Antenatal Care for General Practice 2014 · Antenatal Care for General Practice Information Kit 2014_V01.a This information kit is intended as a guide for general practitioners in

INFORMATION KIT Antenatal Care for General Practice 2014 UPDATED AUGUST 2014

Disclaimer: While every reasonable effort has been made to ensure that the information given in this resource is accurate, Primary Health Tasmania will not accept liability for any injury, loss or damage arising directly or indirectly from any use or reliance on this information. While the Australian Government Department of Health has contributed to the funding of this material, the information does not necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed, by the Australian Government. The Australian Government is not responsible in negligence or otherwise for any injury, loss or damage however arising from the use of or reliance on the information provided herein. The resource is available for download under resources at www.primaryhealthtas/resources/womens-and-childrens-health Primary Health Tasmania Level 4, 15 Victoria Street Hobart t 1300 653 169 f: 6213 8260 [email protected]

Antenatal Care for General Practice Information Kit 2014_V01.a

This information kit is intended as a guide for general practitioners in southern Tasmania. These protocols have been developed in conjunction with the Obstetrics Unit at the Royal Hobart Hospital in an effort to provide consistent care for our shared care patients. This document is designed so that outdated protocols can be replaced in the folder. Updated protocols will be published on the Primary Health Tasmania website at www.primaryhealthtas.com.au

We wish to acknowledge the following in the original production of this kit in 2004: Dr James Brodribb – Private Obstetrician, RHH

Dr Shelby Jarrell – Former Director, Obstetrics & Gynaecology Dept., RHH Dr Stephen Raymond – Former Director, Obstetrics & Gynaecology Dept., RHH

Dr Anne Duffield – Endocrinology Consultant, RHH Women’s and Children’s Services, RHH

General Practice South

Reviewed in 2014 Assoc. Prof. B Lim, Director, Obstetrics & Gynaecology Dept., RHH

Dr Stephen Raymond – Former Director, Obstetrics & Gynaecology Dept., RHH C Bodger, CNC Women’s Health Clinic, RHH,

Dr Anne Duffield – Endocrinology Consultant, RHH Perinatal Mental Health Service

S O’Loughlin, Physiotherapy Services, RHH C Galloway, Lactation Consultant, RHH

D Dillon, CNC, Maternity Unit, RHH. Drs M Veitch & S McKeown, Public and Environmental Health Services

Primary Health Tasmania - Women’s & Children’s Health Reference Group Professor Fiona Judd Perinatal Psychiatrist Child & Adolescent Mental Health Service

Mrs Angela Hay, Perinatal MH Liaison Coordinator, Child & Adolescent Mental Health Services South

http://www.primaryhealthtas/resources/womens-and-childrens-health

mailto:[email protected]

http://www.primaryhealthtas.com.au/

CONTENTS

SHARED CARE INFORMATION AND TOOLS ................................................................................... 1 Introduction to Shared Care............................................................................................................. 1 WACS Contacts .............................................................................................................................. 2 Conditions not suitable for GP to Share Care .................................................................................. 3 Booking into Royal Hobart Hospital ................................................................................................. 4 Schedule of Visits ............................................................................................................................ 5 Hand Held Records ......................................................................................................................... 5 Check List for Shared Care Pregnancy Management ...................................................................... 6 Non-Attendance at the Antenatal Clinic ........................................................................................... 9 Services Provided by the Royal Hobart Hospital .............................................................................. 9

PRE-PREGNANCY ........................................................................................................................... 10 Pre-Pregnancy Counselling ........................................................................................................... 10 Vaccination Advice for New & Prospective Parents ....................................................................... 11

PREGNANCY .................................................................................................................................... 12 Guidelines for Measuring Symphysio-Fundal Height ..................................................................... 12 Abnormal Results .......................................................................................................................... 12 Scans ............................................................................................................................................ 12 Chromosomal Abnormalities.......................................................................................................... 13 Rh D Immunoglobulin (Anti – D) Administration ............................................................................. 18 Hyperemesis Gravidarum - Day Care Protocol .............................................................................. 20 Hypertension ................................................................................................................................. 23 Gestational Diabetes Mellitus - Screening ..................................................................................... 25 Early Bleeding and/or Miscarriage ................................................................................................. 26 Antepartum Haemorrhage ............................................................................................................. 28 Premature Rupture of Membranes ................................................................................................ 29 Decreased Fetal Movements ......................................................................................................... 30 Intrauterine Growth Restriction ...................................................................................................... 31 Smoking Assessment and Management ....................................................................................... 32

LABOUR AND BIRTH ....................................................................................................................... 33 Criteria for Exclusion from Birthing Suite ....................................................................................... 33 Vaginal Birth After Caesarean Section (VBAC).............................................................................. 34 External Cephalic Version ............................................................................................................. 36

POST-PARTUM................................................................................................................................. 38 Breast Feeding .............................................................................................................................. 38 Continence & Women’s Health Physiotherapy............................................................................... 40 Jaundice ........................................................................................................................................ 41 6 Week Postnatal Check (Mother) ................................................................................................. 42

MENTAL HEALTH ............................................................................................................................ 44 Perinatal Mental Health ................................................................................................................. 44 EPDS Screening ........................................................................................................................... 44 Resources ..................................................................................................................................... 45 Major Risk Factors for Postnatal Depression: ................................................................................ 46 Perinatal Depression Referral Options conception to 12 months post delivery .............................. 48

DEFICIENCIES/NUTRITION IN PREGNANCY/INFANTS ................................................................. 49 Anaemia in Pregnancy .................................................................................................................. 49 Iodine in Pregnancy ....................................................................................................................... 49 Vitamin D ....................................................................................................................................... 50 Vitamin K for Newborns ................................................................................................................. 50 Nutrition Before and During Pregnancy ......................................................................................... 50 Listeriosis ...................................................................................................................................... 50

© Primary Health Tasmania Revision Date: June 2016 1

SHARED CARE INFORMATION AND TOOLS

Introduction to Shared Care Women attending the RHH for management of their pregnancy and delivery have the option of having a major part of their antenatal care with their GP. This is dependent upon:

Their wishes

Agreement by their GP

Agreement by the hospital after assessment of risk factors Some of the benefits of shared care for patients are improved continuity and coordination of care, care provided within an established relationship, less travelling time; and convenience. For GPs shared care provides the opportunity to provide total patient care including postnatal; development of linkages with specialist and hospital resident staff, and access to continuing professional development in antenatal care. There is no accreditation requirement for GPs to be involved in shared care in Tasmania, but interested GPs should have some knowledge and interest in maternity care, and be familiar with the maternity shared care protocols. RANZCOG Qualifications GPs interested in extending their skills in this field may choose to undertake a Certificate of Women’s Health or a Diploma with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. For more information go to www.ranzcog.edu.au/education-a-training/certificate-diploma-training.hPrimary Health Tasmania Obstetric Medical Indemnity Insurance It is important that each GP participating in an Antenatal Shared Care check with their insurance company ascertains indemnity coverage for shared care (including shared care with midwives if appropriate).

http://www.ranzcog.edu.au/education-a-training/certificate-diploma-training.html


WACS Contacts

Women’s and Children’s Services (WACS) - Royal Hobart Hospital

Royal Hobart Hospital ph. 6222 8308

General enquiries

Paging medical and senior nursing staff

Inpatient enquiries

WACS Clinics ph. 6166 0000 fax. 6222 8900

Appointments

Antenatal Class Booking

WHC Clinic Co-Ordinator (for clinical enquiries) ph. 6166 8711

Extended Midwifery Service ph. 6222 7010

Lactation Consultants ph. 6222 7929 or 6222 8308

Genetic Counselling ph. 6166 8296 fax. 6222 7961

Pregnancy Assessment Centre (PAC) ph. 6222 8352 (all hours)

Pregnancy complications > 20/40

Assessment in early labour

Feto Maternal Unit (FMU) 6166 6180

Booked appointments for women who have been assessed and require monitoring during their pregnancy.

Early Pregnancy Assessment Service ph. 6166 8824 fax. 6222 8900

early pregnancy bleeding (<20 weeks gestation)

confirmed non-viable pregnancy, or stable suspected ectopic pregnancy

Patient Information Management Services ph. 6166 8447 fax. 6234 9039

Pathology enquiries ph. 6222 8416

Ultrasound ph. 6222 8343

Physiotherapy ph. 6222 8634 fax. 6222 7524

WACS Management Reception ph. 6222 8049

Group Manager of WACS – Sue McBeath

Business Unit Manager - Liza D’Ettorre

Assistant Director of Nursing – Heather Giannaros

Director of Obstetrics and Gynaecology – Sajid Patel

Nurse Unit Manager / Maternity Services – Becky French

Clinical Nurse Consultant Womens Health Clinic – Chris Bodger

Clinical Nurse Consultant (Maternity) – Denise Dillon


Conditions Not Suitable for GP to Share Care Obstetric shared care arrangements can be provided for most pregnant women but may not be recommended for women with specific contraindications listed below. It is recommended that GPs seek advice from an Obstetric Registrar / Consultant to clarify the required management of women with these contraindications. With obstetric consultant support, some GPs may be able to manage women with these conditions. Women presenting with a contraindication, including those listed below and in consideration of their clinical status, should be referred to the RHH (ideally at 12 weeks gestation) for assessment, where it will be decided whether the woman can continue with obstetric share care. The following conditions, identified before or during pregnancy, are not suitable for the woman to be managed in an obstetric shared care arrangement. General History

Endocrine disease including pre-existing insulin or non-insulin dependent diabetes mellitus

Cardiac disease

Renal disease

Hypertension

Respiratory disease

Neurological disease including epilepsy on medication, subarachnoid haemorrhage, multiple sclerosis

Thrombo-embolic disorders or antiphospholipid syndrome

Illicit drug use

Haematological disorders including haemoglobulinopathy, thrombocytopenia, significant anaemia i.e. Hb<90g/dl

Psychosis

Gastro-intestinal disease including Crohns disease, ulcerative colitis

BMI < 17 or > 40 kg/m2

Weight 120 kilograms or more

Genetic - any condition

Infectious diseases such as HIV infection, cytomegalovirus, tuberculosis, syphilis, hepatitis B&/orC

Maternal age under 16 or older than 45 years of age Gynaecological History

Pelvic floor reconstruction

Cervical abnormalities e.g. amputation, cone biopsy

Uterine abnormalities e.g. myomectomy, bicornuate uterus

Infertility treatment

Pelvic deformities e.g. trauma

Female genital circumcision Obstetric History

Severe pre-eclampsia or eclampsia

Perinatal death

Placental abruption

Preterm birth (less than 34 weeks gestation)

Intra-uterine growth restriction

Recurrent pregnancy loss 3 or more times

Suspected cervical incompetence

Having repeat caesarean section

Child with congenital and / or hereditary disorder

Rh or other blood group antibodies

Hypertension


Early Pregnancy Assessment

Rh or other blood group antibodies

Anaemia.

Multiple pregnancy

Haemoglobinopathy Arising During Pregnancy

Any of the above conditions

Antepartum haemorrhage

Fetal abnormality

Suspected intra-uterine growth restriction

Recurrent urinary tract infection

Gestational diabetes or abnormal GTT

Deep vein thrombosis or embolism

Placenta praevia

Non-cephalic presentation at 36 weeks gestation

Gestational hypertension

Pre-eclampsia

Threatened preterm labour

Cholestasis of pregnancy

Premature rupture of membranes

Polyhydramnios

Booking into Royal Hobart Hospital The GP should ensure that the share cared woman is booked into the RHH before 16 weeks gestation and preferably in her first trimester. To initiate the referral process to the antenatal clinic RHH, the referring GP forwards a referral to the Women’s Health Clinic. The referral form can be accessed at www.outpatients.tas.gov.au/clinics/obstetrics The referring GP should indicate on the referral form if the woman is more advanced in her pregnancy or if she wishes to have counselling about amniocentesis / chorionic villus sampling, so the earliest possible appointment can be organised. At the first appointment, the GP should explain the obstetric shared care protocols including the timing and nature of the antenatal visits shared between the participating hospital and GP. This will be emphasised at the woman’s booking-in appointment.

http://www.outpatients.tas.gov.au/clinics/obstetrics


Schedule of Visits

Gestation Location

1st visit Diagnosis GP

2nd visit 10-12 weeks Hospital

3rd visit 20 weeks GP

4th visit 26 weeks GP & RHH Midwife

5th visit 28 weeks (Rh –ve women) GP

6th visit 30 weeks GP


8th visit 36 weeks RHH & Midwives


10th visit 40 weeks RHH

Hand-Held Records The Royal Hobart Hospital uses a state-wide obstetric computer program called Obstetrix Tas. After the woman has been booked into the hospital, they are provided with:-

RHH Maternity Information Package - Maternity Services booklet; and

an Orange wallet which contains a number of information brochures.

Other information given to the woman at her booking in appointment:-

o a growth chart that is tailored for her,

o booking-in information summary,

o pregnancy hand-held record continuation sheet, and

o a printed record of the visit. All these documents form the woman’s hand-held record and are an important aspect of the communication process with the GP shared care program.

GPs: Please update the ‘Hand-Held Antenatal Record’ and the woman’s growth chart at each visit, as well as updating your clinical notes.

Women are to be reminded to carry their booklet with them to every visit with health professionals, including when presenting to pregnancy assessment centre and / or labour ward.


Check List for Shared Care Pregnancy Management

PRE- Confirm woman’s address and phone details are up to date

PREGNANCY BMI

Pre-HIV screening existing illness and/or medication review and allergy status

Check rubella status and immunisation history

Commence folic acid

PAP smear collected & woman to keep diary of menstrual cycles

Document woman’s history of diet, smoking, alcohol, drug use (including illicit drugs). Consider lifestyle behaviour advice.

Family history of inherited disorders

Racial origins (might need to check for haemoglobinopathy etc.)

FIRST VISIT Confirm pregnancy

With GP Record dates and calculate EDD using dates and cycle. If uncertain order dating scan (7-12 weeks) and copy to RHH

Reinforce benefits of folic acid supplementation

Assess if high risk and needs early referral

Provide information about Listeria and foods to be avoided

Advise to cease smoking/illicit drugs (consider lifestyle behaviour advice)

BMI

7-8 WEEKS

With GP

Please ensure woman is informed as to which tests are being performed. Please ensure that the laboratory concerned forwards a copy of these results to the Women’s Health Clinic, RHH.

Organise blood tests - FBE, ferritin, blood group and antibody screen, Rubella titre, Vitamin D, RPR, Hep B, MSU, Hep C HIV and Chlamydia, copy to RHH.

Flu vaccination offered

HIV screening

PAP smear collected if none in the last 2 years

POGTT to be organised if the woman has a history of gestational diabetes, BMI > 35 or has an ethnic background of Aboriginal, Torres Strait Islander, Pacific Islander or South Asian (copy to RHH)

Organise dating scan from 7-12 weeks gestation

Take full medical and obstetric history Advise woman to take vitamin D and folate, if not already commenced

Discuss first trimester screening for Down Syndrome, and organise blood test

(10-13.6 weeks) and nuchal translucency scan (11-13.6 weeks) If woman is 11-13.6 weeks, offer her first or second trimester Down Syndrome screening (copy to RHH). For women who are at risk, discuss options of CVS or amniocentesis. If woman is 14-20.6 weeks, offer second trimester Down Syndrome and NTD screening. Book morphology scan for 19-20 weeks gestation. Refer to pages 13 to16 of this kit for details of screening tests.

Fax referral to RHH to enable booking-in appointment to be scheduled before 16 weeks. For late referrals, please indicated urgency on referral appointment form.

Women who present with vaginal bleeding, abdominal cramps etc at < 20 weeks should be referred to the Early Pregnancy Assessment Service (EPAS) if haematologically stable.


12 WEEKS at Check results of blood, urine, Pap smear and scan

RHH Confirm EDD

Check BP and urine

Fill in shared care card and print growth chart

Woman provided with an overview of the visit schedule and book her 26 (midwife) and 36 (medical & midwife) RHH appointments at this time. Information booklets given to the woman.

Edinburgh Perinatal Depression and psychosocial assessment conducted

20 WEEKS Woman who are > 20 weeks & have complications to be referred to PAC

With GP Review ultrasound scan and Maternal Serum Screening Test (MSST) results and discuss with woman (ideally MSST results already checked)

Routine antenatal check

Organise routine 26 week blood test i.e. FBR, group & antibodies, POGTT, and send copy to RHH

26 WEEKS Routine antenatal check

With GP Discuss pathology results

Woman attends RHH for midwife education

28 WEEKS – GP Check blood results

Offer Anti-D for Rhesus D negative women. Women with antibodies are not suitable for shared care.

30 WEEKS – GP Routine antenatal check Organise routine blood test i.e. group & antibodies for Rhesus negative women

34 WEEKS – GP Routine antenatal check. Check pathology results

Offer second dose of Anti-D for Rhesus D negative women

36 WEEKS – RHH 36 week visit at RHH with medical officers and midwives

38 WEEKS – GP Routine antenatal check

40+ WEEKS - RHH RHH to discuss plans for induction of labour and delivery

Antenatal checks include:

BP (measured on the right arm with

the woman seated, with appropriate size cuff)

symphysio-fundal height in centimetres, and recorded on woman’s customized growth chart

fetal heart & movements

gestation in completed weeks, presentation & descent after 30 weeks

urinalysis(if clinically indicated)

Smoking and use of medications and illicit drugs

Urine Testing Routine urine MC&S should be performed in early pregnancy to assist in the detection of chronic renal disease. Routine urinalysis during pregnancy is a poor predictor of pre-eclampsia, in the absence of hypertension. Routine urinalysis can be eliminated from antenatal care without adverse outcomes for women, after an initial screening MC&S on a midstream specimen.

Weighing There is no conclusive evidence to support routine weighing of women at every antenatal visit. It is not a clinically useful screening tool for the detection of growth restriction, macrosomia or pre-eclampsia. The woman’s BMI needs to be calculated at the woman’s first visit to assist in risk assessment. Weight gain for healthy weight range women is 11-16 kilograms.


CHECK LIST FOR SHARED CARE PREGNANCY MANAGEMENT

POSTNATAL

1 WEEK POST psychological well-being of mother (assess support network)

PARTUM discuss mode of delivery and any complications

check episiotomy or LUSCS scar if necessary

BP

discuss contraception options

encourage pelvic floor and other exercises

check rubella status and advise re-vaccination (HPV)

infant feeding method and success

examine infant

6 WEEK POST psychological well-being of mother (Edinburgh Postnatal Depression

PARTUM Scale – see page 46)

history from mother about PV bleeding, passing urine and bowel motions

discuss resumption of intercourse +/- start contraception

examine abdomen, BP, breasts and perineum if indicted from history

(collect PAP if due)

examine infant as per protocol and discuss maternal satisfaction with

progress

discuss attending child health clinic and mother-baby groups etc

check re started pelvic floor exercises - consider referral to physiotherapy

remind re 8 week immunisations

patient with Gestational Diabetes – OGTT (75g) for GDM positive


Non-Attendance at the Antenatal Clinic If a woman does not attend a ‘booking-in’ appointment at the ANC visit, despite her being sent a number of appointments via mail (including registered mail), she will be referred back to her GP. If the woman has booked in but we are unable to contact her or she refuses to attend, the GP will be notified.

Services Provided By the Royal Hobart Hospital

The Women’s Health Clinic is now located on the 8th floor of the Wellington Centre where the following services are provided:-

Antenatal Clinic for High Risk Women

Antenatal Anaesthetic Clinic

Pre-pregnancy counselling

Complex Care Clinic

Endocrine Clinic (Multi-disciplinary team)

Know Your Midwife (KYM- team midwifery) provides antenatal, intrapartum and postnatal care, thus providing continuity of care

Young Mums Clinic offers a 12 week rotating education program. This is a “one stop shop” such as social worker, midwifery education, antenatal care, pathology collection, lactation consultation, Centrelink and food for this special group.

Medical and Midwife Antenatal Clinic

Prenatal Diagnosis Clinic including provision of amniocentesis and chorionic villus sampling (CVS).

Feto Maternal Unit- booked appointments for women whose pregnancy require monitoring, for example, intra uterine growth restriction, pre-eclampsia or are transferred to our care for on-going management.

Early Pregnancy Assessment Service

Childbirth Education including Tours of Maternity and Neonatal Unit, antenatal, twins, refresher and grandparents

Debrief for previous traumatic births and / or experiences e.g. Still-Birth

Antenatal Exercise Classes

Lactation consultants and breast feeding education

Physiotherapy

Exercise Classes

Hospital Based Services

Pregnancy Assessment Centre (after 20 weeks gestation and still located within the hospital building). This is for women presenting with acute problems during pregnancy e.g. spontaneous rupture of membranes, preterm contractions, etc.

Grief counselling

Genetic counselling

Extended Midwifery Service

Community Based Services

Satellite Midwifery Antenatal Clinics (staffed by midwives from the Womens’ Health Clinic)

Midwifery Group Practise: Philosophy is that childbirth is a natural event and women are allocated a primary midwife who care for them throughout their pregnancy, intra-partum and provide home based post natal care. These women agree to have home based postnatal care which includes a shorter hospital stay unless there are problems.

Mums on the Move (postnatal exercise group)


PRE-PREGNANCY

Pre-Pregnancy Counselling As care in the antenatal period and, particularly, the late antenatal period has improved, further improvements in perinatal mortality and pregnancy outcome will be determined more and more by management of the period of time leading up to conception and the first few weeks after conception.

For this reason, pre-pregnancy counselling is an important and integral part of any woman's health care if she is contemplating a pregnancy. Much of this can be very readily managed in general practice, although it is recognised there are situations where specialist advice will be required. It is suggested that the advice of both the appropriate specialist in the discipline involved and an obstetrician should be sought. Sometimes specialist paediatric advice is appropriate as well. The Genetic Counselling Service should also be involved as appropriate. The following areas should be addressed in the general practice consultation:

1. Rubella immunity testing. If not rubella immune, vaccinate and retest three months later. It is advised to use contraception during this time, although the US Centre for Disease Control notes that there have been no cases of congenital rubella syndrome reported when conception has occurred following vaccination. Hence, conception during this time is not an indication for termination of pregnancy.

2. Hep B or Hep C or HIV testing.

3. Advice re folic acid supplementation. For routine supplementation the dose is 0.5mg per day. Particular attention should be paid to women who have a family history of neural tube defect, an affected child, women with a BMI of 30 or more, women with pre-existing diabetes type 1 & 2 or who are taking drugs that increase the risk of neural tube defects eg anticonvulsants. The dose for women in high risk groups is 5 mg per day. Dosing should commence 1 month prior to conception, and should be continued until at least the 12th week of pregnancy. Check the B12 level prior to commencing folic acid, if the patient has auto-immune disease or a family history of pernicious anemia, particularly in the mother. There is a risk of neurological problems when folic acid supplementation occurs in B12 deficient people. Whilst very rare, it is brought up regularly when people discuss the risks of folic acid supplementation.

4. Past medical history and the use of medications. This is particularly important if a woman is on ACE Inhibitors for essential hypertension. This should be changed to methyldopa prior to pregnancy.

5. Family history. This should include a genetic history and also a history of ethnic origins. Certain groups have a higher risk of specific diseases eg Thalassaemia in people of Mediterranean, South East Asian or North African origin; Tay Sachs disease in Ashkenazi Jews. A family history of cystic fibrosis should also be checked. Consider referral to Genetic Counselor.

6. Advice re the use of alcohol, cigarettes or any illicit drugs.

7. Advice regarding diet in pregnancy and also the issue of Listeria. Advice should be given regarding foods to be avoided. See Deficiencies/Nutrition in Pregnancy/Infants section on page 50.

8. Exercise advice.

9. Advice regarding the work place.

10. Advice should be given to women who will be 35 years and older (at the time of delivery) regarding the issue of chromosome abnormalities, in particular Down Syndrome. Discuss screening versus diagnostic testing.

11. General medical examination with a Pap smear and appropriate STD screening if needed.

12. Dental hygiene and advice for a routine dental checkup.

(Can be adapted as a patient handout)


Vaccination Advice for New & Prospective Parents Many infectious diseases still occurring in our communities could be prevented by vaccination, and many adults are leaving themselves at risk by being inadequately immunised. Vaccination not only provides protection for parents, it confers some protection on new babies. This happens in two ways – firstly by allowing the mother to pass on, during pregnancy, some passive immunity to her newborn baby, and secondly, by reducing the chances of a parent bringing one of these diseases into the home. Patients should be aware that vaccinations may have different costs at different practices. All those planning a pregnancy and all new parents should consider the following vaccinations: Measles, Mumps, Rubella

Until 1966, regular measles epidemics occurred in Australia, so most adults born prior to 1966 have been in contact with measles and are likely to be immune.

All adults born after 1983 should have received a dose of Measles Mumps Rubella (MMR) vaccine in infancy, and been offered a 2nd dose in grade 6 or 7.

Adults born between 1966 and 1983 were not offered this 2nd dose at school, and this age group is experiencing repeated measles outbreaks. They should receive a 2nd dose of MMR vaccine.

Measles is still endemic in many countries and many measles outbreaks in Australia now occur after travellers import the disease from overseas. It is especially important to ensure your MMR vaccinations are complete before overseas travel.

Diphtheria-Tetanus-Pertussis (Whooping Cough): Boostrix / Adacel The Australian Immunisation Handbook 10th Edition (2013) recommends that a single dose of a pertussis containing vaccine (dTpa) is given to women either pre-pregnancy, or as soon as possible after delivery. Alternatively this vaccine can safely be given to women during the third trimester of pregnancy, if 5 years of more have elapsed between the previous dose and the expected date of delivery. This will provide both direct protection (by transplacental transfer of maternal pertussis antibodies) and indirect protection (by immunising the mother) to the infant. Maternal pertussis vaccination may thereby protect infants before they receive their first pertussis vaccination at 6 to 8 weeks of age. The benefits of pertussis vaccination during pregnancy are likely to be greatest during pertussis epidemics. Household and family members and others who are likely to have close contact with babies should also ensure their pertussis vaccination is up-to-date. The Handbook can be found at: www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home Chickenpox (Varicella) Pregnant women who have come into contact with someone with chickenpox and who do not recall having the illness should have a blood test to check their immunity. If they are not immune, they need 2 doses of Varicella vaccine, 4-8 weeks apart. HPV Not recommended. However, where vaccine has inadvertently been given during pregnancy, further doses should be deferred until after delivery. Influenza Annual flu vaccination is recommended for all adults, and especially smokers, those with chronic diseases, those over 65 yrs. of age, pregnant women, and those in contact with the very young or the very old. Pregnant women should be actively encouraged to have the flu vaccine which can be given at any stage during pregnancy.

Fact sheets about these vaccinations, a pre-vaccination check list, and possible reactions to vaccinations are available at the practice.

http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home


PREGNANCY

Guidelines for Measuring Symphysio-Fundal Height Accurate symphysio-fundal height will aid in antenatal assessment. The GP should ensure the following is undertaken to optimise an accurate symphysio-fundal height measurement. The GROW chart is a vital tool for the screening of growth disorders of the fetus. This is an individualised growth chart for the mother and has been shown to improve screening for growth restriction or macrosomia. It is important that the symphysio-fundal height is plotted on the chart at each visit.

Lay the woman in the supine position with her head supported on a single pillow. The couch should be flat.

Measure the highest point of the fundus to the top of the symphysis pubis. Begin measuring from the fundus since this is the more variable end point.

Measure with the tape scale facing downwards so avoiding less influenced by previous results.

Record the measurements to the nearest 0.5 centimetre and enter them on the woman’s growth chart (GROW Chart).

Plot the measurement against the gestation in weeks on the symphysio-fundal height chart. Using the woman’s customised growth chart plot the fundal height. If the fetus appears either small (less than 10%) or large (greater than 90%) for gestational age or on consecutive measurements suggests NO fetal growth or there is slow or excessive fetal growth, then a growth ultrasound is required. If the ultrasound is normal, continue with serial fundal height measurements, but if it is abnormal, refer to RHH for an urgent Obstetric review. If a growth chart has not been developed for the woman, please contact the Women’s Health Clinic and we will create one and fax it to you.

Abnormal Results Any investigations requested by the GP for the woman under his/her care must be followed up by the GP concerned. It is the GP’s responsibility to follow up all abnormal results irrespective of whether a copy has been sent to the participating hospital. If an abnormal MSST result is received and faxed late to the clinic, please call the clinic to ensure it has been received.

Scans All women should be offered screening for chromosomal anomalies. This should be offered in the first and second trimester. The first trimester screening involves nuchal translucency at 11 – 13w6d and biochemistry from 9w0d - 13w6d. The second trimester screening involves biochemistry at 14w0d – 20w6d. The first trimester nuchal translucency ultrasound scan is available at RHH and at private medical imaging services. The blood test is arranged through the SAMSAS (South Australian Maternal Serum Antenatal Screening) Program, which provides services accredited by the Maternal Fetal Medicine Foundation. SAMSAS uses the information from the blood tests and nuchal translucency scan to calculate the risk of chromosomal anomalies for a particular woman and sends the result to the referring doctor.

It is imperative that all the information required on the first or second trimester serum screen request form is filled in as it has a significant influence on the aneuploidy risk assessment outcome. A pregnant woman with an abnormal maternal serum screening result must be promptly referred to the Prenatal Diagnosis Clinic for counselling with a view to offering Chorionic Villus Sampling (CVS), Amniocentesis or further discussion regarding the Non Invasive prenatal Testing.


It is suggested that GPs read and are familiar with the section below – “Chromosomal Abnormalities”. Women who have an increased risk of a chromosomal disorder or those with a family history of genetic disorder should be offered the first trimester screen or referred to the Prenatal Diagnosis Clinic early for appropriate counselling.

Chromosomal Abnormalities

Screening Options 1. Maternal Age

Maternal age is a poor screening test

Offering diagnostic testing to all women over 37 years will detect less than 50% of babies with Down Syndrome, and will expose an unacceptably high number of pregnancies to the miscarriage risk associated with invasive diagnostic testing.

Women of advanced maternal age should be offered first trimester screening as a first step, progressing to diagnostic testing only if the screen indicates an increased risk of aneuploidy. This also applies to all pregnant women of any age as most of the aneuploidies detected in pregnant women are from the younger age group.

It is imperative that all the relevant information required for SAMSAS be provided as it will affect the result.

2. First trimester screening (FTS)

Higher sensitivity and specificity than any other screening test

Calculates numerical risk for trisomy 21 (Down Syndrome) and trisomy 18

Does not screen for neural tube defects

Two components:

i. Blood test (hCG and PAPPA) between 10 – 13+6 weeks

ii. Nuchal translucency scan between 11 – 13+6 weeks

NOTE: Whilst a woman can have her blood taken before her scan, logistically it is more straightforward if she has her blood taken the same day as the scan (i.e. after gestational age has been confirmed)

Cut-off is 1:250 (eg 1:251 = “not at increased risk”, 1:249 = “increased risk”)

Results (usually) available in time to consider CVS if at increased risk

If NT is > 3.5mm patient should be referred to the Prenatal Diagnosis Clinic to discuss invasive testing (increased risk of other chromosomal abnormalities eg Turner syndrome).

3. Nuchal translucency alone

Measured between 11 – 13+6 weeks

Not as accurate as combined first trimester screening

Good option if patient doesn’t manage to get blood taken by 13+6 weeks

Good option for twin/multiple pregnancies

4. Second trimester screening (MSST)

Lower sensitivity and specificity than FTS

Calculates numerical risk for trisomy 21 (Down syndrome), trisomy 18 and neural tube defects

Blood test (AFP, hCG, estriol) between 14 – 20+6 weeks

Cut-off is 1:250 (eg 1:251 = “not at increased risk”, 1:249 = “increased risk”)

Can get false positive results if gestational age has not been confirmed by dating scan (note this is not an issue in FTS because the NT scan serves this purpose)

Increased risk results too late for CVS, but in time for amniocentesis

Good option if patient presents too late for first trimester screening


5. The 18 – 20 week morphology scan

Not recommended as a screening test for Down syndrome specifically but the detection of soft markers should prompt referral to the Prenatal Diagnosis or High Risk Clinic for further discussion.

Has some use in the context of an “increased risk” result from screening, as it can be used to modify the risk issued by FTS/MSST (see below)

Screening: South Australian Maternal Serum Antenatal Screening (SAMSAS) program.

For information sheets and forms on nuchal translucency go to www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.hPrimary Health Tasmania

Options for Those Screened “At Increased Risk” Women who screen “at increased risk” for Down Syndrome have 3 options: 1. Take no action.

Some women will be satisfied with a risk of eg, 1:250, particularly if this is significantly lower than their age-related risk or if they decide against invasive testing.

2. Diagnostic testing

There are two diagnostic procedures, CVS and amniocentesis. Women who receive screening results before 14 weeks will have a choice between the two. Women who receive screening results after 14 weeks will only have the option of amniocentesis.

Chorionic villus sampling (CVS) o Performed from 11 – 14 weeks gestation o Outpatient procedure, local anaesthetic. Takes approximately 30 minutes. o Samples cells from the fetal placenta o Is performed trans-abdominally. Transvaginal procedure is not usually performed

because of the significant increased risk of miscarriage. It is usually deferred in favour of amniocentesis if the placenta is inaccessible by CVS.

o Placental cells are cultured for karyotyping, which detects all major chromosomal abnormalities including all trisomies, Turner syndrome, and many other chromosomal rearrangements.

o Miscarriage risk is approximately 1 in 100 o Results available in approximately 10 – 12 days o For public patients, rapid results (48 hours) by F.I.S.H. (Fluorescence In-Situ

Hybridisation – a limited technique which detects only trisomies 13, 18 and 21 and sex chromosome abnormalities) are available only for women who meet one of the following criteria:

Increased risk screen of 1:20 or greater from FTS or MSST

Increased risk screen at 20+ weeks gestation

Increased risk screen in the presence of ultrasound abnormalities

F.I.S.H. is performed as well as, not instead of routine karyotyping

o Results may be available in time to give those with abnormal results the option of termination by surgical evacuation (around 14 weeks) but the timing is very tight. Terminations of pregnancy after around 14 weeks are carried out by inducing labour.

o CVS is the procedure of choice for couples having pre-natal diagnosis for a single gene disorder or familial chromosomal translocation.

o Mosaicism is detected in approximately 1% of all CVS samples. Usually requires clarification by amniocentesis (mosaicism can be confined to the placenta).

For more information: www.thewomens.org.au/ChorionicVillusSamplingCVS

http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html

http://www.wch.sa.gov.au/services/az/divisions/labs/geneticmed/samsas.html

http://www.thewomens.org.au/ChorionicVillusSamplingCVS


Amniocentesis o Performed from 15 weeks onwards o Occasionally amniocentesis will not be possible or will need to be delayed if there is

difficulty with access to the amniotic sac o Outpatient procedure, takes approximately 20 minutes o Local anaesthetic is seldom used o Samples cells from the amniotic fluid (fetal skin cells and amniocytes) o Cells cultured for karyotyping. Detects chromosomal abnormalities as for CVS o Miscarriage risk is less than 1 in 200 o Results available in approximately 14 days o Rapid results by F.I.S.H. available as described above

For more information: www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Amniocentesis 3. Wait for the 18 – 20 week ultrasound

Ultrasound is a poor screening test for Down syndrome on its own, as approximately half of all fetuses with Down syndrome will have completely normal morphology scans. However, ultrasound can be useful in the context of an “increased risk” screening result.

A normal 18 – 20 week scan (no abnormalities or soft markers) roughly halves the patient’s prior risk of Down syndrome (from FTS or MSST)

For example, a woman who receives an “increased risk” screen result of 1:250, and then has a normal 18 – 20 week ultrasound, can be advised that her risk of Down syndrome is reduced to approximately 1:500.

Some women who are uncomfortable with their increased risk result, but reluctant to have diagnostic testing (eg because of past history miscarriage), will want to await the outcome of the ultrasound before deciding between no action and diagnostic testing.

The main disadvantage of this option is that the patient must wait until at least 18 weeks gestation for their scan. Time is then running out for termination of pregnancy if diagnostic testing is performed and yields abnormal results.

Women who screen at increased risk of a neural tube defect on MSST do not require CVS/amniocentesis but should be referred for a detailed ultrasound.

Counselling of Those Screening “At Increased Risk” of a Chromosomal Disorder

Patients who receive an “increased risk” screening result should be offered a face-to-face appointment to discuss the result. Ideally the patient’s partner/husband should attend. The person counselling the patient should aim to cover the following:

Address anxiety

Assess understanding of what Down syndrome is

Discuss magnitude of screened risk relative to patient’s age-related risk

Outline options (no action/diagnostic testing/wait for 18-20 week ultrasound) including advantages and disadvantages of each

Explain the diagnostic procedures, what’s involved, risk of miscarriage

Explain limitations (a normal karyotype doesn’t rule out all genetic diseases)

Explore patient’s thoughts about raising a child with a disability (resources & support – financial, emotional and family)

Explore patient beliefs concerning termination of pregnancy

Explain termination procedures (surgical evacuation, induction of labour)

Time frame for results

The possibility of detecting an unexpected chromosomal abnormality It is preferable that there is a time interval of at least 24 hours between this counselling and any appointment for a diagnostic procedure to allow the patient time to absorb the information, reflect, discuss with their partner, and reach a decision they are comfortable with.

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Amniocentesis


GPs may elect to counsel their patients themselves, or may elect to refer the patient to the Prenatal Diagnosis Clinic (ph. 6166 8711) or Genetic Counselling service (ph. 6222 8296). See diagram on following page. Dr Kris Barnden conducts a Prenatal Diagnosis clinics at the Royal Hobart Hospital which is dedicated to diagnostic testing (CVS and amniocentesis) for those at increased risk of chromosomal or single gene disorders. If you have counselled your ‘increased risk’ patient yourself, and the patient elects to have either CVS or amniocentesis, you may arrange this by faxing a referral form addressed to RHH antenatal clinic (fax 6222 8900) with a copy of the increased risk report (and dating scan report if MSST) and details about

which procedure the patient is requesting. If you would like your ‘increased risk’ patient to see a genetic counsellor for discussion and help with decision making, please contact the genetic counselling service (ph. 6222 8296). Fax an ORP referral addressed to Prof David Amor and Genetic Counsellors to the Genetic Counselling department (fax 6222 7961). Your patient will be contacted within 24 hours (weekends excepted) and offered a face-to-face appointment (although some patients prefer to receive this counselling by phone). Those patients who elect to have CVS or amniocentesis will be booked into the appropriate Tuesday morning clinic by the genetic counsellor. Those who elect to await the outcome of the 18 – 20 week scan will be followed up by a genetic counsellor after the scan takes place. Normal results from diagnostic testing will be phoned to the patient by either a genetic counsellor or midwifery staff depending on the route of referral. All abnormal results will be phoned to patients by a genetic counsellor or midwifery staff, and an appointment arranged with a consultant obstetrician (usually) within 24 hours. Copies of diagnostic testing results will be faxed to the referring GP. If your patient is requesting pre-natal diagnosis because of a personal or family history of a single gene disorder or familial chromosomal translocation, please refer directly to the genetic counsellors as soon as possible – some ‘work-up’ may be required before pre-natal testing can be offered.

NON INVASIVE PRENATAL DIAGNOSIS TESTING (NIPT) This is a non-invasive prenatal screening test which involves the extraction of free fetal DNA circulating in the maternal blood. It is a very accurate screening test particularly for Trisomy 21 and 18 and for the sex chromosomes but less so for Trisomy 13. A negative test for the above will mean that the risks of Trisomies 21 and 18 are low. However, if the test does not exclude any of the Trisomies, further invasive testing will need to be carried out to confirm or exclude the diagnosis. It is not funded under Medicare and women will have to pay for the test, which currently costs around $900, but the price is anticipated to come down significantly in the future. It takes around 5 – 10 days for the results to be available.

© Primary Health Tasmania 2014 Revision Date: June 2015 17

FOLLOW UP OF INCREASED RISK RESULTS FROM First Trimester Screening (FTS) / Maternal Serum Screen Test (MSST)

Refer to genetic counselling ph. 6166 8296 fax 6222 7961 ORP referral addressed to Prof David Amor and Genetic Counsellors

Increased risk result from FTS or MSST

Counsel patient

Patient chooses diagnostic testing

Patient wants no action

Patient waits for 18 week ultrasound

Genetic counsellor counsels patient

Note: Form must be comprehensively completed.

Call antenatal clinic on ph: 6166 8711 and fax referral to Dr Kris Barnden and CNC of clinic, fax: 6222 8900.

Include copy of FTS/MSST result and scan.

CVS/amniocentesis/NIPT

Patient chooses diagnostic testing

Patient wants no action

Patient waits for 18 week ultrasound

Genetic counsellor arranges diagnostic testing

CVS/amniocentesis Results phoned to patient by genetic counsellor

Results phoned to patient by midwifery staff

Normal results

Abnormal results

All

results

© Primary Health Tasmania 2012 Revision Date: June 2013 18

Rh D Immunoglobulin (Anti–D) Administration

Rh D negative women are at risk of alloimmunisation resulting in the development of haemolytic Anti-D antibodies that are able to cross the placenta to such an extent that an Rh D positive foetus and newborn are at risk of serious morbidity and mortality. Women with Rh D antibodies are not suitable for shared care. The following information therefore relates only to women who are Rh D negative and have no preformed antibodies. If the woman is Rh D negative and has no preformed Anti-D antibodies, the GP should inform her about the need to prevent Rh D sensitisation. This includes:

Anti-D administration if a sensitising event occurs in pregnancy;

routine prophylaxis at 28 and 34 weeks gestation; and

further prophylaxis after birth if the baby is not Rh D negative. Recurrent vaginal bleeding requires discussion with referral to the RHH before administering doses of Anti-D. The GP should note that informed consent for prophylaxis should be obtained early in pregnancy (as soon as the Rh D status has been determined). This is to cover any and all occasions on which Anti-D may become indicated during pregnancy. The woman’s consent for prophylaxis must be documented in her Pregnancy Record.

Dose

Strength Product INDICATION

250 IU Rh D Immunoglobulin 1st trimester (less than 12 weeks) sensitising events, single pregnancy

625 IU Rh D Immunoglobulin 1st trimester sensitising events, multiple pregnancy

625 IU Rh D Immunoglobulin 2nd & 3rd trimester sensitising events

625 IU Rh D Immunoglobulin Routine prophylaxis at 28 weeks

625 IU Rh D Immunoglobulin Routine prophylaxis at 34 weeks

625 IU Rh D Immunoglobulin Post-partum if baby Rh D positive

250-625 IU Rh D Immunoglobulin As determined by Kleihauer testing

Anti-D Prophylaxis for Potentially Sensitising Events Potentially sensitising events are defined as any situation in which there is an increased likelihood of fetal red blood cells entering the maternal circulation. These include:

any uterine bleeding in pregnancy ranging from (threatened) miscarriage to antepartum haemorrhage;

any abdominal trauma in pregnancy; and

any uterine or intra-uterine intervention (such as external cephalic version, amniocentesis, etc). However, the responsibility for prophylaxis rests with the RHH at which these interventions are performed.

If a sensitising event occurs before 13 weeks gestation, the recommended prophylaxis consists of 250 IU (international units) Commonwealth Serum Laboratory (CSL) Rh D immunoglobulin. If a sensitising event occurs at or after 13 weeks gestation, the recommended prophylaxis consists of 625 IU (international units) CSL Rh D immunoglobulin. If a woman has a sensitising event after routine prophylaxis at 28 weeks, she should have a dose of Anti-D regardless of when the prophylactic dose was administered.


Routine Prophylaxis at 28 and 34 Weeks (with or without previous sensitising events) Rh D negative women without preformed Anti-D antibodies should receive 625 IU CSL Rh D immunoglobulin at 28 weeks (after or simultaneously testing for preformed Rh D antibodies) and again at 34 weeks. Basic principles about the timing of the routine prophylaxis are:

the Anti-D administration will provide cover for a minimum of 6 weeks

the risk of sensitisation increases as pregnancy progresses Thus, if the woman has received Anti-D slightly before 28 weeks, the 34 weeks injection should still be given as planned at 34 weeks. If the woman has missed out on receiving Anti-D at 28 weeks (for example because they did not attend), Anti-D should be given at the next visit (better late than never). In that case the second injection should be planned 6 weeks later, provided that the woman is still pregnant. If the woman has received Anti-D for a potentially sensitising event (eg antepartum haemorrhage or trauma) before 28 weeks, she should still receive Anti-D at 28 and 34 weeks as scheduled unless the Anti-D for the sensitising event was administered less than 1 week before the prophylactic dose being due. Administration of Anti-D immunoglobulin must be conducted in her shared care pregnancy hand-held record and GP records.


Hyperemesis Gravidarum - Day Care Protocol Hyperemesis is very common in pregnancy. In the main this can be managed very well at the level of general practice. There are simple measures that can be undertaken to relieve the majority of women with this condition. It is important to point out, however, that nausea can continue often until 16 weeks or more.

Management in General Practice

Full history and examination

Urine analysis and possible MSU to check for urinary tract infection

Consider ultrasound scan to check for multiple pregnancy

Remember that there are other conditions that can lead to vomiting such as raised intracranial pressure (benign intracranial hypertension) and space occupying lesions within the brain.

Simple management measures:

- encourage early carbohydrate intake first thing in the morning

- avoid prolonged hot showers

- advise to have regular intake of high carbohydrates food throughout the day in multiple meals rather than three main meals

- avoid prolonged periods of standing, particularly in hot weather or in hot buildings in winter time.

If these measures do not work then:

- try a ginger supplementation

- acupressure

- acupuncture

See algorithm on page 21 for medical treatment of mild to moderate symptoms.

For women not responding to the above measures

If under 20 weeks, refer to Department of Emergency Medicine

If greater than 20 weeks gestation and “booked in”, refer to Pregnancy Assessment Centre

Assessment will be made as to whether admission to hospital is required for rehydration and anti-emetic therapy.

Assessment and management may include:

U&Es & creatinine, LFTs

MSU (discretionary)

temperature, pulse and blood pressure four hourly

intravenous fluid replacement: the standard protocol would be for two litres of Hartman’s Solutiongiven over six hours; if ketotic will need 1/5 N. Saline with 4.5% Dextrose

rectal prochlorperazine along with oral pyridoxine and doxylamine

For very severe hyperemesis, intravenous haloperidol or promethazine can be used, or ondansetron orally, but this is best managed as an inpatient as these patients are usually very sick and may have electrolyte disturbances requiring careful replacement.

Discharge from the centre

patient must have someone drive them home after assessment

it is preferable that the woman has family support/assistance at home for 24 hours following discharge

appropriate anti-emetic therapy as ordered

persistent vomiting would result in the woman being readmitted.


Tasmanian Public Hospitals (Tasmanian Health Service)

Nausea and Vomiting in Pregnancy (NVP): Medical Treatment Algorithm*2013

*This algorithm assumes that other causes of nausea and vomiting have been ruled out. Admit for intravenous fluids if dehydrated.

If the women’s condition does not improve go to the next step.

Mild or moderate symptoms

Pyridoxine (vitamin B6) 50mg orally up to four times a day. (uncategorised by TGA)

Add Doxylamine (Restavit©)(H1 antagonist) 12.5mg orally nocte, increasing to 25mg at night then add 12.5mg mane and afternoon as required. (TGA Category A)

Prochlorperazine (Stemetil©) 5 to 10mg orally two or three times a day or 25mg PR once to twice a day. (TGA Category C)*

Promethazine (Phenergan©) 10 to 25 mg orally three to four times a day. (TGA Category C)*

Severe, persistent or resistant nausea and vomiting

Ondansetron (Zofran©) 4mg tablet orally two or three times a day. (TGA Category)

B1)

Consider changing regimen to ANY of the following:

Prochlorperazine 12.5mg IM every 8 hours (TGA Category C)*

Promethazine 12.5mg to 25mg IM every 4 to 6 hours (TGA Category C)*

Metoclopramide 10mg IV/IM every 8 hours (TGA Category A)

Ondansetron 4mg IV/IM every 8 to 12 hours (TGA Category B1)

If symptoms persist:

Seek Specialist Advice

Thiamine IV 100mg daily for 2-3 days, followed by intravenous multivitamins, is recommended for every woman who requires IV hydration and has vomited for more than 3 weeks.

If this treatment is unsuccessful, trial pyridoxine with one of the other drugs below. Repeat trial of pyridoxine with alternative drug if first and second combinations are unsuccessful:

Metoclopramide (Maxolon©, Pramin©) 10mg orally three or four times a day (TGA Category A)

*TGA Category C listing details: When given in high doses during late pregnancy, phenothiazines have caused prolonged neurological disturbances in the infant.


NVP Algorithm References:

AGOG Practice Bulletin No. 52. Nausea and Vomiting of Pregnancy, Obstetrics and Gynaecology 2004 103(4) 803-814

The Royal Women’s Hospital Clinical Practice Guideline; Nausea and Vomiting of Pregnancy: Medical Treatment Algorithm. July 2009

SOGC Clinical Practice Guidelines; Management of Nausea and Vomiting of Pregnancy. No120, October 2002

Therapeutic Guidelines; Nausea and Vomiting During Pregnancy

Australian Categorisation Scheme for prescribing medications in pregnancy. www.tga.gov.au Summary of Sources of information:

This document is largely based on The Royal Women’s Hospital Clinical Practice Guideline; Nausea and Vomiting of Pregnancy: Medical Treatment Algorithm. July 2009. Changes to this document are defined below.

The order of box 3 (composing 5 boxes joined together) is based on Therapeutic Guidelines; Nausea and Vomiting During Pregnancy

The order of box 6 is based on SOGC Clinical Practice Guidelines; Management of Nausea and Vomiting of Pregnancy. No120, October 2002 which also notes that Metoclopramide has limited evidence of efficacy in this condition and states that Phenothiazines are safe and effective for severe NVP.

Reference to using prednisolone has been removed from the document following discussion with Obstetricians and Gynaecologists state-wide as use of this medication sits firmly in the realm of ‘seek specialist advice’.

The information in box 8 is from AGOG Practice Bulletin No. 52. Nausea and Vomiting of Pregnancy ,Obstetrics and Gynaecology 2004 103(4) 803-814

The information in box 9 is from Australian Categorisation Scheme for prescribing medications in pregnancy. www.tga.gov.au

Proposal for STDC consideration:

Ondansetron 4mg tablet be available on the Tasmanian Public Hospital Formulary for the outpatient management of nausea and vomiting of pregnancy by obstetricians and gynaecologists with regard to the proposed treatment algorithm, as a maximum quantity of 30 tablets (no repeats), at $25 for general patients and the concessional rate for concessional patients.

http://www.tga.gov.au/

http://www.tga.gov.au/


Hypertension Hypertension is a common condition managed by general practitioners. However, blood pressures that might be acceptable in non-pregnant patients can be quite unacceptable during pregnancy and be associated with significant risks to the health of both the mother and the baby. A diastolic blood pressure of 90mmHg at 30 weeks is > 3 standard deviations from the mean, and at near term is > 1.5 standard deviations from the mean. In pregnancy, endothelial damage and the risks of cerebrovascular accident can be shown to be occurring once the systolic pressure reaches or exceeds 160 mmHg. Hypertension in pregnancy can be categorised as Pregnancy Induced Hypertension (PIH), pre-eclampsia or essential hypertension. In primigravida, pre-eclampsia is the most common; in multi gravidae essential hypertension is the most common. Hypertension in pregnancy is diagnosed when two readings, six hours apart are > 140/90. BP is generally taken in the sitting position. It should be borne in mind that women with a large arm may have a falsely elevated blood pressure, and readings should be taken with a wide cuff. With regard to pre-eclampsia, it should be borne in mind that hypertension is a late sign of this disease. The pathophysiology starts at 16 weeks and many of the abnormal physiological functions associated with pre-eclampsia will be well and truly established by the time hypertension becomes apparent. Pregnant women who complain of epigastric pain or discomfort should not be presumed to have heartburn and should have their BP checked and urinalysis carried to exclude proteinuria. Pre-eclampsia may sometimes present with this symptom alone due to liver capsular stretch. Management of Hypertension in Pregnancy

1. Who to refer

Patients with blood pressure > or = 140/90 mmHg after 10 minutes rest: refer to Feto Maternal Unit (FMU) if woman comes directly from the clinic and PAC if the woman comes from the community or if FMU is closed.

Patients with blood pressure > or 170/110 mmHg: refer for direct admission to hospital

Note: After 30 weeks consideration should be given to induction of labour if BP is significantly elevated and the clinical circumstances such as deteriorating fetal condition are appropriate.

2. Initial Assessment at FMU or PAC

BP should be measured with the patient seated. Four measurements over 2 hours

urinalysis for protein and glucose will be performed

CTG will be recorded

blood will be drawn for FBE, U & Es, urate, LFTs and renal function tests. Results of blood tests will be available by the end of the session.

3. Subsequent Management

If the blood pressure is < 140/90 mmHg and proteinuria is < 30 or <++ and the CTG is reactive, the patient will be followed up in Antenatal Clinic

If the blood pressure is more than 150/100 mmHg or proteinuria is >30 or >++ or the platelet count is less than 100, that patient will be reviewed by the Registrar or Staff Specialist

If the systolic blood pressure is between 140 and 150 or diastolic pressure is between 90 and 100 and proteinuria is minimal, and the platelet count is more than 100, arrangements will be made for her to be monitored jointly between FMU and the antenatal clinic. Occasionally, they may also be suitable for shared monitoring with the GP.

These patients will be seen two to three times per week in the FMU and the appropriate follow up arranged.


Protocol for Management of Hypertension All referrals to be forwarded to the Pregnancy Assessment Centre (PAC). The consultant or registrar on-call will review and determine when the woman should be seen. If BP > 140/90 +/- proteinuria, the woman needs same day referral to FMU or PAC. The following protocol applies to hospital management of pregnancy-related hypertension.

BP > 140/90 And <160/110

Half hourly BP x 4 Urinalysis

CTG and AFI Bloods - FBE, LFTs, Urate and U & E's

BP > 150/100 Proteinuria > 30 or Platelets < 100,000

Follow up at RHH antenatal clinic or back to GP

Senior registrar or Staff Specialist Review

BP 140-150/90-100

And proteinuria <30

And platelets > 100,000

ADMIT

Review FMU 2-3 times/week

* FMU Review will include: Every visit: Weekly Half hourly BP x 4 Bloods - FBE and Urinalysis Urates CTG 24 hour urine Ultrasound scan to assess fetal growth, interval to be determined by growth parameters.

BP < 140/90 and Proteinuria < 30


Gestational Diabetes Mellitus - Screening

Background The prevalence of Gestational Diabetes (GDM) is rising. Abnormalities of glucose metabolism in pregnancy range from very mild tendencies to hyperglycaemia to overt diabetes mellitus that has been unsuspected previously. Good control of blood sugar in early pregnancy has been shown to be effective in reducing pregnancy loss at all gestations. In order to improve outcomes, early diagnosis is essential. In order to minimise risk for diagnosed diabetics, good control pre-conception is required. 1 Screening All pregnant women should have their glucose tolerance checked and since last year, the old Glucose Challenge Test is no longer being used. ALL women will be offered a 75gm Glucose Tolerance Test at 26 weeks gestation. The following women will have a POGTT done at booking, and repeated at 26 weeks if this is normal:

History of GDM in any of the past pregnancies

History of giving birth to a macrosomic baby – weight over 90th centile in any of the past pregnancies

History of unexplained stillbirth or recurrent miscarriages

History of having had a baby with congenital malformations – especially cardiac or neural tube defects

BMI greater than 35

Family history – in first degree relatives eg parents, grandparents, siblings – of diabetes

Belonging to an ethnic group with high prevalence of diabetes – indigenous Australians, Pacific Islanders and South Asians

Previous diagnosis of Polycystic Ovary Syndrome

Medications corticosteroids and all the antipsychotics but particularly zyprexa (olanzapine), clozapine, risperidone, quetiapine (Seroquel)

Aged 40 years or older

Previously elevated BGL Diagnosis

Indication Optimal time for test

Test Diagnostic criteria (venous plasma glucose mmol/L)

Clinical suspicion of GDM

Any time 75 gm POGTT (fasting)

Fasting 5.1 mmol/L ;

1 hour 10.0 mmol/L

2 hours 8.5 mmol/L

High Risk screening At booking (by 16 weeks) Repeat at 26 weeks if booking GTT is normal.

75 gm POGTT

Fasting 5.1 mmol/L ;

1 hour 10.0 mmol/L

2 hours 8.5 mmol/L

Follow up After delivery, patients with a diagnosis of GDM should have a follow-up Glucose Tolerance Test done not less than 6 weeks later. 1 Royal Hobart Hospital, (2011) Clinical Practice Guidelines and Protocols, Screening for Glucose Metabolism Abnormalities in

Pregnancy. MAT 1-0031


Early Bleeding and/or Miscarriage General Practitioner referral to Early Pregnancy Assessment Service (EPAS) Phone: 6166 6180 Fax: 6222 8900 8th Floor, Wellington Clinic

EPAS is available to manage women with early pregnancy bleeding (<20 weeks gestation). It is also the appropriate referral point for women with a confirmed non-viable pregnancy, or stable suspected ectopic pregnancy.

The EPAS is available Monday to Friday between 0830 to 0930 hours. The service is unavailable on public holidays.

For women who are stable, after hours referral should follow the referral process outlined below.

Unstable women should be referred immediately to the Emergency Department if less than 20 weeks gestation.

Referral Process Complete the referral form and fax to 6222 8900. Download referral from: www.outpatientsouth.tas.gov.au/clinics/obstetrics History

LMP

Relevant history eg previous ectopic, prior presentations, collapse prior to presentation Confirmation of Pregnancy

By either documented serum or urinary BHCG or ultrasound confirming pregnancy

Otherwise perform urinary or serum BHCG Assessment of Pain and Bleeding

Vital Signs BP, pulse, temperature If BP < 90/50, pulse > 100 or temperature > 37.5°C then refer to ED

Assess PV loss If soaking a sanitary pad in 40 mins or passing large clots then refer to ED

Assess pain If pain is absent or central cramping pain then EPAS referral If pain is moderate or severe or adnexal then refer to ED Referral to EPAS

Phone 6166 6180 after 0830 hours during normal business hours

Fax EPAS referral and results of any relevant investigations (FBC, blood group or prior USS results) to 6222 8900

Please indicate nominated specialists for private patients – mark “Private Patient”

Miscarriage/Perinatal Death Counselling Stillbirth and Neonatal Death Support (SANDS) SANDS offer many local services for parents, families and health professionals. They promote awareness, knowledge, support and understanding following the death of a baby from the time of conception through to infancy. Web: www.sands.org.au Phone: 1300 072 637 (National number)

http://www.outpatientsouth.tas.gov.au/clinics/obstetrics

http://www.sands.org.au/


SIDS and Kids

The SIDS and Kids bereavement support services assist families who have experienced the sudden and unexpected death of a baby or child, during birth, pregnancy or infancy, regardless of the cause.

Services include counselling, parent and family support, peer support, sibling support, grandparent support groups, group activities, annual memorial services, telephone counselling and a national 24 hour free-call 1300 bereavement support line.

Services are available to families and their support network free of charge. Web: www.sidsandkids.org Phone: 1300 308 307 (24 hour bereavement support line) Pregnancy Loss Australia Pregnancy Loss Australia provides pregnancy and infant loss support Australia-wide for bereaved families who suffer the loss of their baby or babies at any time during pregnancy or after birth. This includes miscarriage, stillbirth, termination of pregnancy for foetal abnormality and neonatal death. Please note the support line is available during business hours via an answering machine. Please leave your name, number and a brief message and our Counsellor will get back to you as soon as possible. Web: www.teddyloveclub.org.au Phone: 1800 824 240 (bereavement support line)

http://www.sidsandkids.org/

http://www.teddyloveclub.org.au/


Antepartum Haemorrhage (APH)

APH is by definition bleeding in pregnancy after 20 weeks gestation. It is not uncommon, however it is not normal. A definitive search should be made for the cause of bleeding as any form of antepartum haemorrhage is associated with an increased risk of perinatal mortality and morbidity. Common causes are:

Placenta praevia

Placental abruption

Other causes: - bleeding haemorrhoids - bleeding from the vagina or cervix directly - there are other rarer causes.

Initial Management by General Practitioner

1. Determine that vital signs are normal i.e. heart rate, blood pressure etc.

2. Check history for ultrasound to check whether placenta praevia has been reported.

3. Clinical examination to determine the presence of fetal heart sounds.

4. In the absence of placenta praevia and obvious abruption, a gentle examination with a speculum can be undertaken to determine whether the bleeding is coming from the cervix (this may have followed intercourse and seeing the bleeding point will make management easier).

5. Do not perform a digital examination through the cervix. If the bleeding is from either placenta praevia or placental abruption

Check whether resuscitative measures and urgent transfer are required.

Otherwise, refer to the Pregnancy Assessment Centre 6222 8352 at the Hospital.

Make sure full antenatal information accompanies patient, including blood group. At the Pregnancy Assessment Centre

1. History will be taken for any previous PV bleeding or known placenta praevia.

2. Inquiry will be made about presence of pain and its relation to the bleeding.

3. Assessment of the amount of blood loss will be made. Preparation will be made to transfer to the labour ward if this is heavy or the patient is clinically unwell.

4. If there is small or moderate loss then the patient is made comfortable in the PAC.

5. Assessment is made for signs of labour, and if present transfer to the labour ward is arranged.

6. No PV is performed at this state. Vital signs are checked and the fetal condition is assessed. CTG is performed. (This will sometimes depend on gestation.)

7. The Doctor will be paged to see the patient.

8. An IV may be required.

9. Anti-D may need to be administered for Rh negative women.

10. May require admission to maternity ward until the cause of bleeding is determined by formal ultrasound or examination. Further management can then be planned.


Premature Rupture of Membranes The presence of ruptured membranes is a significant event for a woman as it heralds the end of the pregnancy. Incorrect management can lead to the introduction of infection. Necessary equipment for assessment of these women.

Sterile speculum

Standard microbiological swab for culturing the vaginal fluid (checking for pathogens such as group B streptococcus)

Sometimes diagnosis of premature ruptured membranes is difficult. In multigravid women, urinary incontinence is a common cause for fluid loss. In the absence of any fluid in the vagina, it is reasonable to reassess the woman later in the day or the next day. A history of continuing leaking fluid loss requires formal assessment in hospital. It is not recommended that a digital examination be performed. Sterile speculum examination is, however, reasonable. On referral to the Pregnancy Assessment Centre (Hospital based):

Speculum examination to confirm diagnosis and swabs taken

Presence or absence of contractions noted

Assess signs for evidence of infection, including temperature, tachycardia, offensive discharge, abdominal tenderness

CTG

Ultrasound may be performed to assess fetal size, presentation and liquor volume

A decision about further management will be made. Generally the patient would be admitted for rest and observation as there is an increased risk of the onset of premature labour within 24 - 48 hours of premature rupture of membranes. Thereafter patients may be managed, following discussions with the medical staff, as outpatients. They will usually be commenced on a 10 day course of oral Erthromycin to reduce the risk if the gestation is below 34 weeks.

Patients suitable for this are:

Any patient with pre labour rupture of membranes who

o If preterm, has spent approximately two days as an inpatient.

o If at term, is not due for induction within 24 hours.

Patients with no pathogens on vaginal swabs.

Patients where the presentation of the fetus is cephalic.

Women, who prior to discharge following their initial admission, are willing and able to:

o take their temperature three times per day and record it

o refrain from sexual intercourse

o avoid prolonged public transport journeys, and to travel by car where possible

o to call and return to the hospital immediately if they feel unwell, develop a temperature

(i.e. > 37.4 C), notice diminished fetal movements, begin contracting, have any abdominal pain or tenderness, or if there is any change in the colour of the liquor or vaginal discharge.


Decreased Fetal Movements Fetal movements are very subjective. Women live with their babies and hence appreciate well the movements of their babies. Some babies move very little and this may be their characteristic pattern throughout the pregnancy. Other babies move a lot. Throughout the pregnancy the quality of the movements will change as the pregnancy advances, from the typical kicking movements felt early on to more of the gross body movements presenting as swells rolling across the abdomen from side to side. While women have predominantly kicking movements, they will feel these movements at any time. However, as the pregnancy proceeds and the movement pattern changes to gross body movements, there is less perception of these movements during times of activity of the mother. Hence typically they will describe that the movements are not very common between getting up and evening time. However if close inquiry is made, it would be apparent that when the woman is sitting at meal times or resting after the evening meal she would be aware of rolling movements across her abdomen. Women need to understand that these movements are indicative of a healthy baby. If the woman gives a history of no movements over a 12 hour period, then assessment of the baby is appropriate. On referral to the Pregnancy Assessment Centre (Hospital based):

History is taken of general well-being and about the pregnancy.

The history of movements is taken, in particular their frequency, character and when they were last felt.

If the woman is not eating or drinking much, this history should be discussed, and in addition as to whether she is smoking and how heavily.

Attention to vital signs in the pregnancy and abdominal palpation is undertaken. It should be remembered that fetal constriction by oligohydramnios will affect movement patterns.

CTG is performed.

Findings are documented.

If normal, the woman will be transferred back to her routine care.

If the Doppler’s are normal but risk factors are present, she will require regular growth assessment

If suspected suboptimal growth, regular ultrasound dopplers and weekly review in clinic

Please remember to make sure that the woman brings with her the shared care card and information/details about the pregnancy to date. For more information, about fetal movements, please see www.stillbirthalliance.org.au/parent4.htm for further information regarding Pregnancy, Your Baby’s Movements and What They Mean.

http://www.stillbirthalliance.org.au/parent4.htm


Intrauterine Growth Restriction Intrauterine Growth Restriction (IUGR) is defined as being present when the estimated fetal weight is < the 5th percentile. This may be suspected by clinical features of a small fundal height and the absence of, or reduction in, amniotic fluid. If the fundal height appears small for dates i.e. below the 5th percentile than expected for dates, the patient should have an ultrasound (with 1 week) If the result shows suspected IUGR, referral should be made to FMU where the following protocol is in place:

Ultrasound confirming

Estimated Fetal Weight (EFW) < 5th centile

Refer to FMU

Normal Doppler

Abnormal Doppler

Weekly CTG

Weekly Amniotic Fluid Index

Weekly Doppler Fortnightly EFW

2 x weekly Doppler

Weekly Amniotic Fluid Index Weekly CTG

Fortnightly EFW


Customised Antenatal Growth Chart

If the woman does not have a customised fetal growth chart, please contact the Clinical Nurse Consultant, Women’s Health Clinic, to have one created and faxed. A trial of a customised fetal growth chart can be obtained at: www.gestation.net/fetal_growth/download_grow.htm

Smoking Assessment and Management Smoking rates in pregnancy from 2009-11 were 22.2% in Tasmania, well above the national average of 13.9%. Encouraging smoking cessation, or reduction of smoking where cessation is unlikely, is highly beneficial for both mother and fetus. Smoking cessation training in providing brief interventions (‘ABC’) can be provided in GP practices. Contact the Statewide Smoking Cessation Coordinator on 6166 0759 for details or to book a time. Online training is also available from www.atdc.org.au/smoking-cessation-abc/

http://www.gestation.net/fetal_growth/download_grow.htm

http://www.atdc.org.au/smoking-cessation-abc/


LABOUR AND BIRTH

The care of the woman during labour and birth is the responsibility of the maternity team at the RHH. The RHH will provide a discharge summary of the pregnancy and birth outcome for the GP at discharge of the woman. It is planned that this task will be performed electronically in the near future.

Criteria for Exclusion from Birthing Suite The aim is to provide a much more user friendly environment and to allow the partner to stay following the birth of the baby to assist with parenting. However it is not always suitable for women to occupy these rooms in view of the layout of the rooms and the need for medical equipment within the rooms in complicated labours. There are exclusions to the use of the birthing suites and assessment will be made at ‘booking-in’ and during the pregnancy to determine suitability for use in labour. Antenatal women do not use the birthing suites. The length of stay in a Birth Suite is 24 – 48 hrs then discharge or, if for some reason discharge is delayed, then the woman is transferred to a ward bed for ongoing management. Exclusion criteria:

Pre-term less than 36 weeks

Post term beyond 10 days

Multiple birth

Breech

Pre-eclampsia of moderate or severe degree

IUGR

Known macrosomia

Pelvic disproportion

Premature rupture of membranes for induction

Diabetes

Ante-partum haemorrhage(within 7 days)

History of post-partum haemorrhage >than 1000 mls

Meconium stained liquor of grades II and III on admission

Excessive maternal weight – body mass index > 30 at the time of booking in.

Known fetal malformation

Abnormal admission CTG It is recognised that some flexibility will be necessary within the unit, as dictated by bed utilisation. An assessment will be made at Booking Clinic as to whether a woman should be excluded from the Birthing Suite. If not, exclusion can occur at any stage during the pregnancy dependent upon the above conditions. Reassessment will be made at 36 weeks and on admission in labour.


Vaginal Birth After Caesarean Section (VBAC) Also Known As Trial of Scar A woman with a history of a classical caesarean section (vertical incision in the uterus, not abdominal wall) should be advised to have an elective caesarean section around 38 weeks in subsequent pregnancies. The risk of scar rupture is as high as 3% and in fact most of these occurred prior to, or soon after, the onset of labour. With the advent of lower uterine segment caesarean section, the risk of scar dehiscence is 1/200 and where the indication for the original caesarean section is a non-recurring one, it is appropriate to offer the woman a VBAC. Some women will not want this but it is important to convey to them that this is a safe option. Women considering their birthing options should understand that, overall the chances of a successful planned VBAC are 60-80% (RANZCOG, 2010) and 90% for those who have had a subsequent normal vaginal delivery following a caesarean section (RCOG, 2007). *Minimal statistics exist regarding the issue of a VBAC with two previous caesarean sections. There is no clear data on safety and in general, women will not be encouraged to undergo a VBAC, having had two previous caesarean sections. There will be women who, especially if they have had a normal vaginal birth between their caesarean sections, will want a VBAC when they have had 2 caesarean sections. Their wishes should be considered on an individual basis by the consultant obstetrician.* It is important that the counselling regarding a VBAC is undertaken by the doctors who will conduct that labour and therefore such counselling should occur in the Antenatal Clinic by a consultant. Benefits of a VBAC are:-

reduced blood loss;

less likelihood of infection;

shorter recovery time and hospital stay;

reduced chance of readmission after giving birth;

less need for strong pain relief medications;

reduced risk of complications in future pregnancies;

less risk of the baby having breathing problems and being admitted into the nursery;

reduced complications associated with major abdominal surgery;

improved chance of early physical contact with baby and initiating breast feeding;

enhanced ability to care for baby more effectively after delivery;

some women experience a high level of satisfaction after a vaginal birth; and

reduced risk of future placental problems from repeat caesarean section. VBAC Not Advisable

After a previous vertical/classical caesarean section birth where the uterine incision has involved the upper segment of the uterus.

After some uterine surgery.

After a previous uterine tear or rupture.

Because of a maternal or foetal reason for an elective caesarean section.

If the baby remains in a breech presentation.

If you have a multiple pregnancy, even if you have had a previous successful VBAC.

Two or more previous caesarean deliveries*. See information above


Factors which improve a successful VBAC include:

waiting at least 18 months after a caesarean section before becoming pregnant again;

no complications such as medical problems;

healthy weight range Body Mass Index (BMI) of less than 30 and eating low GI foods;

going into labour naturally before 41 completed weeks of pregnancy with baby lying head down in an anterior position;

baby’s estimated weight less than 4000 grams. Factors which reduce a successful VBAC can include:

induction of labour;

being overweight i.e. BMI of more than 35;

no previous vaginal birth or labour;

previous caesarean section for failure to progress; and

large baby (over 4000 grams). If induction of labour is contemplated this will require a Consultant or Senior Registrar review. When the Woman is in labour, it is advisable:-

that an intra-venous cannula (IV) is inserted.

baby’s heart rate monitored continuously by the cardio-toco graph (CTG) machine as fetal heart issues will often precede potential scar problems. (Women can request telemetry CTG monitoring) and

the woman’s labour closely monitored by assessing contractions and requesting permission to perform vaginal examinations.


External Cephalic Version Breech presentation is common in premature pregnancies. The incidence of breech presentations decreases to term, when it is around 3 - 4% and at 30 - 32 weeks, it is about 10 - 15%. Therefore the vast majority will turn spontaneously and require no intervention. Women should be reassured that a breech presentation during the early phases of pregnancy can be a normal finding and that no action need to be taken until at least 35 or 36 weeks. Breech presentation presents a problem when labour is pre-term, or when premature rupture of membranes occurs. External cephalic version is best performed in the clinic situation as the baby can be assessed. Heart rate abnormalities following external version are not uncommon and hence monitoring facilities need to be present. In addition, complications such as an abruption can occur. The decision to perform external cephalic version (EVC) is usually undertaken after 37 weeks, as this reduces the likelihood that the baby will revert spontaneously back to breech. There is an increased incidence of fetal abnormalities associated with breech presentation. This is known to be more common with Down Syndrome, hydrocephaly, and some neuromuscular disorders such as myotonia congenita (Thomsen’s disease). Patients suitable for ECV

Breech presentation after 36 weeks gestation

The patient should have an ultrasound to confirm the presentation and exclude fetal abnormalities and placenta praevia.

The patient’s blood group should be known.

Caesarean section is a relative contraindication and will be decided on a case by case basis.

Woman to be referred to antenatal clinic for assessment prior to ECV.

Procedure Fasting is not required. IV Cannulation is not required.

A CTG is recorded immediately prior to the procedure. If it is not reactive, ECV will not be undertaken.

Woman position in a left lateral tilt.

Real time ultrasound to confirm breech presentation.

Terbutaline 250 mcg given subcutaneously 15 minutes prior to ECV.

Fetal heart is checked every two minutes during the procedure.

Procedure abandoned if excessive maternal discomfort or prolonged fetal heart rate deceleration.

Repeat CTG for minimum of 60 minutes regardless of outcome of ECV.

Maternal observations are monitored after the procedure.

Kleihauer test and Anti-D administration for all Rh negative women. Subsequent Management

If the ECV is successful the patient will return to her referring doctor for the next routine visit.

If the ECV is unsuccessful the management might include discussion around the options for delivery i.e. vaginal breech or caesarean section. Another option is to arrange a repeat attempt at ECV one week later.

The procedure usually takes 2-3 hours and is performed in the Pregnancy Assessment Centre (not the MFAU), RHH.


Protocol for External Cephalic Version

Referral into Antenatal Clinic Breech > 37 weeks &

no contraindication to ECV

Non-reactive CTG/Abnormal CTC

Reactive CTG

ECV in PAC

Kleihauer if Rh negative

Contact referring doctor

CTG for at least 60 minutes

Reactive CTG

Return to referring doctor

Cancel Procedure

Finish counselling


POST-PARTUM

Breast Feeding

Support and Advice Contact for RHH Lactation Consultants:

Phone: 6222 7929 or 6222 8308, or pager no. 5984 Australian Breastfeeding Association

Website: www.breastfeeding.asn.au Phone: 24 hour breastfeeding helpline 1800 MUM 2 MUM (1800 686 268)

A national toll free 24 hour helpline, staffed by Australian Breastfeeding Association volunteers across Australia, is available. For free, confidential breastfeeding advice and support, women can call 24 hours a day.

Child Health and Parenting Service, Regional office

Phone: 6230 7899 [each child’s Personal Health Record (Blue Book) will have a list of local clinics and contact details]

Monash Obstetric and Breastfeeding Drug Information Centre Phone: (03) 9594 2361 (business hours)

Toxicology Data Network – search the drugs and lactation database Website: http://toxnet.nlm.nih.gov/

Low Milk Supply Baby - Signs

Poor weight gain – gaining less than 115 grams per week

Baby below birth weight at 2 – 3 weeks of age – with careful review of weight loss at birth

Note: generally the normal pattern of weight gain is: o in first week, lose 5% - 10% of birth weight o by two to three weeks, has regained birth weight o up to 3 months, average gain of 115 – 230 grams per week.

Passing small amount of concentrated, yellow, strong-smelling urine, less than 6 times a day

Infrequent small amount of hard, dry, green stools

Dry skin and mucous membranes, poor muscle tone, dull eyes.

Lethargic, poor feeding or scheduled feeding. Mother

Assess mother – i.e. medication use, frequency and effectiveness of feeding, medical history Causes - Mother:

Poor breast development, past breast surgery, nipple abnormalities

Retained products of conception

Rigid feeding schedules

Use of nipple shields, medications

Pregnancy

Some medical conditions i.e. Abnormal thyroid function, polycystic ovarian syndrome Causes - Baby:

Poor suck (premature, sleepy baby, jaundice, neurological impairment, cardiac baby)

Oro-facial abnormality i.e. Tongue tie, cleft lip/palate

http://www.breastfeeding.asn.au/

http://toxnet.nlm.nih.gov/


Management (does depend on age of baby):

correct positioning & attachment

increased frequency & duration of effective feeds and/or expressing

avoid dummy use

skin 2 skin contact

rest, relax, diet & fluids for mum

avoid substances known to decrease milk supply – smoking, cold and flu tablets

express after feeds to stimulate supply and for top-ups

if formula is required – ensure it is given after feeds, mum encouraged to express for top-ups and to stimulate supply

Consider Domperidone (maximum dose is 20mgs QID, an authority can be obtained for the mother to get repeat, large quantity prescriptions)

Referral to Lactation Consultant

MASTITIS TREATMENT Breastfeeding can and should continue and the breast milk is quite safe for the baby. Contributing factors

Missed feeds

Milk stasis, incomplete emptying

Cracked or damaged nipples

Maternal stress / fatigue

Hyperlactation

Nipple creams Ensure breast drainage with effective feeding techniques, gentle massage, warmth to breast pre-feeds and cold packs after, anti-inflammatories, analgesia, rest and fluids. When feeding, try to position baby with chin pointing to affected area. Antibiotics would be indicated for:

Fever > 38.5

Erythema or cellulitis of the breast

Unresolved symptoms for more than 24 hours

Recurrent episodes As Staph. Aureus is the most likely organism, antibiotics should be penicillinase-resistant and continued for 10 days, eg:

Dicloxacillin or Flucloxacillin 500mg 6 hourly

Cephalexin 500mg 6 hourly

Erythromycin 500mg 6 hourly (if penicillin allergy) Severe mastitis may require IV antibiotics. If a breast abscess develops, it can be managed by repeated needle aspiration (under ultrasound control if necessary). Otherwise formal surgical drainage may be required. In almost all cases breastfeeding can be continued. Lactation Consultant referral is often beneficial.


Continence & Women’s Health Physiotherapy

The prevalence of incontinence and prolapse in women who have had a baby is very high affecting 1 in 3 and 1 in 2 respectively. Up to ten percent of women are likely to undergo surgery due to these problems. Pelvic floor muscle training is known to reduce the severity and prevalence of these conditions; however the majority of women do not do their exercises. Close to half of all women perform the exercises incorrectly and may be making their problem worse. Continence & Women’s Health physiotherapists can provide women with accurate assessment and advice on correct pelvic floor muscle exercise to optimise outcomes post-partum. They are also trained in the use of trans-abdominal real-time ultrasound as a non-invasive option for checking pelvic floor activation. Please refer women to Continence & Women’s Health Physiotherapy for:

Non-invasive pelvic floor activation check (strengthening advice)

Incontinence (urinary or faecal) or other pelvic floor dysfunction

Prolapse

Low back or pelvic girdle pain

Diastasis of Rectus Abdominus Muscle (DRAM)

Coccyx pain

Carpal tunnel Syndrome / De Quervain’s tenosynovitis Royal Hobart Hospital Physiotherapy Department Continence & Women’s Health physiotherapy, Level 2 H Block RHH, 7000 Phone: 6222 8634 Fax: 6222 7524 Community Continence Service - Physiotherapy Clarence Integrated Care Centre, 16-22 Bayfield St, Rosny Park, 7018 Phone: 6282 0360 Fax: 6282 0348 Note: All referrals will be triaged and addressed in collaboration with Community Physiotherapy

Services, Southern Tasmania.


Jaundice The significance of jaundice in the newborn largely depends on the age of the infant at onset. Jaundice in the first 24 hours This is abnormal and is most likely due to blood group incompatibility between mother and fetus. Haemolysis causes a rapid increase in serum bilirubin in a few hours. Investigations: Serum bilirubin (SBR): total and conjugated (direct), maternal and baby’s blood group, direct Coomb’s test, FBE. The baby requires paediatric review and should be readmitted to hospital immediately if on early discharge. Jaundice on days 2 to 5 This is most likely to be physiological if:

Onset day 2 – 4

Jaundice is mild i.e. confined to head, neck and upper body

The baby is not low birth weight or preterm

The baby is afebrile, feeding well, alert i.e. well

The baby is passing normal coloured bowel motions and urine, and there are no other abnormalities If these criteria are fulfilled, it is not necessary to measure SBR or do other investigations. If these criteria are not fulfilled, SBR is ordered and the baby should have paediatric review. If the baby is unwell it should be reviewed by a paediatrician, as other investigations including a sepsis screen may be required. Prolonged jaundice (i.e. > 14 days) Prolonged jaundice needs investigating. Sudden onset at this stage suggests haemolysis due to a red blood cell enzyme abnormality (eg G6PD deficiency). Urgent admission to hospital is necessary. A prolongation of jaundice from the first few days of life can initially be investigated as an outpatient. Unpigmented stools suggest obstruction to bile flow, which requires prompt investigation. Causes: raised, conjugated SBR – a) biliary atresia b) neonatal hepatitis c) choledochal cyst raised, unconjugated SBR - a) hypothyroidism b) sepsis c) red cell enzyme abnormalities

If the above are excluded, the bilirubin is unconjugated, and the baby is well and breastfeeding, the likely diagnosis is breast milk jaundice. This occurs in 2 – 4% of breastfeeding infants, is not associated with kernicterus (bilirubin encephalopathy) and does not require any treatment. Reassurance that breastfeeding should continue is important.


6 Week Postnatal Check (Mother)

Obstetric and Early Infancy Shared Care Program

(For completion by general practitioner) ……../……../…. (Date of Consult)

Last Name First Name D.O.B ___________________________________________________________________________________________________________

*(Questions to ask mother) 1. General health/comments How do you feel about yourself and your baby? How is your partner coping? Supports?

................................................................................................................................................

................................................................................................................................................ 2. B.P ......................................................... LMP: ....................................................................... 3. Feeding: Breast Formula Mixed

4. Breast/Nipples: ........................................................................................................................

5. Abdomen wound: Scar: .........................................................................................................

6. Last Smear: Date: ............................ Result: .......................................................................

7. Perineum/Pelvic Examination: Vagina Vulva Pelvic Floor

Adnexa Uterus Perineum

8. Rubella Status: Immune Not Immune

Vaccinate? Yes No

9. Intercourse: Resumed? Yes No

Problems? Yes No

10. Contraception: Yes No

11. Incontinence: Urinary Yes No

Faecal Yes No

12. Follow up of pregnancy complications: (eg. Gestational diabetes hypertension) Yes No

13. Referrals to other services:

Child & Youth Health Community Health Centre

Lactation Consultant Nursing Mothers Association

Continence & Women’s Health Social Work

Physiotherapy Other

14. Comments: ..............................................................................................................................

...................................................................................................................................................

NB: This form is a guide only, for your postnatal examination of mother and is to be retained by you

for your records


6 Week Postnatal Check (Baby)

Obstetric and Early Infancy Shared Care Program

(For completion by general practitioner) ……../……../…. (Date of Consult) Mother’s Last Name Mother’s First Name D.O.B Sex 1. Birth Weight: % (percentile) ................. Kgms % ......... 2. Birth Head Circumference: ................. cms % ............ 3. Birth Length: ................. cms % ............ 4. Fontanelle: ................................................................... 5. Eyes: Appearance: ....................................................................................................... Tracking: ............................................................................................................ Facial Symmetry: ............................................................................................... 6. Smiling: Yes No Observed History only

7. Nutrition: (appearance) ............................................................................................................ 8. Cardiovascular: ? murmurs ......................................................................................................... 9. Abdomen: ?organomegaly .......................................................................................................... 10. Femoral pulses present Yes No 11. Hip testing a) Right Normal Abnormal

b) Left Normal Abnormal 12. Males: testes fully descended: a) Right Yes No

b) Left Yes No 13. Females: External genitalia Normal Abnormal 14. Jaundice: Yes No 15. Feeding Type ..................... Frequency .................. Formula ................. Mixed ....................... 16. Hearing: ............................................................... 17. Bowel Habits: .......................................... 18. Immunisation discussed: ...................................... 19. Cot safety advice: .....................................

20. SIDS awareness discussion: ................................

6 Week Check

Bare weight% .................. Kgms %

(percentile)

Head circumference ............ cms %

Length .................. cms %


MENTAL HEALTH

Perinatal Mental Health The perinatal period (including pregnancy and the following year) is a time of great change in a woman’s life, and it is common for her to experience a wide range of emotions. For many women, the feelings of worry and stress resolve by themselves, but in others, pregnancy and early parenthood can trigger symptoms of more serious mental health problems. These may be problems experienced for the first time during or following pregnancy, or a return of problems such as anxiety or depression experienced in the past. In addition, women with longstanding mental disorders such as schizophrenia or bipolar disorder may find these are more difficult to manage in the perinatal period. While estimates vary, research suggests that depression, anxiety or both are experienced by at least 1 in 10 women during pregnancy and 1 in 6 women in the year following birth. Depression and related disorders may affect the wellbeing of the woman, her baby and her significant other(s), and have an impact on relationships within the family during a time that is critical to the future health and wellbeing of children. Given the frequency of these mental health problems, it is recommended that all women be routinely screened for depression during and following pregnancy. The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used instrument for such screening. Psychotic disorders such as schizophrenia and bipolar disorder each affect 1-2% of the population, and can have a major impact on a woman’s pregnancy, the wellbeing of her infant and the subsequent mother-infant relationship. Thus, it is recommended all women with psychotic disorders are referred for specialist assessment once pregnancy is confirmed. Identifying and addressing parental mental health problems may prevent future mental health problems in infants and young children and support the development of secure attachment relationships between infants, young children and their primary caregivers.

EPDS Screening

RHH All women are offered the opportunity to complete the Edinburgh Postnatal Depression Scale (EPDS) during the ‘booking-in’ visit at the RHH. Women complete the screening questionnaire and discuss results with the midwife. All GPs will receive the EPDS summary form which shows the woman’s score, findings from her psychosocial assessment and any referrals that have been made to other health professionals.

Women who have a high EPDS (13 or more or a positive score to question 10) at their ‘booking-in’ appointment will be offered an appointment with the Perinatal Psychiatry Clinic. The perinatal psychiatrist/registrar will send a letter to the referring GP detailing the results of the assessment & management plan. When the management plan includes recommendation of referral for cognitive behavioural therapy the psychiatrist will make a referral to a psychologist at Relationships Australia through the ATAPS pathway with linkage back to the patient’s GP.


Perinatal and Infant Mental Health Team (PIMH) The PIMH Team is a consultation-liaison service for women who are pregnant and booked to deliver at or who have had a baby at the Royal Hobart Hospital in the preceding 12 months. ANTENATAL REFERRALS

From the Antenatal clinic or from treating general practitioner

o Woman has EPDS score ≥ 13

o Woman reports past history of mental illness

o Woman has current mental health problems

o Woman currently prescribed any of the following; lithium, sodium valproate,

carbamazepine or an antipsychotic medication

From Adult Mental health Service for second opinion (±shared care arrangement)

POSTNATAL REFERRALS

The team has limited capacity for postnatal follow-up

If not previously seen by PIMH team during pregnancy/maternity admission, referrals for

assessment of maternal mental health should be made by either

o The patient’s general practitioner

o The Adult Mental Health Service psychiatrist

Referrals for assessment of/intervention with mother-infant relationship

SPECIALIST ADVICE

The PIMH team psychiatrist/registrar can provide advice regarding patients on 6166 0476

Patients can be seen for assessment and advice prior to becoming pregnant re the

management of existing mental disorders

Information regarding use of psychotropic medications during pregnancy or when a

woman is breastfeeding is available at www.ppmis.org.au

The Perinatal and Infant Mental Health Team contact details

Tel 6166 0476 or 0428 314 849 (Mon-Fri) and fax 6233 9427

[email protected]

Resources GP Screening The Edinburgh Postnatal Depression Scale (EPDS) is available on Medical Director and Best Practice as a template.

Medical Director – EPDS is found under the “Assessment” menu. It will step users through the questions, automatically dropping the Q and A's into the consultation notes. It gives the score at the end, but the score will need to be manually put into GP notes in order to keep it.

Best Practice – EPDS is found under the “Clinical” menu. It will step through the questions, dropping the final score into the daily notes, but not the individual question responses.

http://www.ppmis.org.au/



The EPDS is available in a range of other languages:

Arabic, Chinese, English, Hindi, Khmer, Laotian, Macedonian, Serbian, Spanish, Tagalog, Thai, Turkish, Vietnamese can be sourced from: www.mhcs.health.nsw.gov.au/publication_details/7000.asp

The Edinburgh Perinatal Depression tool can also be used to assess the woman’s emotional health and well-being at her post natal check visits. This assessment tool is not intended to predict depression or anxiety, or to replace clinical diagnosis. It should not be used a diagnostic tool, rather, it should be used as part of the overall clinical assessment of the women’s emotional health and well-being.

Scoring the Edinburgh Perinatal Depression Scale For questions 1, 2 and 4, items are scored 0, 1, 2, or 3, with the first option scored 0 and the last option scored 3.

Questions 3 and 5 – 10 are reverse scored, with the first option scored 3 and the last option scored 0. Adding the scores for the 10 items yields a total score of between 0 and 30. Scores over 12 - probable PND

Scores of 9 – 12 - borderline

Score below 9 - probably not depressed

Major Risk Factors for Postnatal Depression:

Demographic Personality

younger and older age neurotic

unmarried overly sensitive

non-English speaking background worrier

lower social class obsessional

History

Obstetric

past history of depression or PND obstetric problems:

- traumatic delivery

Social - Caesarean section

inadequate social support - forceps delivery

life stress - IVF infants

Interpersonal

Infant

dysfunctional relationship with parents preterm infants

dysfunctional relationship with partner physical problems

reflux

http://www.mhcs.health.nsw.gov.au/publication_details/7000.asp


Perinatal Depression Referral Options for Southern Tasmania – (next page)

Beyond Blue Perinatal Mental Health Resources available at: www.beyondblue.org.au/resources/health-professionals/perinatal-mental-health Including:

Clinical Practice Guidelines for Depression and Related Disorders of anxiety, bipolar disorder and puerperal psychosis, in the Perinatal Period

Psychosocial assessment and management of perinatal mental health disorders: A guide for primary care health professionals

Edinburgh Postnatal Depression Scale

http://www.beyondblue.org.au/resources/health-professionals/perinatal-mental-health


Perinatal Depression Referral Options conception to 12 months post delivery

INDIVIDUAL MENTAL HEALTH TREATMENT OPTIONS

ATAPS (Access to Allied Psychological Services) Program

GP referral for 6 to 12 (after GP review) sessions of focused psychological strategies.

Free to eligible clients (experiencing disadvantages such as financial, transport, distance, etc)

Provided by experienced, credentialed clinicians employed by Relationships Australia

See www.outpatients.tas.gov.au/clinics/obstetrics for referral templates and associated documents

Private Credentialed Allied Health Professionals

GP referral for 6 to 10 (after GP review) sessions of focused psychological strategies

Some providers bulk-bill, others incur a gap fee

See www.primaryhealthtas.com.au/resources/mental-health-allied-health-professionals-southern-tasmania for list of providers with details

INPATIENT HOSPITAL SERVICES AND DAY PROGRAMS

PHONE SERVICES

Mental Health Helpline - 1800 332 388

Phone advice, information, triage and referral

Single point of entry to DHHS Mental Health Services for people with serious mental illness

24 hour service with message bank when phone busy

Child Health & Parenting Service (CHAPS) Parenting Line - 1300 808 178

Free (but not for mobile phones) phone line for support, information and referral

PANDA (Post & Antenatal Depression Association) phone counselling service - 1300 726 306

Free telephone counselling from 9am to 7pm weekdays with answering machine for after hours

See www.panda.org.au/ for more information and resources

Raising Children Network-is a resource for parents from newborns to teens.

http://raisingchildren.net.au/

The Hobart Clinic - phone 6247 9960 www.thehobartclinic.com.au

Private hospital with inpatient and outpatient day programs for women with depression

Referral by GP or psychiatrist

St Helens Mother and Baby Unit – phone 6221 6411 www.sthelensprivatehospital.com.au/index.php/our-services/

Anyone can refer, including self-referral

Inpatient and day programs for public and private patients - enquire about costs for various services

Services for women with perinatal depression, maternal exhaustion, unsettled baby etc

FAMILY/PARENTING SERVICES

Good Beginnings - 6223 5810

www.goodbeginnings.org.au

Free outreach family support with qualified workers and volunteers

Child Health & Parenting Service (CHAPS) Parenting Centre - 6233 2700

Centre based or outreach face to face counselling sessions with RN

10 week post natal depression group offered 4 times per year

Individual sessions free, group sessions negotiable cost

http://www.outpatients.tas.gov.au/clinics/obstetrics

http://www.primaryhealthtas.com.au/resources/mental-health-allied-health-professionals-southern-tasmania



http://www.panda.org.au/

http://www.thehobartclinic.com.au/

http://www.sthelensprivatehospital.com.au/index.php/our-services/

http://www.sthelensprivatehospital.com.au/index.php/our-services/

http://www.goodbeginnings.org.au/


DEFICIENCIES/NUTRITION IN PREGNANCY/INFANTS

Anaemia in Pregnancy The routine checking of haemoglobin (Hb) in early pregnancy forms a base line for management of the risk of iron deficiency anaemia. Effort should be made to optimise Hb levels before birth, to protect maternal health and to make blood transfusion less likely in the event of haemorrhage. Supplementation should be prescribed on the basis of laboratory evidence of <100 g/L. The woman’s Hb should be repeated at 28 weeks preferably at the same time as the glucose load i.e. 26–28 weeks. It is not generally useful to order iron studies in pregnancy unless there is a concern about the possibility of haemoglobinopathies. It must be remembered that there is a normal haemodilutionary effect in pregnancy and if the Hb parameters are in the normal range (115–160 g/l) then additional iron supplementation is not usually required in the absence of other risks such as previous postpartum haemorrhage, expected need for caesarean section or placenta praevia.

A blood film may guide diagnosis. The following list of tests should all be undertaken:

Blood film

Reticulocyte count

Iron studies (serum iron, serum transferrin, total iron binding capacity)

Serum and red cell folate levels

Iodine in Pregnancy

The National Health and Medical Research Council (NHMRC) recommends that all women who are pregnant, breastfeeding, or considering pregnancy take an iodine supplement of 150 micrograms (μg) each day to help make sure that their baby’s brain and nervous system develops normally.

While mandatory fortification of bread does increase iodine intake in the general population, iodine requirements during pregnancy and lactation to support the neuropsychological development of the foetus and baby are substantially greater.

There are a number of commercial vitamin and mineral supplements designed for pregnancy and lactation that contain iodine. Women who are pregnant, breastfeeding or considering pregnancy should talk to a pharmacist about the most suitable supplement to meet their needs. Women with pre-existing thyroid conditions should talk to their doctor prior to taking an iodine supplement.

Further information including a literature review and the full statement can be viewed on the NHMRC website - www.nhmrc.gov.au/publications/synopses/new45_syn.htm

For further information about this matter, please contact Public Health Services at [email protected]

http://www.nhmrc.gov.au/publications/synopses/new45_syn.htm



Vitamin D Vitamin D deficiency in mothers is the most important causative factor for Vitamin D deficiency in infants. Babies of women with vitamin D deficiency during pregnancy are at risk of Hypocalcaemia, Rickets, Myopathy and reduced intrauterine long bone growth. Around 33% of Tasmanians are regarded as Vitamin D deficient in Summer and Autumn, and 67% in Winter and Spring. It is difficult to get enough Vitamin D in Tasmania from mid-April to mid-September from the sun1. People with darker skin and women who wear veils or headscarves are at increased risk. Vitamin D screening should be offered to pregnant women, and supplementation commenced for those at risk. Vitamin D in Tasmania resource (last reviewed February 2014): www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/155132/1404_PHS_VitD_Poster_01.pdf

Vitamin K for Newborns www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch38_vitamin_k_brochure_2010.pdf

Nutrition Before and During Pregnancy and while breastfeeding Handouts for patients from the Community Nutrition Unit Nutrition before and during pregnancy www.dhhs.tas.gov.au/__data/assets/pdf_file/0004/82471/30_Nutrition_before_pregnancy_2011.pdf

How well are you eating? For pregnant and breastfeeding mums www.dhhs.tas.gov.au/__data/assets/pdf_file/0005/151790/How_well_are_you_eating_Preg_and_BF_Under_18yr_July_2013.pdf

Nutrition for young mums www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/82473/32_Nutrition_for_young_mums_2011.pdf

Your daily food and drink checklist – Pregnancy and breastfeeding www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/151791/Food_and_drink_checklist_Preg_and_BF_Under_18yr_July_13.pdf

Vegetarian eating for mums www.dhhs.tas.gov.au/__data/assets/pdf_file/0007/82474/33_Vegetarian_Eating_for_mums_2011.pdf

The discomforts of pregnancy www.dhhs.tas.gov.au/__data/assets/pdf_file/0008/82475/34_The_discomfort_of_pregnancy_2011.pdf

Listeriosis Handout for patients from the Community Nutrition Unit – www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/82479/38_Listeriosis_2011.pdf

Why should I breastfeed Handout for new mothers/parents from the Community Nutrition Unit www.dhhs.tas.gov.au/__data/assets/pdf_file/0009/82476/35_Why_should_I_breastfeed_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0017/155132/1404_PHS_VitD_Poster_01.pdf

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ch38_vitamin_k_brochure_2010.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0004/82471/30_Nutrition_before_pregnancy_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0005/151790/How_well_are_you_eating_Preg_and_BF_Under_18yr_July_2013.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0005/151790/How_well_are_you_eating_Preg_and_BF_Under_18yr_July_2013.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/82473/32_Nutrition_for_young_mums_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/151791/Food_and_drink_checklist_Preg_and_BF_Under_18yr_July_13.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/151791/Food_and_drink_checklist_Preg_and_BF_Under_18yr_July_13.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0007/82474/33_Vegetarian_Eating_for_mums_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0008/82475/34_The_discomfort_of_pregnancy_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/82479/38_Listeriosis_2011.pdf

http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0009/82476/35_Why_should_I_breastfeed_2011.pdf

Documents

Antenatal Care for General Practice 2014 · Antenatal Care for General Practice Information Kit 2014_V01.a This information kit is intended as a guide for general practitioners in