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Southern Zone Management Unit

Queensland Health

Protocol
for
Shared Antenatal Care
Endorsed by the Southern Zone Clinical Network’s
Maternal, Neonatal and Gynaecological Expert Panel

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CONTENTS

1. Antenatal Pathway 3
2. Summary 4
3. Patient Eligibility 6
4. Registration for Shared Antenatal Care 6
5. Dating the Pregnancy 7
6. The Pregnancy Health Record 7
7. Frequency of visits 8
8. Immediate assessment at the Hospital 10
9. Ultrasound Scans 10
10. Antenatal Colposcopy 9
11. Routine Pathology Tests 11
12. Prenatal Diagnosis / genetic counselling 11
13. Guidelines for Antenatal Care 12

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PREGNANCY CONFIRMED/SUSPECTED

General Practitioner History (obstetric, medical, surgical, psychosocial)

Observations
Examination (general, obstetric)
Drug ingestion & allergy
Prenatal diagnosis must be discussed with women
AN Bloods aged 35 and over at delivery and those with a
Information Package history of genetic diseases or previous baby with
Questionnaire congenital abnormalities. Refer to genetics services.
Nuchal Translucency testing is available for early
chromosomal anomaly screening. Genetic
counselling will be provided at the ultrasound visit.

1st Hospital visit Ultra sound scan offered – discuss implications.

(12 - 16 weeks) Establish firm EDC
Women with medical problems to be reviewed by
specialist obstetrician.
Confirm model of care

Subsequent visits Observation (BP, Uterine size, fetal

heart, presentation, liquor volume)

28 weeks Full blood count (FBC)

Antibody screen (Rh –ve patients)
Glucose challenge test (GCT) if risk

36 weeks Full blood count (FBC)

Antibody screen

41 weeks If undelivered must be reviewed by

registrar or consultant with a view
to fetal assessment and induction of
labour
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SUMMARY
Registration for shared antenatal care
• The decision to enter shared antenatal care is a joint decision made by
the woman, her general practitioner/midwife and the hospital maternity
unit, all of whom share responsibility.
• All women should be reviewed by both her general practitioner and the
hospital obstetric unit as soon as practicable after confirmation of
pregnancy.

The Pregnancy Health Record

• The patient-held Pregnancy Health Record is designed to identify risk
factors.
• Please notify the Midwife at your local hospital (see contact details at
front of record) for any risk factors which may require monitoring or
intervention.
• Action oriented problems are designed to identify concerns that may lead
to an intervention strategy other than routine care. Notes are designed
to highlight patient concerns and minor problems in pregnancy.

Frequency of Visits
• Overall, the traditional protocol:
- 4th weekly to 28 weeks
- 2nd weekly to 36 weeks
- weekly until delivery

• This may vary according to action oriented problems. The hospital clinic
will choose the schedule for their visits and record this in the
appointment section. The remaining visits are to the general
practitioner.

Ultrasound Scans
• Ultrasound in the first trimester should only be performed for relevant
complications. A routine dating and morphology scan is offered 18 to 20
weeks.
• Nuchal Translucency testing is now being offered by a number of centres
between 11 weeks– 13 weeks and 5 days. Please refer to page 10 for
further information.

Routine Pathology Tests

• General Practitioners are encouraged to order routine blood tests and
arrange for a copy of the results to be sent to the Maternity Outpatients.
If this is not possible, routine blood tests may be ordered at the hospital
during a booking in visit. The care giver who checks the results and
informs the patient must transcribe these results on to the Pregnancy
Health Record.
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IF YOU HAVE ANY CONCERNS ABOUT YOUR PATIENT FOLLOWING A

HOSPITAL VISIT PLEASE PHONE:

GOLD COAST HOSPITAL

• SHARED CARE COORDINATOR (07) 55 718 211

OR
• MATERNITY UNIT (AFTER HOURS) (07) 55 718 325
OR
• SHARED CARE COORDINATOR (07) 55 718 610

IPSWICH HOSPITAL

• ANTENATAL CLINIC (07) 3810 1310

OR
• BIRTH SUITE (AFTER HOURS) (07) 3810 1242 or 3810 1247

LOGAN HOSPITAL

• SHARED CARE COORDINATOR (07) 3299 8527

OR
• ASSESSMENT UNIT (AFTER HOURS) (07) 3299 8663
OR
• MATERNITY SHARED CARE LIAISON (07) 3299 8527

BEAUDESERT HOSPITAL

• MAIN SWITCH (07) 55 411 411

OR
• MATERNITY UNIT (07) 55 419 206

MATER HOSPITAL

• SHARED CARE COORDINATOR (07) 3840 8823

OR
• ASSESSMENT UNIT (AFTER HOURS) (07) 3840 8111
OR
• MATERNITY SHARED CARE LIAISON (07) 3840 8823

REDLAND HOSPITAL

• SHARED CARE COORDINATOR (07) 3821 9655

OR
• ASSESSMENT UNIT (AFTER HOURS) (07) 3821 9655
OR
• MATERNITY SHARED CARE LIAISON (07) 3821 9706

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ROYAL WOMENS’ HOSPITAL

• SHARED CARE COORDINATOR (07) 363 67182

OR
• ASSESSMENT UNIT (AFTER HOURS) (07) 363 62302

TOOWOOMBA HOSPITAL

• ANTENATAL CLINIC (07) 46166201

• BIRTH SUITE (AFTER HOURS) (07) 46166212

• MATERNITY WARD (Harbison) (07) 46166223

1. Patient Eligibility

All pregnant women are potentially suitable for shared antenatal care. The
decision is a joint decision made by the woman, her general practitioner
and the hospital obstetric unit, all of whom share responsibility.

The most important principle underlying shared care is that the designation
of high and low risk is a continuing process throughout the pregnancy, as
more than one fifth of those designated as low risk on first antenatal visit
will have their risk status changed during the course of their pregnancy. A
further percentage will have their risk status changed during labour. In
certain circumstances a high risk patient may be accepted into a shared
care program providing all health care providers are familiar with the stated
risk factors and consequent management strategies. This would require
close collaboration between General Practitioners and the hospital.

It is most important in all cases to demonstrate consistency in the approach

between all care givers and the pregnant woman.

2. Registration Antenatal Care

All patients should be seen in hospital based antenatal clinic by 16 weeks

or as soon as possible if risk factors are identified or the patient is not
participating in a shared care arrangement.

2.1 History

The patient’s family, medical and obstetric history should be documented

on the patient-held Pregnancy Health Record by the shared care GP, or if
this is not practicable by a hospital based midwife at a “booking in” visit.

This process could identify risk factors that may require early intervention
or monitoring. Please notify the hospital contact person of such risk
factors. For example, patients offered antenatal diagnosis (e.g.
amniocentesis) based on age or previous history criteria, a past history of
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recurrent abortion, or major medical conditions that may complicate the
pregnancy.

It is recommended that both the GP and the hospital unit review the woman
as early as possible to maximise risk factors analysis.

2.2 Routine Blood Tests

Routine blood tests (see section 9) should be ordered at the first antenatal
visit. The hospital or local pathology unit may perform these tests. It is
essential that results are available for all care givers and must therefore be
included in the Pregnancy Health Record. Shared antenatal care is more
efficient for all care providers if tests requested and results were transcribed
into the Pregnancy Health Record in the appropriate place.

2.3 Documentation

The Pregnancy Health Record is held by the woman throughout her

pregnancy to enable all her care givers to review and comment and to
increase the patient’s participation in her own care. The hospital will keep
the record following confinement and the woman and/or shared care
provider may be given a photocopy if requested. Further details can be
provided on request. See Guidelines for Pregnancy Health Record.

3. Dating the Pregnancy

Best estimate of the expected date of confinement should be completed at

about 20 weeks gestation, when all applicable information is available. You
are encouraged to involve the woman in this process by carefully explaining
the reasons and listening to the woman’s viewpoint.

4. The Pregnancy Health Record

The Pregnancy Health Record is in an antenatal pathway format and will act
as a prompt to both General Practitioners and hospital professionals about
the important issues to be covered at significant points in the pregnancy.

Action oriented problems are designed to clearly identify concerns that may
lead to an action above and beyond routine antenatal care.
e.g: past history of premature labour – admit if any contractions.
APH repeated unexplained- serial growth measurements.

The section entitled “notes” beneath each visit is designed to record

concerns not necessarily requiring further action later in the pregnancy.
This is a very important area for all members of the team to become aware
of the individual woman’s experience of pregnancy.

All care providers are encouraged to record tests requested and the results.
This process will enable rapid appreciation of timing and results of

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pathology tests ordered throughout the pregnancy. In addition this ensures
that someone has checked the results of tests.

5. Frequency of Visits

Routine antenatal visits are scheduled according to the time-honoured

protocol ie:
- 4th weekly to 28 weeks
- 2nd weekly to 36 weeks
- weekly until delivery

The frequency of visits may be modified in view of the action-oriented

problems listed throughout pregnancy.

The pregnant woman must clearly understand that should she perceive a
problem she is free to return for a non-scheduled visit at any time, or phone
for advice. Indeed the woman is encouraged to communicate her concerns
immediately rather than wait until the next scheduled visit, as early
identification of problems is important to minimise morbidity. This can be
undertaken by the Maternity Outpatients Clinic or Shared Care General
Practitioner but may involve consultation.

Phone the Shared Care Coordinator on:

Gold Coast Hospital (07) 55 718 211

Ipswich Hospital (07) 3810 1310
Logan Hospital (07) 3299 8527
Beaudesert Hospital (07) 55 411 411
Mater Hospital (07) 3840 8823
Redland Hospital (07) 3821 9655
Royal Womens’ Hospital (07) 363 67182
Toowoomba Hospital (07) 46166201

Should the woman be admitted to hospital antenatally, a brief summary of

the admission will be forwarded to the Shared Care General Practitioner
and a note recorded in the Pregnancy Health Record following discharge.

All pregnant women participating in shared antenatal care should be

reviewed by the Maternity Outpatients clinic at 16 weeks (first visit), at 30
weeks (midwife visit), 36 and 41 weeks. The care giver may wish to vary
this pattern of visits in view of their assessment of the particular case, and
if so the reason ought be clearly documented in the “notes” section.
Secondly the shared care general practitioner may wish the hospital to take
over continuing care at any stage.

Should you be concerned that inappropriate action resulted from a hospital

visit, please ensure your concern is conveyed to the Shared Care Co-
ordinators. Your support is vital to the success of this program.
Communication between a hospital and a General Practitioner has been a
problem in every shared care program implemented within Australia. All
participants in shared antenatal care are free to telephone at any stage.
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The Maternity Outpatients Department hours:-

Gold Coast Hospital
Monday – Thursday 9am – 3pm
Enquiries & Bookings (07) 55 718 610
Shared Care Liaison (07) 55 718 610
After hours please telephone the
Maternity Unit (07) 55 718 325

Ipswich Hospital
Monday – Friday 8.30am – 4.30pm
Enquiries & Bookings (07) 3810 1310
Shared Care Liaison (07) 3810 1242 or 3810 1247
After hours please telephone the
Birth Suite (07) 3810 1242 or 3810 1247

Logan Hospital
Share Care Coordinator (07) 3299 8527
Shared Care Liaison (07) 3299 8527
After hours please telephone the
Assessment Unit (07) 3299 8663

Beaudesert Hospital
Main Hospital Switch (07) 55 411 411
Maternity Unit (07) 55 419 206

Mater Hospital
Tuesday – Friday 7.30am – 4pm
Enquiries (07) 3840 8330 or (07) 3840 8456 Bookings (07) 3840 8842
Shared Care Liaison (07) 3840 8823
After hours please telephone the
Assessment Unit (07) 3840 8111

Redland Hospital
Monday – Friday 8am – 4pm
Enquiries (07) 3281 9655 Bookings (07) 3240 8244
Shared Care Liaison (07) 3821 9706
After hours please telephone the
Assessment Unit (07) 3821 9655

Royal Womens’ Hospital

Maternity Outpatients
Monday to Friday, 7.30am – 4pm (07) 363 67182
Shared Care Liaison - 0412 918 578
After hours please telephone the
Assessment Unit (07) 363 62302.

Toowoomba Hospital
Maternity Outpatients (07) 46166201
Maternity Ward (Harbison Ward) (07) 46166223
After hours please telephone the
Assessment Unit (07) 46166212
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The General Practitioner is encouraged to return the woman for an obstetric

review should any of the following problems arise during the course of
antenatal care.
i. Abnormal routine screening test for which no clear intervention
has been noted in the action oriented problems.
ii. Hypertension, ie a reading >140/90 during the course of
pregnancy
iii. Uterine growth unusually large or small.
iv. Increased uterine activity reported.
v. Significant decrease in fetal movements.
vi. Any other problems which represent a departure from normal
antenatal course and which may require attention before a
routine clinic visit.

6. Immediate Assessment at the Hospital

Immediate assessment at the hospital is recommended particularly in the

following cases:
i. Intractable vomiting.
ii. Threatened preterm delivery.
iii. Preterm rupture of membranes.
iv. Undiagnosed abdominal pain or severe backache.
v. Antepartum haemorrhage – on all occasions.
vi. Unusual migraines, visual disturbances.
vii. Seizures or faints, which no clear diagnosis has been reached.

7. Ultrasound Scans

First trimester ultrasound should be performed for relevant complication

that is, vaginal bleeding. If Nuchal Translucency assessment is requested
this has to be performed between 11.0 and 13 weeks 5 days. This service is
offered to all pregnant women regardless of age, and is for early screening
for chromosomal anomalies. Genetic counselling will be provided at the
time of ultrasound. A number of centres are accredited for this service and
details can be obtained from the Maternal Fetal Unit at the Mater Mothers’
Hospital (07) 3840 1896.

A routine dating and morphology scan is also offered between 18 and 20

weeks gestation. It is desirable that all obstetric scans be performed to
optimise information to be gained, therefore an ultrasound service with a
special interest in obstetric ultrasound is recommended.

It is important that copies of all reports not performed at the hospital

be forwarded to the hospital so that the results can be kept in the
records.

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If complications occur late in the second or third trimester, women should
be referred to the hospital for assessment. It is possible at this stage that
all future ultrasonic examination (particularly for fetal growth), should be

performed with facilities that are capable of performing this sub-specialist

procedure. A high degree of knowledge and upgraded ultrasonic equipment
including Doppler, is recommended and this could possibly preclude a
number of imaging centres that are more than capable of performing the
earlier ultrasonic examination.

8. Antenatal Colposcopy

Women with documented negative cytology within the previous 18 months

do not need a repeat cervical (Pap) smear in pregnancy. Women with
cervical intra-epithelial neoplasia diagnosed by cytology during pregnancy
should be referred for colposcopy.

9. Routine Pathology Tests

• Investigation When to perform

• Full blood count Initial visit
• Blood groups and antibody screen Initial visit
• Syphilis serology Initial visit
• Rubella immunity Initial visit
• Hepatitis B Surface Antigen Initial visit
• Urine test Initial visit
• Cervical smear discussed Initial visit
• Repeat haemoglobin and antibody 28 weeks
screen
• Repeat haemoglobin and antibody screen 36 weeks
• In addition, HIV/Hep C screening should be offered to all high risk
pregnant women accompanied by appropriate counselling

10. Prenatal Diagnosis / Genetic Counselling

• Please refer to the “Genetics in General Practice “ booklet for guidelines

on who should be offered prenatal diagnosis.
• Women aged 35 or over at delivery
• Previous Down Syndrome or other chromosome abnormality
• Patients with a family history of an inherited disorder

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11. Guidelines for Antenatal Care

The Southern Zone Management Unit, Queensland Health

Management of Normal Antenatal Care

VISIT INFORMATION/ACTION INVESTIGATIONS

Booking in • Document personal, family, social and • Routine pathology
visit (for obstetric history. tests (if not arranged by
those not
done by GP)
• Referral to social worker, psychiatrist, GP)
nutritionist, physiotherapist • Cervical cytology
• Information leaflets (unless documented
-contact phone numbers negative cytology
-education classes within the previous 18
months)
• Models of care
• Nuchal Translucency
• Assess need for genetic counselling Testing
(11-13 weeks + 5 days)
First • Confirm model of care • Ultrasound offered
hospital
visit
• Develop individualised care plan and
(12 - 16 address action oriented problems.
weeks) • Antenatal diagnosis discussed if
indicated.
• Convey results of routine investigations.
• Fetal heart by Doppler
• Referral to other services
(physiotherapist, dietitian etc)
18-20 • Ultrasound Scan reviewed by the Doctor
weeks
36 weeks • Birth plan • Haemoglobin
• Analgesia in labour • Antibody screen
• Newborn Care
• Discuss signs of labour and expectations
• Length of postnatal stay
• Extended Midwifery Service/Early
Discharge Program
41 weeks • Discuss induction of labour guidelines • Cervical assessment
• Clearly explain that currently there is no • Offer and book
evidence to support the effectiveness of induction at 41week
any particular methods of antenatal fetal visit or Fetal
surveillance monitoring (clinics vary
in approach)

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