- CT – Emergency LSCS for Severe Hypertension of Pregnancy, TPL, Fetal Distress
- LSCS performed- massive blood loss
- Transferred directly to POWH ICU
- Day 3 -Develops fatty Liver further deterioration
- Day 5 – wound breakdown of CS site
- Remains in POWH ICU for 11 days
- Transferred fro ICU to RHW Acute Care Unit
- Day 13 – deterioration of Liver function-readmitted to POWH ICU
Complex Case Presentation
- CT (patient)- transferred at 30 weeks gestation for Grade four Threatened Premature Labour and Pregnancy Induced Hypertension .
- Admitted to Birthing Unit
- Mothers condition unstable
- BP 170/110 mmHg
- Proteinuria
- liver function abnormalities
- renal impairment
- thrombocytopenia
- intra-uterine growth restriction
- neurological impairment
When Normal Birth Plans Go Pear Shaped
WOMAN SUB-OPTIMAL OUTCOMES
• Uncontrolled hypertension
• Placental abruption
• Sudden hypotension
• Pulmonary oedema
• Renal failure
• Eclamptic seizures
• Intracerebral haemorrhage
• Fetal compromise
• Maternal death
- Constraints to the transfer of care of the obstetric patient increasing LOS:
- Standard care- maternal or neonatal complications
- MFM patients- surgical consults
- In utero transfers for prematurity
- Complex cases- Psychosocial admissions for mental health, CUPS (Chemical Use in Pregnancy), interventions involving FAC’s (Family and Community Services)
- Privately insured patients- counterintuitive to LOS
- Babies admitted to co –located hospital -Sydney Children’s Hospital
Wendy Hudson,
Bed Manager Royal Hospital for Women
what ever we are talking about at the RHW
A little about the RHW
- Only Women’s Hospital in NSW
- Major referral quaternary hospital
- 4200 birth per annum
- 3000 publicly insured
- 1200 privately insured
- Neonate:
- Suppression of preterm labour may be contraindicated in women with maternal or fetal compromise such as : -- - Severe pre-eclampsia
- Placental abruption / antepartum haemorrhage
- Sepsis
- Threatened premature labour only accounts for 6 – 10% of births but is responsible for 75% of neonatal morbidity and mortality
- Baby delivered by LSCS and transferred to NICU
- Ventilated 9 days, CPAP for 3 days
- Remained in NICU for 7weeks and 4days
Towards Normal Birth
Implications to Care Coordination
- June 2007 at the RHW a forum
- Increased LOS
- ICU and ACU admissions- pathology costs
- Nursing hours
- Premature infant and LOS in NICU- transfer costs to referral hospital on transfer of care of neonate at 5 weeks and 4 days
Bed Management Strategies
- Readmitted to RHW ACU
- Transferred to Postnatal Services day 18
- Baby remains in NICU
- Implications on discharge for patient
- Transfer of woman from out of area with no local supports
- Prematurity of Newborn –admission to NICU
- Admission to ICU
- Readmission to ICU
- Medical complications from maternal condition-
- liver function abnormalities
- renal impairment
- thrombocytopenia
- Psychosocial-lack of engagement with newborn
- Constraints to relationship
- Direction to NSW Maternity services regarding increasing the vaginal birth rate in NSW and decreasing caesarean section operation rate
- To develop, implement and evaluate strategies to support women and to ensure that midwives and doctors have the knowledge and skills necessary to implement this policy
- Increase the number of spontaneous labours
- Decrease the number of labour interventions
Maternity-Towards Normal Birth in NSW PD2010-045
- Daily Patient Flow/Bed Management meetings-
- discuss all birthing unit admissions and plans for the proceeding two days
- Antenatal Ward and Postnatal Services for all issues
- Expected discharges for day
- Planned admissions for the day
Bed Management Strategies
Midwifery Support Programe- MSP
Models of Care
- Expected Date of Discharges
- Monitor delays in system
- Monitor inter hosptal transfers
- Monitor transfers out of RHW
- AHNM’s meet at 1700 and 2200 with Maternity Services
- Midwives Clinic and GP Shared Care
- Midwifery Group Practice (MGP)
- Malabar Community Midwifery Link Service
- Doctors Clinic
- Private Obstetrician
- Maternal Fetal Medicine
- Specialist Midwifery Clinic for Women with Special needs (10 /month)
- Working toward the Eligible Midwife- Midwife in Private practice- complex births in the hospital setting
Midwives in Group Practices - 40 %
- 6 Midwifery Group Practice of 5-6 FTE (EFT) midwives –women of all risk
- Groups are paired and 2 groups collaborate & consult with a named obstetrician
- Incorporate a Publicly funded homebirth service (2011/12)- midwifery workforce issues with establishment
- Midwifery Group Practice of 4 FTE - Indigenous Community Link Program (Malabar Group Practice) named obstetrician
- 1 Maternal Fetal Medicine Midwifery Group Practice – 1 Clinical Midwife Consultant and 3 FTE midwives (2011)
Look after more approximately 1500 women –
half of the publicly insured women
- Provide Postnatal support in the woman’s home
- Discharge- <48 hours Normal Birth
- Discharge < 72 hours Caesarean
- Eligible:
- Medically well
- Breastfeeding independently
- Feeding baby independently if formula feeding
- Following medical review if complicated antenatal, intra partum, postpartum episode
MSP- Births - Accepted
MSP -Home Visits
The Royal Hospital for Women, Randwick