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  • 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

Thank you!

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

  • MoH Patient Flow Portal-

  • 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

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