including information on the recognition of postnatal depression and management within the local community, should be available to both mothers and their carers.

      5. Communication

      • Within a multidisciplinary team, care should be taken to ensure continuity of care and advice given to expectant mothers. Communication plans should ensure all parties involved in the care of mother and baby are informed of decisions and management plans around the time of delivery and perinatal period.
      • All shared care programs should have maternity record cards for the mother to carry with them; this card should detail all relevant clinical information as the pregnancy progresses.
      • Shared care providers should be provided with timely details relating to intra- and post-partum events to assist them in discussing details about events surrounding the birth and postnatal period. Where possible summaries should be generated at the time of discharge and forwarded to the shared care provider. The patient should be given clear instructions regarding follow up arrangements.

      6. Assessment

      Shared care programs should have regular ongoing assessment of:

      • their practicality
      • their effectiveness as indicated by outcome-based parameters determined by the coordinating body
      • patient satisfaction with the program.


      Safety mechanisms

      Mechanisms are required to ensure the adherence to protocols and the best outcome for the mother and baby. These may include:

      • Documentation and follow up of non adherence by all parties
      • Regular review of protocols
      • Indications for referral to other specialties, which may include:
        • Complications in a previous pregnancy
        • Obstetric complications
        • Procedures
        • Medical complications
        • Fetal / neonatal complications
        • Intrapartum complications
        • Puerperal complications


      Sample Shared Antenatal Care Protocols and Guidelines

      South Eastern Area Health
      Monash Health
      Cairns Base Hospital
      ACT Health

      Benefits and potential pitfalls of a shared antenatal care program

      Patient benefits

      • care in the setting of an established therapeutic relationship
      • community base care in the GP’s surgery
      • holistic care
      • more convenient consultation times
      • less waiting time in hospital clinics
      • less travelling time and expense
      • improved continuity and coordination of care

      Hospital benefits

      • resources rationalisation
      • financial (fewer antenatal visits for low risk pregnancies)
      • human resources (obstetric staff able to devote more time to high risk pregnancies)
      • enhanced relationship between specialist staff and local GPs

      GP benefits

      • continuity of care; improved links with hospital staff
      • improved opportunities to provide total patient care
      • participation in obstetric services
      • access to CPD in antenatal care

      Potential pitfalls

      • Local conditions may vary and some flexibility may be required e.g. less formal arrangements may be necessary for rural practitioners sharing care with metropolitan-based obstetrician.
      • Informed patient consent is vital
      • Breaches of protocol
      • Poor communication between health care providers e.g. delays in discharge summaries, and between health providers and the patient
      • ‘Turf wars’ between professionals e.g. GPs and midwives
      • Duplication of investigations
      • Missed investigations requiring action
      • Medical indemnity issues
      • Women’s status may change from low risk, rendering her ineligible for shared care

      Adapted from Lombardo & Golding, Aust Fam Physician 2003

      References

      1. Australian Health Ministers’ Advisory Council 2012, Clinical Practice Guidelines: Antenatal Care – Module 1. Australian Government Department of Health and Ageing, Canberra. http://www.health.gov.au/antenatal (Accessed 24 June 2014)
      2. NSW Department of Health, on behalf of the Maternity Services Inter-jurisdictional Committee 2008, Primary Maternity Services in Australia: A Framework for Implementation. Australian Health Ministers’ Advisory Council, Canberra. www.ahmac.gov.au/cms_documents/Primary%20Maternity%20Services%20in%20Aus... (Accessed 24 June 2014)
      3. NHMRC (National Health and Medical Research Council) 2010, National Guidance on Collaborative Maternity Care, NHMRC, Canberra.
      4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG) 2011, WPI9: Policy Statement on Shared Maternity Care Obstetric Patients in Australia. http://www.ranzcog.edu.au/documents/policy-statement-on-shared-maternity... (accessed 24 June 2014)
      5. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG) 2012, College Statement C-Obs 30: Maternal Suitability for Models of Care, and Indications for Referral within and Between Models of Care. www.ranzcog.edu.au/documents/maternal-suitability-for-models-of-care-and... (Accessed 24 June 2014)
      6. Lombardo M, Golding G. Shared antenatal care: A regional perspective. Aust Fam Physician 2003; 32:1-7.