Antenatal Guidelines Kemh

Government of Western Australia
North Metropolitan Health Service

Women and Newborn Health Service
Antenatal Shared Care

Guidelines for General Practitioners
Seventh Edition
CONTENTS Page
Introduction2
Referring Women to KEMH 2
Referral pathways 5
Antenatal shared care visits 7
Preconception counselling, folate and iodine 8
Obstetric medication information 9
Documentation and routine assessments 9
Non-medicare eligible patients 10
Early Pregnancy Assessment Service (EPAS)10
Emergency Centre 11
Guidelines for exclusion from shared care 12
Preterm birth (WA Preterm Birth Prevention Initiative) 13
Guidelines for immediate antenatal assessment 14
Infectious diseases and immunisation in pregnancy 14
Investigations15
Vitamin Supplementation in pregnancy 18
Obesity in pregnancy 20
Gestational Diabetes Mellitus (GDM) screening 22
Fetal anomaly screening 26
Fetal morphology ultrasound 30
Rural patients 30
Maternal Fetal Medicine Service (MFM) 31
Maternal Fetal Assessment Unit (MFAU) 31
Women and newborn drug and alcohol service (WANDAS) 31
Guidelines for investigation of patients at risk of haemoglobinopathy 32
Use of anti-D in pregnancy 35
How to obtain anti-D 35
Perinatal Mental Health Services 37
Postnatal complications 39
Appendix 1 – Edinburgh Postnatal Depression Scale (EPDS) 42
Appendix 2 – Perinatal Anxiety Screening Scale (PASS) 44
Appendix 3 – Care choices provided at KEMH 46
Appendix 4 – Important telephone numbers 51
Introduction
The aim of this booklet is to provide clear guidelines for general practitioners
(GPs) involved in the shared care of low-risk antenatal patients with King Edward
Memorial Hospital (KEMH) and other maternity care providers in Western
Australia. The purpose of shared care is to improve the quality and convenience
of care for women.
Referring women to KEMH

In 2014, the Department of Health launched the Central Referral Service (CRS)
to manage specialist outpatient referrals in the public health system.
Antenatal referrals
At the time of publication, antenatal referrals were outside the scope of the
Central Referral Service. Please refer to the Health Professionals page of the
KEMH website for updates.
Routine referrals
GPs are requested to refer low risk antenatal patients to their local maternity
service based on their postcode of residence. (See Table 1 on page 4)
GPs are requested to clearly indicate their intention to share care on the referral.
For low-risk women who are referred to KEMH, the first visit is usually at 14-20
weeks gestation. If GPs are unsure if a woman is low or high risk, they can refer
to the local maternity service which will assess the referral and send on to KEMH
if required. All secondary maternity services (except Bentley Health Service) are
able to take women with a BMI up to 40.
High risk antenatal patients may be referred directly to KEMH Outpatient
Department. Please refer early as these women may need to be seen at an
earlier gestation.
Fax: (08) 6458 1031
Referrals for women requiring review within 7 days

If the woman resides within KEMH catchment area, the GP should contact
KEMH Clinical Midwifery Nurse Manager (Ambulatory Services)
Phone (08) 6458 2222 page 3419.
If woman resides outside KEMH catchment area, the GP needs to contact their
local maternity service to discuss the referral.
2
Urgent referrals
<20 weeks gestation Contact the KEMH Gynaecology Registrar
Ph: (08) 6458 8222 and request them to be paged
>20 weeks gestation Contact the KEMH Obstetric Registrar
Ph: (08) 6458 2222 and request them to be paged
The KEMH Outpatient Referral Form can be downloaded from the Health
Professionals section of the KEMH website:
Download Form here
Referrals using GP software that include all the relevant history and information
are also welcome.
The following information is required on all referrals to the hospital:
• Woman’s current contact details
• Last Menstrual Period (if known)
• Estimated Due Date
• Gravida and parity
• Weight, height and BMI
• Booking blood pressure
• GP’s intention to share care
• Any relevant medical and obstetric history
• If interpreter services are required
Which general practitioners can provide shared care with KEMH?

All GPs who undertake shared care must be registered medical practitioners
in WA, have appropriate personal medical defence cover to undertake shared
antenatal care, be of good character and have adequate antenatal experience
or supervision.
For queries
The Clinical Midwifery Nurse Manager (Ambulatory Services), can be contacted
on (08) 6458 2222, pager 3419 from 8.00am to 3.00pm Monday to Friday, or
fax (08) 6458 1031, if you have any queries regarding these guidelines.
For urgent issues call (08) 6458 2222 and ask for the appropriate staff member:
• For gestation less than 20 weeks – Gynaecology registrar
• For gestation over 20 weeks – Obstetric registrar
• For gynaecology issues – Gynaecology registrar
3
Table 1 Postcodes within hospital catchment areas
HOSPITAL POSTCODES (inclusive of all numbers within ranges)
Armadale Health Service 6108-6112, 6121-6126
Bentley Hospital 6100-6105, 6107, 6151, 6152
Fiona Stanley Hospital 6147-6150, 6153-6160, 6162-6164, 6166
Joondalup Health Campus 6019, 6020, 6023-6038, 6061, 6064-6067
6000, 6001, 6003-6013, (6014 Jolimont/Floreat/Wembley),
KEMH
6015, 6016, 6050, 6051, (6052 Bedford), 6053, 6062
6014-6015, 6017-6022, (6052 Inglewood), 6059-6061,
Osborne Park Hospital
6063
Peel Health Campus 6180, 6207, 6208, 6210, 6211
Rockingham General
6165, 6167-6176
Hospital
St John of God 6054-6058, 6066, 6068-6074, 6081-6085, 6090, 6500,
Midland Public Hospital 6556, 6558 (plus Wheatbelt region)
Please Note: Frequent review of postcodes is undertaken taking into account

population growth, service demand and service capacity.
Requests for female practitioners

Patients at KEMH will be seen by medical practitioners on the basis of
their clinical need, without reference to the medical practitioner’s gender,
age, religion, race or nationality. KEMH doctors are well qualified medical
practitioners who conduct themselves professionally and the Hospital does
not discriminate between doctors on the basis of the above criteria.
This information should be made clear to patients who book at KEMH.
Websites for general practitioners
Antenatal Shared Care Guidelines overview – click here
Patient information about Pregnancy and childbirth
Having a baby in WA – click here
4
Referral pathways
Woman/GP requests care at KEMH
Semi-urgent
Routine referral or
Appointment required
non-urgent Urgent referral
within one to two
(low-risk)
weeks.
If patient lives outside GP to contact KEMH >20 weeks gestation <20 weeks gestation
If patient lives in KEMH catchment area Clinical Midwifery Contact KEMH Contact gynaecology
KEMH catchment area (see page 2), GP to Nurse Manager obstetric registrar. registrar.
(see page 2), GP to advise patient they (Ambulatory Services).
send letter to KEMH are suitable to deliver Phone: (08) 6458 2222 Phone: (08) 6458 2222
antenatal clinic. in their local maternity Phone: (08) 6458 2222 and request them to be and request them to be
unit. Pager: 3419 paged. paged.
GP to send a letter to
local antenatal clinic.
At the time of publication, antenatal referrals were outside the scope of the Central Referral Service.
Please refer to the Health Professionals page of the KEMH website for updates.
5
Antenatal shared care visits
The table below details the recommended practice for women with low-risk
pregnancies undertaking shared care. More frequent visits may be relevant
depending on the clinical situation.
Please note: women may not be seen by a doctor at KEMH antenatal clinic.
Visit Encounter Provider
1st visit Confirm pregnancy and expected date of delivery. GP

Medical history and examination: cardiovascular,
respiratory and breast
Complete initial routine investigations - see page 15.
Counsel and offer first trimester screening, regardless of
woman’s age (ideally 10 weeks for blood test, 12 weeks
for ultrasound scan) - see page 27.
Complete Edinburgh Postnatal Depression Scale (page 42).
Discuss alcohol, smoking, diet, exercise, back care, minor
discomforts, illicit drug use.
Discuss influenza vaccine (depending on time of the year)
and recommend vaccine is given prior to influenza season.
Check for use of folate supplements.
14 weeks Routine assessment GP
Ensure patient has the results of their first trimester
screening test if performed.
Counsel and offer maternal serum screening at 15 to 17
weeks if first trimester screening not done – see page 27.
Book 19 week ultrasound anatomy scan – see page 30.
Refer to booking hospital – see page 2 (Antenatal Referrals).
If you are ordering maternal serum screening or 19 week
ultrasound indicate this on the referral letter.
Discuss parent education classes.
14 to 20 Antenatal visit at KEMH – assess suitability for shared- KEMH
weeks care, rebook for 36 weeks (40 weeks if GP obstetrician).
Edinburgh Postnatal Depression Scale (EPDS).
Perinatal Anxiety Screening Scale (PASS).
Audit C (alcohol assessment) & smoking assessment.
Discuss breastfeeding, when to go to hospital, parent
education classes (metro), allied health services.
6
Visit Encounter Provider
24 weeks Routine assessment. Order 28 week investigations: full GP

blood count +/- iron studies (if at risk of anaemia), blood
group and antibody screen if Rhesus negative.
28 weeks Routine assessment. Administer prophylactic anti-D if GP
Rhesus negative - see page 35.
Pertussis vaccine to be given between 28-32 weeks
gestation.
Review investigation results.
30 weeks Routine assessment for primigravida women or those with GP
previous complications.
32 weeks Routine assessment. GP
34 weeks Routine assessment. GP
36 weeks Follow up KEMH / GP obstetrician KEMH
on Organise investigations - see page 16.
Blood group and antibody screen if required.
Administer anti-D if Rhesus negative – see page 35.
EPDS, PASS, Audit C (alcohol) and smoking assessment.
Discuss birth plan, pain relief, car seats and capsules,
child health nurse, contraception, choices for feeding,
community resources, support at home, six week postnatal
assessment, six week infant assessment by GP.
40 weeks Remainder of care at KEMH (if under GP obstetrician). KEMH
Postnatal Baby check: weight and head circumference, full GP
check examination, first immunisations (8 weeks)
Mother check: discuss delivery, check blood loss/uterine
6-8
size and perineum or LUSCS wound, breastfeeding, screen
weeks
for PND/anxiety, discuss contraception, Pap smear if due,
update immunisations (rubella and varicella), OGTT if GDM
(repeat 1-2 yearly)
Medications: review/adjust any changes made
during pregnancy e.g. thyroxine, anticonvulsants,
antihypertensives.
Third degree tears: if women have problems contact the
Clinic Referral Coordinator on (08) 6458 2222 page 3548 to
fast-track an outpatient review.
Fourth degree tears: women are routinely reviewed at
KEMH at approximately six weeks postpartum.
7
Preconception counselling, folate and iodine
Identify women who are thinking about pregnancy.
• For those at high risk of fetal abnormality, referral for genetic counselling
may be appropriate. Phone Genetic Services of W.A. (08) 6458 1683.
• Women with Type 1 or Type 2 Diabetes, are invited to attend the Diabetes
Service at KEMH for counselling. Phone (08) 6458 2163.
• Women with a severe mental illness such as schizophrenia, bipolar
affective disorder or puerperal psychosis, can be referred to the CAMI
(Childbirth and Mental Illness) Service for pre-conception counselling.
Phone (08) 6458 1521.
Folate:
Folate supplementation from 1 month pre-conception and during the first
trimester (up to 12 weeks), is associated with a 50-70% reduction in the rate of
neural tube defects (NTD).
Folate Dose Indication

0.4mg/day Most women
5mg/day Women with a multiple pregnancy
Women at high risk of a neural tube defect
- Personal history of open NTD
- Previous affected child or family history of NTD
- Anticonvulsant medication
- Obesity
- Pre-pregnancy diabetes
- Malabsorptive conditions
Iodine
The National Health and Medical Research Council (NHMRC) recommends
that all women who are considering pregnancy, pregnant or breastfeeding,
take an iodine supplement of 150mcg/day. Women with pre-existing thyroid
conditions should seek advice from their doctor prior to taking a supplement.
Pregnancy is a time of increased iodine requirements for production of thyroid

hormones, which are important in the growth and development of the nervous
system. There has been some re-emergence of iodine deficiency in Australia
with the reduction in consumption of iodine fortified food and salt.
8
Obstetric medication information
The Pharmacy Department at KEMH provides an information service on the
safety of medications taken during pregnancy and breastfeeding.
The Obstetric Drug Information Service can be contacted on (08) 6458 2723,
Monday to Friday from 8.30am to 5.00pm. If GPs have urgent enquiries after
hours, a pharmacist can be contacted via KEMH switchboard
Phone: (08) 6458 2222.
Documentation and routine assessments

At each visit ensure routine checks are recorded in the hand-held Pregnancy
Health Record. Writing should be clear, concise and legible. If using Medical
Director or other software, please print out each visit and include this in the
hand-held record.
A routine check consists of:
• Blood pressure (<140/90)
• Weight (please see the table below for recommended weight gain
based on BMI)
• Urinalysis (< + protein)
• Fundus should be measured from 24 weeks
• Fetal movements from 24 weeks
• Fetal heart rate from 20 weeks (earlier if Doppler available)
Note: Some peripheral oedema is now usually regarded as normal in
pregnancy.
Pre-pregnancy Total Weight Rate of Weight Gain Second
BMI Gain and Third Trimester
Underweight 12.5kg - 18kg 510g/week
BMI <18.5
Normal Weight 11.5kg - 16kg 420g/week
BMI 18.5-24.9
Overweight 7kg - 11.5kg 280g/week
BMI 25-29.9
Obese 5kg - 9kg 220g/week
BMI > 30
9
Non-medicare eligible patients
Patients who are not eligible for Medicare (including overseas students and
non-insured patients) who require antenatal care are able to access care at
King Edward Memorial Hospital if they live in the north metropolitan area or
Fiona Stanley Hospital if they live in the south metropolitan area. Fees will
apply and patients will be asked to pay prior to their appointment.
For more information please contact the Private Patient Liaison Officer.
Phone: (08) 8458 1066
Email: [email protected]
Early Pregnancy Assessment Service (EPAS)

KEMH has a specialised service to review patients with problems in the first
trimester of pregnancy including pain and bleeding which may represent
suspected miscarriage or ectopic pregnancy. Patients need to be referred to
the service and are given an appointment to attend.
Time: 8.30 to 12.30 Monday, Wednesday and Friday (excluding public holidays)
Venue: Emergency Centre, KEMH
Appointment: Booking an appointment at EPAS is possible 24 hours a day.
Phone: (08) 6458 1431
Alternatively, call the KEMH switchboard on (08) 6458 2222 and ask for
EPAS midwife (Pager: 1431).
Who may be referred?

Women in the first trimester of pregnancy who have had a positive
pregnancy test and one or more of the following:
• abdominal/pelvic pain
• vaginal bleeding
• previous ectopic
• previous tubal surgery
• two or more previous miscarriages
• IUCD in-situ
Please advise patients to fast from 7.00am (they may have water only) in case
they need to go to theatre that day.
If the patient is haemodynamically unstable, has severe pain or heavy
vaginal bleeding please call the Emergency Centre on (08) 6458 1431.
10
Emergency Centre
Women will be seen at anytime in the Emergency Centre if they have severe
pain, heavy vaginal bleeding or an ectopic pregnancy is suspected.
Note: An ultrasound will not necessarily be performed, particularly out of hours
or outside of EPAS hours.
If you are referring a patient, notification by phone is always appreciated by
the staff in the Emergency Centre. Please advise patients to fast from 7.00am
(they may have water only) in case they need to go to theatre that day.
For early pregnancy loss, the Emergency Centre offers management by:
• Expectant management
• Medical management using misoprostol
• Dilatation and curettage (D&C)
This will be discussed with patients on an individual basis and if a woman
elects to have medical management, she will be followed up in the Emergency
Centre.
If you require clinical advice, a registrar or consultant is available in-hours in
the Emergency Centre. Please phone (08) 6458 1431 or (08) 6458 1433.
Alternatively, phone the KEMH switchboard (08) 6458 2222 and ask for the
appropriate staff member depending on the time of day:
0800-2200 Gestation < 20 weeks Gynaecology Registrar
Gestation > 20 weeks Obstetric Registrar
2200-0800 Any gestation On-call registrar
When you refer a patient to the Emergency Centre, please send any reports
with the patient, such as ultrasound, blood group or quantitative BhCG, but do
not worry if these tests have not been done.
Anti-D
It is recommended that anti-D is given to all Rhesus negative and antibody
negative women if there is risk of fetal-maternal transfusion of blood, such as
a miscarriage. If women do not require a medical review at KEMH it is usually
more convenient for them to be given anti-D by their GP.
For further information on how to obtain anti-D, see page 35.
11
Guidelines for exclusion from shared care
The following are guidelines to help GPs identify women who are not suitable
for antenatal shared care. Any concerns can be discussed with the Clinical
Nurse Midwifery Manager (Ambulatory Services) or the KEMH Senior Obstetric
Registrar. Phone (08) 6458 2222 and ask for the staff member to be paged.
General
No documented evidence of antenatal care prior to 24 weeks gestation.
Medical history
• Significant cardiac disease
• Essential hypertension
• Previous deep vein thrombosis or pulmonary embolus
• Renal disease
• Type 1 or Type 2 Diabetes Mellitus
• Unstable thyroid disease
• Chemical dependency - Refer to Women and Newborn Drug and Alcohol
Service (WANDAS) – see page 31
• Epilepsy/seizures or use of anticonvulsant drugs
• Bleeding disorders
• Chronic carriers of Hepatitis B – see page 17
• HIV infection
• Known bony pelvic deformity
• Systemic lupus erythematosus
• Current malignant disease
• Asthma requiring hospitalisation or requiring oral or parenteral steroid
therapy in the past five years
• Rubella titres indicating recent infection
• Significant anaemia (Hb <100 g/L)
• Maternal Phenylketonuria (PKU)
• Any significant condition for which the woman is being monitored by a
physician or psychiatrist
12
Previous obstetric/gynaecological history
• Previous pregnancy requiring intensive monitoring or with poor outcome.
• History of preterm delivery (prior to 34 weeks). (See below)
• One or more pregnancies with Intra Uterine Growth Restriction (IUGR)
• Gestational Diabetes Mellitus requiring insulin
• Severe pre-eclampsia.
• Recurrent miscarriage including mid-trimester loss.
• Infertility requiring surgery or fertility drugs other than clomiphene.
• Previous infant with major congenital anomaly and/or inherited disorder.
Current pregnancy
• Twin pregnancy: Order 12 week ultrasound to determine chorionicity.
If monochorionic diamniotic, arrange a 16 week scan to look for twin-to-twin
transfusion and contact KEMH if results abnormal.
• Atypical red cell antibodies.
• Adolescent (if first pregnancy and due date before 18th Birthday) – Refer to
Adolescent Antenatal Clinic.
• Morbid obesity BMI > 40 (Rockingham and Fiona Stanley Hospitals accept
patients with BMI up to 45).
Preterm birth (WA Preterm Birth Prevention Initiative)

• Many cases of preterm birth may now be preventable
• Women with prior spontaneous preterm birth between 20-34 weeks should
be prescribed natural vaginal progesterone 200mg daily from 16-36 weeks.
• Measurement of cervical length should be routine in the “anatomy” scan.
• Women with a shortened cervix (10-20 mm) in mid-pregnancy should be
prescribed natural vaginal progesterone 200mg daily until 36 weeks.
• Babies should be delivered from 38 weeks, unless unavoidable.
• Practitioners should continue to support pregnant women to reduce smoking.
• Women at high risk of preterm birth may benefit from referral to, or
consultation with, the Preterm Birth Prevention Clinic at KEMH.
Outpatient Fax (08) 6458 1031.
• For more information contact MFM Service: Phone (08) 6458 2848
Fax (08) 6458 1060 or see website
13
Guidelines for problems requiring immediate
antenatal assessment
Listed below are problems which should be discussed with the patient’s
booking hospital to organise patient review. This is not an exhaustive list.
For women booked at KEMH, please contact the Obstetric Senior Registrar for
advice. Phone: (08) 6458 2222 and ask switchboard to page.
Pregnancy complications
• Antepartum haemorrhage
• Hypertension (>140/90)
• Threatened preterm labour
• Premature rupture of membranes
• Abnormal fetal anatomy ultrasound scan
• Reduction in fetal movements
• High presenting part and unstable lie in late pregnancy
• Polyhydramnios
• Intrauterine growth restriction (IUGR)
• Abnormal fetal presentation after 36 weeks e.g. breech
• Rhesus antibodies
• Proteinuria greater than one plus (>1+)
Infectious diseases and immunisation in pregnancy

• Women with infectious diseases in pregnancy often do not need referral to
KEMH. Please phone KEMH (08) 6458 2222 first to discuss the patient.
- Gestation < 20 weeks: Gynaecology registrar
- Gestation > 20 weeks: Obstetric registrar
• Live attenuated vaccines are not recommended during pregnancy (e.g.
MMR, varicella, rotavirus, BCG, oral typhoid vaccine). If given inadvertently,
specialist consultation is advised.
• Inactivated influenza vaccine is safe to give during pregnancy and is
recommended as pregnant women are at increased risk of influenza related
infectious complications.
• Pertussis vaccine is recommended in the third trimester.
• For other clinical advice, please contact the on-call Microbiologist at KEMH
through the KEMH switchboard (08) 6458 2222.
• For routine advice on pregnancy, travel and vaccinations, please contact a
specialised travel medicine clinic.
14
Investigations
Investigations may be ordered privately or at KEMH. Photocopies of all tests
should be sent to KEMH - Fax (08) 6458 1031. Please write ‘copy to KEMH
Antenatal Clinic’ to assist clerks.
1. Initial routine investigations for each pregnancy at first antenatal visit

(obtain informed consent for each test):
• Full blood picture
• Blood group and atypical antibody screen
• Syphilis serology
• Rubella titre
• Hepatitis B surface antigen
• Hepatitis C antibodies
• HIV antibodies
• Blood sugar level
- if random BSL ≥ 7.8 needs Oral Glucose Tolerance Test (OGTT)
- if fasting BSL ≥ 5.1 indicates Gestational Diabetes Mellitus
• Midstream urine
• Chlamydia/Gonorrhoea screening
2. All women should be counselled and offered fetal anomaly screening
(see page 26).
3. Investigations to be considered depending on the woman’s clinical
circumstances:
• Early dating ultrasound if dates uncertain
• Pap smear (if not done within two years)
• Early OGTT if high risk of gestational diabetes (see page 22)
• Iron studies if at risk of anaemia.
• Haemoglobinopathy screening if in high-risk group e.g. high risk ethnic
background, FHx of haemoglobinopathy (see page 32)
• Twin pregnancy: Order 12 week ultrasound to determine chorionicity.
If monochorionic diamniotic, arrange a 16 week scan to look for
twin-to-twin transfusion and contact KEMH if results abnormal.
15
• Vitamin D:
- Vitamin D screening is recommended if women are at risk of Vitamin
D deficiency (dark skinned women, women with lack of sunlight
exposure including women with religious covering, obese women and
women with fat malabsorption)
- Vitamin D = 50nmol/L is considered normal
- If Vitamin D deficiency is identified (mild if Vitamin D 30-49 nmol/L,
severe if <30 nmol/L), supplementation is recommended until
cessation of breastfeeding (see page 18).
4. 19 weeks gestation:
• Fetal anatomy ultrasound (GP to organise)
5. 28 Weeks (arrange prior to 28 week visit e.g. at 24 week visit)
• Full blood picture +/- iron studies (if at risk of anaemia)
• Blood group and atypical antibody screen (for rhesus negative women)
• Oral Glucose Tolerance Test (OGTT) for all women
6. 36 weeks (KEMH will organise)

• Full blood picture
• Blood group and atypical antibody screen if rhesus negative (only if the
woman missed her 28 week anti-D)
• Low vaginal swab and rectal/perianal swab for group B streptococcus
screening. Patients with a positive result will receive intravenous
antibiotics during labour.
Group B streptococcus (GBS) infection

All patients with the following risk factors will need to receive intravenous
antibiotics during labour to reduce the risk of infant infection:
• previously infected infant with Group B streptococcus
• Group B streptococcus identified in the urine in pregnancy (GBS urinary
tract infection or bacteriuria), regardless of GBS swabs at 36 weeks
• positive vaginal/rectal/perianal swabs at 36 weeks.
Please send in all urine and swab results to KEMH.
16
Chlamydia and Gonorrhoea screening
• For all women at booking – self obtained lower vaginal swab (SOLVS) and
first void urine PCR (FVU)
• Women living in STI endemic areas (Kimberley, Pilbara and Goldfields)
should be offered additional screening:
- Between 28 and 36 weeks gestation repeat HIV and syphilis serology
- At 36 weeks gestation repeat chlamydia and gonorrhoea screening
Hepatitis B – chronic carriers

• Chronic carriers of Hepatitis B have core Antigen positive and e Antibody
negative.
• Check viral load and refer to Hepatology Service at Royal Perth Hospital
advising that the woman is pregnant.
• Antiviral therapy in pregnancy may reduce vertical transmission to the fetus.
• Lifelong antiviral therapy may reduce cirrhosis and hepatocellular
carcinoma.
17
Vitamin supplementation in pregnancy
In addition to folate and iodine (see page 8), some women may require other
vitamins during pregnancy and breastfeeding.
Vitamin D
Maternal Vitamin D deficiency is associated with hypocalcaemia in the
newborn, which can lead to convulsions, muscle cramps or weakness. Severe
deficiency of vitamin D can disrupt skeletal mineralisation and lead to rickets
and defective tooth enamel. It may also be associated with other long term
health problems for the infant. The prevalence of Vitamin D deficiency in
Australian neonates is up to 40-57%, with severe deficiency in 11-19% (rates
vary according to season and location).
General population screening of pregnant women is not currently
recommended. Instead, a risk based screening approach is adopted. Those
considered at high risk of Vitamin D deficiency should have levels performed
with initial antenatal screening bloods and treatment initiated as necessary.
High Risk groups include:
• Dark Skinned women
• Lack of sunlight exposure: religious covering (veiled women), chronic
illness or hospitalisation.
• Obesity (pre-pregnancy BMI ≥ 40)
• Medical conditions: Fat malabsorptive conditions
Vitamin D Treatment
Level (nmol/L)
Optimal >78 -
Sufficient/normal Consider 400 IU/day as part of a
>50
pregnancy multivitamin
Mild Deficiency or 1000 IU/day plus calcium (RDI) –
insufficiency 30-49 for 6 weeks
(RDI = recommended daily intake)
Severe 2000 IU/day plus calcium (RDI) –
<30
Deficiency for 6 weeks
After 6 weeks of treatment, a maintenance dose of 1000 IU/day plus calcium
(RDI) is recommended until cessation of lactation. The Vitamin D level is
not required to be rechecked. Babies born to Vitamin D deficient women will
require Vitamin D supplementation.
18
Vitamin B12
Consideration may be given to supplement vegetarians and vegans with
Vitamin B12, with a recommended daily intake of 2.6mcg/day.
Iron
Routine iron supplementation is not recommended during pregnancy due to
the associated side effects which may include nausea and constipation.
There is a greater requirement for iron during pregnancy and the
recommended daily intake of iron during pregnancy is 27mg/day. Screening
with a haemoglobin at initial antenatal bloods and at 28 weeks is routine. If
anaemia is detected then further investigation and treatment is necessary.
Iron deficiency is common during pregnancy and there is additional risk if
women are vegetarians or have a multiple pregnancy. Preparations with high
elemental iron content (>100mg/unit) are recommended to reverse anaemia.
Iron absorption is impaired if women take their iron supplement at the same
time as supplements containing calcium. Vitamin D/Calcium supplements
should therefore be taken at a different time to iron supplements.
Brands of iron
High dose elemental iron (>100mg/unit): Ferrograd C, Ferrogradumet,
Ferro-f-tab, Ferro-tab
Medium dose elemental iron (30-99mg/unit): Fefol, Elevit
Low dose elemental iron (<30mg/unit): Iron Maxx, Pure Innovation, Spatone,
Fab Iron, Swisse Multi, Metagenics Veggie Caps, Floradix (liquid iron), some
Pregnancy multivitamins
Calcium
The recommended daily intake for Calcium is 1300mg (14-18years old)
and 1000mg (19-50 years old) during pregnancy and lactation. If oral
intake of calcium rich food (dairy, soy products) is inadequate, than oral
supplementation with 1000mcg Calcium is recommended. There is also
evidence of a benefit of calcium supplementation in reducing the risk of
complications of hypertensive disease and pre-eclampsia in those at high risk,
particularly in people with low calcium intake in their diet. The World Health
Organisation (WHO) recommends 1.5-2g of Calcium supplementation in
pregnant women with low dietary calcium intake.
19
Obesity in pregnancy (BMI = 30 and above)
50% of pregnant women are now overweight or obese. Obesity in pregnancy
increases morbidity and mortality for both mother and baby.
At the time of publication, all maternity services (excluding Bentley Hospital),
were able to provide antenatal care and delivery for women up to BMI = 40.
Rockingham and Fiona Stanley Hospitals were able to provide antenatal care
and delivery for women up to BMI = 45. KEMH has no limit for BMI.
Complications of obesity in pregnancy

Maternal
• Early miscarriage
• Stillbirth – 2-3 fold increase
• Hypertension/Pre-Eclampsia – 50% increase
• Diabetes- 3 times more common
• Nutritional deficiencies
• Pre-term labour/Delivery
• Thromboembolism
Fetal
• Congenital anomalies – cardiac/neural tube defects
• Macrosomia
• Early neonatal death
• Increased obesity and metabolic disorders in childhood.
Pre-pregnancy management
• Advice on weight reduction including exercise and dietician referral
• Commence folic acid 5mg/day to prevent neural tube defects
Bariatric surgery
• Previous bariatric surgery increases the risk of nutritional deficiencies
during pregnancy
• Maternal complications are decreased by bariatric surgery though the risk
of intrauterine growth restriction is increased.
20
Pregnancy management
First trimester
• Influenza vaccination is especially recommended
• Discussion regarding healthy weight gain i.e. total weight gain of 5-9kg
• Screened for and correct nutritional deficiencies (anaemia, Vit C/Vit D)
Second trimester
• Early OGTT should be organised
• Anatomy scan: request at 20-22 weeks, include BMI on request form
Third trimester
• Increased frequency of visits is required to monitor for complications such
as pre-eclampsia and intrauterine growth restriction
• OGTT should be repeated at 28 weeks if early OGTT normal
• Referrals: - Physician referral if additional risk factors or medical history
- High risk anaesthetic referral for BMI >50
• Anaemia and nutritional deficiencies are screened for again at 28 weeks
• Consider thromboprophylaxis if two or more risk factors are present
• Ultrasounds:
- Minimum of two growth and wellbeing scans should be performed
- BMI > 40 should have additional growth scan at 38 weeks
Delivery planning
• Home birth is not recommended
• Previous caesarean section – the likelihood of successful VBAC is very low
in obese women and BMI >40 have increased risk of scar dehiscence
Intrapartum
• All obese women require IV access +/- increased monitoring in labour with
fetal scalp electrode for fetus/intrauterine pressure catheter for contractions
• Early epidural is recommended if patient requests
Post partum
• Venous thromboembolism prophylaxis
Contraception
• Oral contraceptives are less effective in women >90kg
21
Gestational Diabetes Mellitus (GDM) Screening
Definition:
GDM is defined as glucose intolerance of variable severity with onset or first
recognition during pregnancy.
Screening principles:
The Australian Diabetes in Pregnancy Society (ADIPS) recommends universal
screening for diabetes in pregnancy.
KEMH recommends inclusion of plasma glucose with booking bloods and
results acted on as follows:
Non-fasting plasma glucose ≥ 7.8mmol/L proceed to OGTT
Fasting plasma glucose ≥ 5.1mmol/L is diagnostic of GDM
The routine screening tool for GDM is a 75g Oral Glucose Tolerance Test
(OGTT) which is recommended at 24-28 weeks for low risk women. If women
are identified as being at increased risk, OGTT should be performed at the
first opportunity after conception. If the initial OGTT is negative, these women
should be monitored closely and have a follow-up OGTT.
Any woman may be tested for diabetes at any time during pregnancy if there
is clinical suspicion based on symptoms or other factors such as heavy
glycosuria, fetal macrosomia or polyhydramnios.
Diagnostic criteria:
The current ADIPS guidelines (Nov 2014) have been produced with the
assistance of the Royal Australasian College of Obstetrics and Gynaecology
(RANZCOG) and the Royal College of Pathologists of Australia (RCPA).
A diagnosis of GDM is made if one or more of the following glucose levels are
elevated after OGTT:
Fasting plasma glucose ≥ 5.1mmol/L
1 hour plasma glucose ≥ 10.0mmol/L
2 hour plasma glucose ≥ 8.5mmol/L
If OGTT is logistically difficult, the following may be considered to investigate
and diagnose GDM:
Non-fasting plasma glucose ≥ 7.8mmol/L proceed to OGTT
Fasting plasma glucose ≥ 5.1mmol/L is diagnostic of GDM
HbA1C > 48mmol (6.5%)
22
Recommendations for early testing for GDM for women
with risk factors:
Women, not known to have pre-existing glucose abnormalities, but with risk
factors for GDM, should be tested early in pregnancy according to a tiered
approach.
Moderate risk factors for GDM:

1. Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander,
Pacific Islander, Maori, Middle Eastern, non-white African
2. BMI 25 – 35
Women with either ethnicity or a body mass index (BMI) of 25-35 as their
only risk factor should be considered as “moderate risk” and should initially
be screened with either random or fasting plasma glucose in early pregnancy.
If this is normal then follow with an OGTT at the usual time of 24-28 weeks
gestation, unless clinically indicated earlier.
High risk factors for GDM:
1. Previous GDM or elevated blood glucose level
2. Maternal age ≥ 40 years
3. BMI > 35
4. Hypertension prior to 20 weeks gestation in current pregnancy
5. Polycystic ovarian syndrome
6. Medications: corticosteroids, antipsychotics
7. Family history DM (1st degree relative with diabetes or a sister with GDM)
8. Previous macrosomic baby (birth weight > 4500 g or > 90th centile)
9. Previous baby with congenital abnormalities
10. Previous unexplained stillbirth
OR presence of both moderate risk factors: ethnicity and BMI 25-35
Women at “high risk” of GDM (one high risk factor or two moderate risk
factors) should undergo an OGTT at the first opportunity after conception.
If this is normal then follow with an OGTT at the usual time of 24-28 weeks
gestation, unless clinically indicated earlier.
23
Pre 24 weeks 24-28 weeks
gestation* gestation
Plasma glucose with OGTT
Low risk
booking bloods
If 1 risk factor: OGTT
Moderate risk Plasma glucose with
Ethnicity (as above) booking bloods
BMI 25-35 If 2 risk factors:screen
as if high risk*
High risk OGTT at the first OGTT
• Previous GDM or high BSL opportunity after
• Maternal age ≥ 40 conception.
• BMI > 35
• Hypertension prior to 20
weeks
• Polycystic ovarian syndrome
• Medications: corticosteroids,
antipsychotics
• Family history of DM
• Previous macrosomic baby
• History of unexplained
stillbirth
• Previous baby with
congenital abnormalities
• *Ethnicity(as above) plus
BMI 25-35
After Diagnosis:
If a woman is diagnosed with GDM, she will be referred to the diabetes
educators/dietitian for education and to learn how to monitor her blood glucose
levels at home.
Recommended target capillary blood glucose levels for women diagnosed with
GDM are:
Fasting capillary blood glucose (BG) ≤ 5.0 mmol/l
1 hour Blood glucose after commencing meal ≤ 7.4mmol/l
2 hour Blood glucose after commencing meal ≤ 6.7mmol/
24
Management in the post-partum period:
1. Women diagnosed with GDM should have a 75g OGTT, preferably at 6-12
weeks post-partum, with classification according to the WHO criteria for
Diabetes Mellitus.
2. Women diagnosed with GDM should have regular ongoing surveillance
as they have an approximate 30% risk of a recurrence of their GDM in a
subsequent pregnancy and up to 50% risk of developing type 2 Diabetes
Mellitus within 10-20 years.
Further information
Any queries about testing, screening, diagnosing or managing diabetes should
be directed in business hours to the diabetes midwife (08) 6458 2222 page
3309 or the physician’s registrar, (08) 6458 2222 page 3369. Queries can also
be directed to the Diabetes Service phone (08) 6458 2163 and messages
can be recorded on an answering machine if the office is unattended. These
messages will be followed up on the next business day.
Urgent out-of-hours queries can be referred to the senior obstetric registrar on
duty or physician on call by phoning (08) 6458 2222.
Full guidelines – click here
25
Fetal anomaly screening
All women, regardless of age, should be counselled and offered the option
of fetal anomaly screening. First trimester screening is the recommended
screening test for fetal chromosomal abnormalities (mainly trisomy 21, 13 and
18).
Women with high risk screening tests for chromosomal abnormalities should
be referred to the Maternal Fetal Medicine (MFM) service. A referral for
opinion/management does not satisfy Medicare requirements for an ultrasound
or diagnostic test such as chorionic villus sampling or amniocentesis. It is
therefore necessary to include a request for ultrasound or diagnostic test in
your referral so that the MFM midwives do not have to contact the GP/referring
doctor for another referral. For example - ‘Please provide assessment and
management +/- ultrasound +/- CVS/amniocentesis as appropriate’.
Please also indicate on the referral if you would like KEMH to take over
management if an anomaly is found. In the case of an actual anomaly, it is
suggested that the woman is referred directly to Maternal Fetal Medicine.
In this case, to ensure Medicare requirements are met and the woman’s
experience is as efficient as possible, the referral will need to include the
following information: ‘Please provide counselling, tertiary review ultrasound
and management’.
For enquiries, please contact the MFM Clinical Midwife Consultant.
MFM: (08) 6458 2848 Fax: (08) 6458 1060
Ultrasound Department: (08) 6458 2830
For more information on the MFM service see page 31.
For women who require assessment and management of third trimester
growth and wellbeing please contact the Maternal Fetal Assessment Unit
Ph (08) 6458 2199 (see page 31).
26
Screening for Down syndrome
1. First trimester screening (FTS)
• The first part of this test is a blood test to determine the levels of the
hormones free BHCG and PAPP-A. This is ideally done at 10 weeks (but
can be done anytime from 9 weeks to 13 weeks 6 days). The blood test
was previously routinely done on the day of the ultrasound, however the
Fetal Medicine Foundation has found that an earlier test improves the
sensitivity and specificity of the test.
• The second part of the test is an ultrasound that is performed between 11
weeks, 4 days and 13 weeks, 4 days (ideally 12 weeks). The ultrasound
determines the thickness of the nuchal translucency - an area behind the
neck and under the skin of the fetus that appears black on the ultrasound
image.
• Based on a woman’s age, the nuchal thickness and the hormone levels, a
result is given in terms of the particular woman’s risk of carrying a fetus with
Down syndrome, compared to her age-related risk.
Table of maternal age vs Down syndrome risk
Chance of having a live-born

Maternal Age
baby with Down syndrome
20 to 24 1:1500
25 1:1350
30 1:900
35 1:400
40 1:110
45 1:30
2. Maternal serum screening (Triple Test)

This test involves a blood test which is performed between 15 and 17 weeks
gestation. No pre-test ultrasound is required unless the EDD needs to be
confirmed. The test gives two results:
• the risk of a chromosomal abnormality (Down syndrome most commonly)
• the risk of an open neural tube defect - based on the maternal serum alpha
fetoprotein level (MSAFP).
27
3. Non-invasive prenatal testing
Non-invasive prenatal testing (NIPT) employs genome sequencing technology
to assess cell free fetal DNA in the maternal circulation and has application as
a high-level screening test for trisomy 21, 18, and 13, and sex chromosome
aneuploidy. This field is rapidly evolving. Position statements from several
international organisations (e.g. International Society for Prenatal Diagnosis,
American Congress of Obstetricians and Gynaecologists) regarding the clinical
use of NIPT are available online.
PathWest and most private pathology providers offer NIPT. It is not currently
funded by Medicare and patients are required to pay out of pocket for this
service. KEMH does not offer NIPT except in a strictly limited number of high
risk women with contraindications to invasive diagnostic testing, where it is
considered on a case-by-case basis. Turnaround times are up to 14 days from
sample collection. In 5% of cases, the level of cell free fetal DNA is not great
enough to report a result and a recollection is required.
NIPT may be employed in screening for aneuploidy in two ways:

1. As a primary screening modality, where a maternal blood sample is
collected after 10 weeks gestation. This allows a detection rate of around
99% for trisomy 21, with a positive predictive value of around 80% in
the average-risk population. False positive results do occur, and results
should be confirmed with invasive testing prior to acting on the result. All
women who have primary NIPT screening MUST also be offered a 12-
week ultrasound scan to assess for major fetal structural anomalies and to
determine the chorionicity of multiple pregnancies.
2. As a secondary screening modality, in women who have screened
high risk with either the first trimester screen (FTS) or maternal serum
screen. This approach avoids the risks of invasive diagnostic testing. Some
authorities advocate offering NIPT to women at intermediate risk after FTS,
such as those of risk 1:2500 or greater, to improve the detection rate of
trisomy 21. Such an approach may detect around 98% of cases of trisomy
21, by performing NIPT in those 20% of women who screen at intermediate
risk by FTS.
NIPT has wider applications which are evolving rapidly with technological
advances. NIPT is currently being marketed for rare microdeletion syndromes
(e.g. “22q” or Di George Syndrome). Routine use of these “extended panels” is
not currently recommended due to a relatively high false positive rate and low
positive predictive value.
28
4. PAPP-A (pregnancy associated plasma protein-A)
Maternal serum pregnancy associated plasma protein-A (PAPP-A) is one of
the blood tests taken at 9-14 weeks (ideally 10 weeks) as part of the First
Trimester Screen. A low PAPP-A (< 0.4MoM) is associated with poor early
placentation and increased frequency of adverse obstetric outcomes.
A low PAPP-A in the first trimester may indicate an increased risk of Trisomy
21. A low PAPP-A in the first trimester with normal chromosomes is associated
with stillbirth, infant death, intrauterine growth restriction (IUGR), preterm birth
and pre-eclampsia.
All women should be counselled and offered first trimester screening. If a
woman returns a low PAPP-A result, a specialist referral should be made by
20 weeks gestation for assessment regarding the need for closer maternal and
fetal surveillance. This may include Growth scans with Doppler assessment at
24, 28, 32 and 36 weeks.
Screening for Neural Tube Defects

This can be done as part of the maternal serum screening test at 15 to
17 weeks or by testing MSAFP alone at 15 to 17 weeks. If the screening test
shows the pregnancy to be at increased risk for an open neural tube defect
(MSAFP > 2.5 MoM), referral for a targeted fetal ultrasound examination is
indicated. This is a technically demanding ultrasound examination and should
be conducted by practitioners with expertise in fetal ultrasound.
Who should be offered MSAFP testing?
1. Women considered at high risk for having a fetus with an open neural tube
defect. This includes women with an open neural tube defect themselves,
women who have had a previous pregnancy with an open neural tube
defect, women taking anticonvulsant medication and women with Diabetes
Mellitus who have poor peri-conceptual control (HbA1C > 8.5%).
2. Morbidly obese women, in whom fetal ultrasound imaging quality is
compromised, should also be offered MSAFP to potentially improve
detection rates of severe structural fetal anomalies.
29
Fetal morphology ultrasound
Fetal anatomy ultrasounds are the recommended screening test for fetal
structural anomalies and placental localisation. It is offered to all women
between 18 and 20 weeks gestation (ideally 19 weeks).
As the KEMH booking visit for low risk patients is done at 20 weeks gestation,
general practitioners are requested to arrange this ultrasound externally prior
to the booking visit and women should bring their ultrasound with them to this
appointment.
If ultrasounds are booked at KEMH, this needs to be arranged 2-3 weeks in
advance. Please fax the referral to the Ultrasound Department on
(08) 6458 2700 and an appointment letter will be sent to the patient.
Any queries should be directed to the Ultrasound Department by phoning
(08) 6458 2830. Enquiries regarding procedures (e.g. CVS or amniocentesis)
or high-risk results should be directed to the Maternal Fetal Medicine service
Ph: (08) 6458 2848 or Fax: (08) 6458 1060.
Rural patients: KEMH will endeavor to coordinate an ultrasound with a
woman’s antenatal clinic appointment if this is pre-arranged.
High-risk pregnancies: if there is a history of a previous fetal anomaly,
recurrent pregnancy loss, abnormal screening results, multiple gestation or
morbid obesity, ultrasounds for these women may be booked at KEMH.
Rural patients
Ultrasounds for rural women may be performed at KEMH either the day before
the Antenatal Clinic appointment or early in the morning on the day of the
appointment but this must be pre-arranged.
Rural doctors requiring assistance with arrangements for their rural patients
can liaise with the Clinical Nurse Manager via (08) 6458 2222, pager 3419
between 8.00am and 3.00pm Monday to Friday, or fax (08) 6458 1031. The
Antenatal Clinic Manager can assist with coordinating appointments, arranging
ultrasounds, accommodation needs and if a patient requires referral to another
service, such as a social worker.
If rural doctors require medical advice including patient management and
need for transfer/admission, they can contact the obstetric consultant or senior
registrar via the 24 hour free-call number 1800 428 615.
30
Maternal Fetal Medicine Service
The Maternal Fetal Medicine (MFM) Service provides tertiary level ultrasound
assessment and diagnosis of pregnancy complications and ongoing pregnancy
management by a multidisciplinary team.
The service provides maternal fetal medicine diagnosis and treatment, in
particular for conditions such as congenital abnormalities, rhesus disease,
intrauterine growth restriction and twin to twin transfusion syndrome.
The specialists and midwives of the MFM Service at KEMH can provide
counselling and/or management for women who have an increased risk of fetal
abnormality on their screening test. They also monitor and manage women
who have a high-risk pregnancy. This includes women at risk of preterm birth
(see page 15).
Phone: (08) 6458 2848
Fax: (08) 6458 1060
The Maternal Fetal Assessment Unit

The staff in the Maternal Fetal Assessment Unit (MFAU) assess women who
develop complications after 20 weeks of gestation including (but not limited
to): hypertension, possible premature rupture of membranes, reduced fetal
movements, threatened premature labour, antepartum haemorrhage, urinary
tract infections and concerns about fetal growth and wellbeing.
The Unit is open 24 hours a day.
Phone: (08) 6458 2199
The Women and Newborn Drug and Alcohol Service

The Women and Newborn Drug and Alcohol Service (WANDAS) offers
obstetric and social support to pregnant women who are using drugs and
alcohol.
Services include:
• Close monitoring during pregnancy
• Counseling and information on drug and alcohol treatment options
• Information about the effects of drugs and alcohol during pregnancy
Phone: (08) 6458 1582
31
Guidelines for Investigation of Patients at risk of a
Haemoglobinopathy
Haemoglobinopathies are autosomal recessive disorders which imply that they
must be inherited through both parents who may have the disorder themselves,
or be carriers. Normal haemoglobin contains a haem molecule that combines
with four globin chains; two are classified as alpha and two as beta chains.
Thalassaemia results from decreased synthesis of the globin chains in adult
haemoglobin. It is classified as alpha (α)-thalassaemia when there is absent or
decreased α-chain synthesis, or beta (β)-thalassaemia when there is absent or
decreased β-chain synthesis.
Sickle cell disease occurs when the structure of the beta globin chain is
abnormal. Defective genes produce abnormal haemoglobin beta chains
resulting in Haemoglobin S (HbS). Sickle cell disease (HbSS) occurs when
abnormal genes are inherited from both parents. A sickle cell trait is when a
person inherits only one sickle cell gene and does not have disease.
Effect of Haemoglobinopathies:
HAEMOGLOBINOPATHY GENE INHERITANCE EFFECT
Alpha thalassaemia minor or One or two defective Asymptomatic normally.
α-thalassaemia trait α genes May have mild anaemia.
Beta thalassaemia minor or One defective β gene Asymptomatic normally.
β-thalassaemia trait. May have mild anaemia.
HbH Disease Three defective β genes Ranges from asymptomatic to
requiring regular blood transfusion.
Alpha thalassaemia major Four defective α genes Bart’s disease /
Hydrops fetalis
Beta thalassaemia major Two defective β genes Severe anaemia. Require frequent
blood transfusions. May result in
death in early childhood.
Sickle Cell trait One defective β gene Asymptomatic.
Sickle Cell Disease Two defective β genes Spontaneous abortion.
Pre-term birth, intra-uterine growth
restriction, perinatal death.
32
antenatal screening and fetal diagnosis within a suitable timeline if the co
unaware of the risk.
• Diagnosis of the haemoglobin disorders requires combined assessment o
iron status and Haemoglobin HPLC (High-performance liquid chromatogr
• Where a woman is pregnant and a carrier, organise partner testing and w
underway, an expeditious referral for genetic counselling. Phone Genetic
of Western Australia (08) 9340 1525.
Ethnic groups with a clinically significant prevalence of
haemoglobin disorders:
Ethnic groups with a clinically significant prevalence of haemoglobin diso
Beta Thalassaemia All ethnic groups other than Northern European
0
Alpha Chinese, South East Asian, Mediterranean
Thalassaemia (αα/--)
Haemoglobin E South East Asian
Haemoglobin S African (including African-American and African-Caribbean), Greek,
Southern Italian, Turkish, Arab, Indian.
Screening:
Conditions to be detected as part of preconception or antenatal screening
• Significant
The aim of screening
Maternal (or carrier testing)
Haemoglobinopathies is to
– important for identify
antenatal carriers
care. of
Sickle Cell Disease Hb SS, Hb SC, Hb S/β Thalassaemia,
haemoglobin disorders in order to assess the risk of a couple having etc a
β Thalassaemia major
severely affected child and to provide information on the options available
β Thalassaemia intermedia
HbtoH manage
Disease their risk. α-/--
Maternal Conditions requiring partner testing
• Carrier
Ideally, high-risk individuals are offered
States in mother:
pre-conception testing.
Possible significant fetal disorders
• InHb
theASantenatal setting, time is important.
Hb SS, Hb Early S/ β Thalassaemia
SC, Hb(first trimester) screening is
Hb AC Hb SC
recommended
Hb AD Punjab since it can be difficult
Hb SD
to achieve
Punjab antenatal screening and
fetal diagnosis
Hb AO
Arab
within a suitable timeline
Hb SO if the couple is unaware of the risk.
Arab
β Thalassaemia Trait β Thalassaemia major, Hb S/ β

• Diagnosis of the haemoglobin disorders requires combined assessment
Thalassaemia
ofHb
theAEFBP, iron status and Haemoglobin HPLC (High-performance liquid
Hb E/β Thalassaemia
Hb A Lepore
chromatography). Hb Lepore/β Thalassaemia, Hb S/Lepore
See algorithm below.
δβ Thalassaemia Trait β Thalassaemia maj or, Hb S/δβ
• Where a woman is pregnant and a carrier, organise partner testing and
Thalassaemia
0 0 0
α
refer to the KEMH Antenatal Clinic. Barts hydrops fetalis ( α /α or --/--)
Thalassaemia Trait ( αα/--) Hb
Any compound heterozygous state including one or more of the above conditions
• Any
If homozygous
results show there
state of theis no risk
above of significant haemoglobinopathy to the
conditions
offspring of the couple, the woman will be referred back to the GP to
organise local antenatal care and birth at her local hospital. This may occur
without a face-to-face consultation with the woman.
new Page 22
• Genetic counselling is available from Genetic Services of Western Australia
Clinical guidelines for investigation of patients at risk of a Haemoglobinopathy
• (08) 6458
Algorithm 1525 for couples if both partners are carriers.
corrections
New Page 23
Note: For second and third trimester, a Kleihauer test should be performed (1-2
after the bleeding or sensitising event) so additional anti-D may be given if requi
33
Investigations of patients for Haemoglobinopathy
RISK FOR HAEMOGLOBINOPATHY
High Risk Low Risk
1. Ethnic Background FBP FBP

• Africa including Iron Studies
American or Caribbean
• Asian Hb Studies (HPLC)
• Mediterranean **MCV < 80
• Pacific Islander
• Middle Eastern Normal: MCH < 27
• New Zealand Maori No further action
2. Family history of
haemoglobinopathies Iron Studies
Low Normal
Hb Studies*
Treat Iron deficiency if present
(HPLC)
Possible / confirmed Hb variant or Thalassaemia trait:

Refer to KEMH antenatal clinic - Fax 6458 1031
- ANC Manager Phone 6458 2222 Page 3419
Expedite partner testing if patient is confirmed as a carrier
* Hb studies can be requested as an add-on to the FBP

** MCV = mean cell volume, MCH = mean cell haemoglobin
34
Use of anti-D in pregnancy
It is recommended that anti-D (625 IU) be given to all rhesus negative,
antibody negative women at 28 and 36 weeks gestation. These women will
therefore need to be seen at 28 weeks and 36 weeks. Anti-D is also given
to these women at KEMH after the birth of their baby if the baby is rhesus
positive. A blood test for blood group and antibodies needs to performed prior
to administering the 28 week dose of anti-D.
It is recommended that anti-D be given to all rhesus negative, antibody
negative women if there is risk of fetal-maternal transfusion of blood.
Anti-D should be given within 96 hours of the onset of bleeding (the earlier the
better). The dose is as follows:
First trimester – 250 IU (minidose vial).
Indications are threatened or inevitable miscarriage, termination of pregnancy,
chorionic villus sampling and ectopic pregnancy.
Note: For a multiple pregnancy give 625 IU.
Second and third trimester, postnatally – 625 IU (full dose vial).

Indications are at 28 weeks, 36 weeks, postnatally (if baby is rhesus
positive) and episodes when a fetal-materal haemorrhage may occur such
as amniocentesis, external cephalic version, antepartum haemorrhage or
abdominal trauma.
Note: For second and third trimester, a Kleihauer test should be performed
(1-24 hours after the bleeding or sensitising event) so additional anti-D may be
given if required.
How to obtain anti-D

KEMH prefers women in the metropolitan area, who have a small early
pregnancy bleed or minor antepartum haemorrhage and do not need a tertiary
assessment, to see their GP for anti-D. This is usually more convenient as
women who are referred to the Emergency Centre at KEMH for anti-D may
have to wait a few hours during business hours while paperwork is completed,
and blood group and antibody testing is performed (even if grouping has
already been performed by a private laboratory). After business hours, women
may experience a longer delay.
35
Metropolitan GPs may obtain anti-D from the Red Cross by phoning
(08) 9325 3030 anytime with patient details. Delivery is at the patient’s
expense. Patients or relatives may pick up GP orders from the Red Cross.
Anti-D itself is free of charge. GPs who undertake ongoing antenatal shared
care are able to obtain a small quantity of anti-D from the Red Cross to keep in
their practice.
Certain private pathology laboratories are able to provide anti-D for patients in
addition to performing antibody screening. Some laboratories will courier the
anti-D to your GP surgery or may even be able to administer the anti-D to the
patient. The following laboratories are able to provide anti-D:
• St John of God Pathology
Hollywood ph: (08) 9346 7102
Murdoch ph: (08) 9366 1750
Subiaco ph: (08) 9382 6690
• Western Diagnostics Pathology Myaree: (08) 9317 0863
• Clinipath West Perth: (08) 9476 5222
A phone call to your laboratory will ascertain whether they stock Anti-D and/or
administer it.
Regional hospitals usually keep a small stock of anti-D.
Record keeping
Anti-D is a blood product and must be traceable. GPs must keep a register of
patients who are given Anti-D and the batch number they receive. This register
must be kept in a central location, not in the individual patient notes.
GPs may download an Anti-D register here.
Pathology request forms

When requesting blood testing for blood group and antibody screening, the
request form should include the following information: current gestation,
number and gestation of previous pregnancies, history of blood transfusions,
any previous antibodies detected and dates of anti-D prophylaxis.
36
Perinatal Mental Health Services
There are two clinical services located at KEMH that provide perinatal mental
health care and advice. These are the Department of Psychological Medicine
and the Mother and Baby Unit (MBU).
Department of Psychological Medicine

The Department of Psychological Medicine provides a consultation-liaison
service to KEMH. Department staff respond to urgent consultation requests in
hospital, and are embedded in various specialist clinics (such as WANDAS,
oncology, adolescent, pelvic pain) in a liaison role. Outpatient assessments
and treatment are offered to patients of KEMH whose medical condition is
affecting their emotional health, or whose emotional health is affecting their
medical condition. Services are provided for up to six months after discharge
or up to twelve months for mothers of babies hospitalised in the Special Care
Nursery. The department is constituted by psychiatry, psychology and nursing
staff. All referrals are reviewed by the triage officers to determine the most
appropriate service for each patient. The state-wide CAMI (Childbirth and
Mental Illness) service for pregnant women with serious (low prevalence)
psychotic disorders is part of the Department’s functions, and state-wide
preconception counselling services for women with serious (low prevalence)
psychotic illnesses is also provided. The other functions of the department are
research and education. Psychiatry staff members are happy to be contacted
by GPs who require clinical advice.
The department can be contacted on (08) 6458 1521.
Mother and Baby Unit

The Mother and Baby Unit (MBU) is an eight bed, authorised acute care,
inpatient unit for the care and treatment of mothers (and their babies up to 12
months) with perinatal mental health disorders. The unit is a state-wide tertiary
service and cannot provide an emergency response. Referrals are accepted
from GPs, Mental Health Services, Emergency Departments, Child Health
Nurses, concerned relatives and/or the patients themselves.
Once a referral is accepted, the referred patient will either be invited for an
assessment at the Unit or MBU staff will assess the patient in other health
services if an inpatient, before an offer of admission is made. The unit is a
family friendly, home-like environment and partners are also encouraged to
stay overnight when appropriate.
37
Staff members from the unit are available to provide information to GPs and
other health care professionals and are able to provide links to the KEMH
Psychiatrists if additional information is required.
Contact with MBU nursing staff in the first instance can be made by ringing the
Nurses Station on (08) 6458 1771.
The Edinburgh Postnatal Depression Score (EPDS) and Perinatal Anxiety
Screening Scale (PASS) (see pages 42-45) are recognised as valuable
screening tests for possible depression and anxiety, both in pregnancy
and the postnatal period.
It is recommended that both tests are undertaken at least once in early
pregnancy and again at around 32 weeks. However, the scales can be used at
any stage of the pregnancy and/or the postnatal period.
For EPDS: Ask the woman to mark the response that most accurately reflects
how she has felt in the last seven days for each of the questions. The scoring
is from zero to three except in the questions marked with an * where the
scoring is reversed, i.e. three to zero. Add all of the scores together.
If the woman scores higher than zero in the last question or has a total score of
12 or above assess her clinically for depressive illness. If the score is 9, 10 or
11, she is at increased risk for mood disorder and should be monitored closely.
For PASS: Ask the woman to mark the response that most closely describes
her experience of symptoms over the past month for every question. The
scoring is from zero (“not at all”) to three (“almost always”) and all scores are
added together.
A cut-off score of 26 is recommended to differentiate between high and low
risk for presenting with an anxiety disorder.
Range of scores also gives an indication about severity of anxiety with
asymptomatic women more likely to score between 0-20, women with mild-
moderate symptoms more likely to score between 21-41 and women with
severe symptoms more likely to score between 42-93. Women with higher
scores are at increased risk for anxiety disorder and should be monitored
closely.
For more information regarding Department of Psychological Medicine:
click here
For more information regarding the Mother Baby Unit:
click here
38
Postnatal Complications
Post partum haemorrhage (PPH)
Traditionally PPH has been defined as a blood loss of 500ml or more during
puerperium and severe PPH as a blood loss of 1000ml or more. Post partum
haemorrhage can also be classified as primary (within 24 hours of delivery)
and secondary (between 24 hours and six weeks postpartum).
Women who experience a major primary post partum haemorrhage may
require one or more of the following interventions:
• Urgent transfer to theatre for investigation / management
• Urgent return to theatre for investigation / management
• Placement of Bakri tamponade balloon or similar
• Laparotomy
• Insertion of uterine compression suture (B-Lynch suture or similar)
• Uterine artery ligation
• Internal iliac artery ligation
• Arterial embolisation
• Hysterectomy
Recommended GP follow up for major post partum

haemorrhage
Anaemia / Iron deficiency
Many women who experience a major post partum haemorrhage receive
packed cells while an inpatient. Packed cells have a shorter half life than a
patient’s own red blood cells and thus, the patient may experience a fall in
Haemoglobin (Hb) on discharge. Women are likely to be discharged on oral
iron supplementation to counter this. Iron supplementation three times daily
should result in a 2g/dL increase in Hb over 3 weeks if taken and absorbed
properly. A check of Hb at 4 weeks is helpful to determine if your patient
requires further iron supplementation (possibly parenteral) or rarely, a packed
cell transfusion.
39
Debriefing
Prior to discharge, a woman who has experienced a major post partum
haemorrhage, and if possible their support person, should have been
debriefed by a senior member of her treating team regarding her delivery and
post partum haemorrhage management. Post partum haemorrhage can occur
very quickly and may involve a sudden requirement for transfer to an operating
theatre, a general anaesthetic, being parted from a newborn infant and in
severe cases being asked to consent to a hysterectomy. For many women it is
not until they leave hospital that questions and concerns regarding what was
occurring at this time emerge.
It is important that any issues are addressed promptly as postnatal depression
and rarely post traumatic stress disorder have been seen in women following
major PPH. If you feel your patient requires further debriefing or discussion
please contact the treating team at KEMH who will organise a time to see her.
Implications for future pregnancies

Post partum haemorrhage has up to a 10% recurrence rate. Your patient’s
history should be made aware to any obstetrician or obstetric unit you refer her
to. Maintaining an adequate antepartum Hb and active management of the
third stage of labour would be recommended in future pregnancies.
Rare complications
Asherman’s Syndrome, intra-uterine adhesions caused by endometrial
damage from curettage, is a rare complication following PPH. Infertility is
the most common clinical presentation but patient’s may also present with
hypomenorrhoea or amenorrhoea, cyclical pelvic pain or recurrent pregnancy
loss. If Asherman’s syndrome is suspected the patient should be referred to a
gynaecologist for a hysteroscopy.
Sheehan’s Syndrome, infarction of the pituitary gland after PPH resulting
in hypopituitarism, occurs in the setting of severe hypotension complicating
PPH. Severe cases present in the first few days to weeks post partum with
lethargy, anorexia, loss of weight and an inability to lactate. Less severe cases
may not present for many weeks to months and involve an inability to lactate,
failure to resume menses and a loss of pubic hair. Mild fatigue, anorexia and
weight loss can also occur in less severe cases. On investigation growth
hormone, prolactin, gonadotrophin and thyroid stimulating hormone levels
are all deficient. Patients should be referred to an endocrinologist for further
management.
40
Pre-eclampsia
Recommended GP Follow Up for Pre-eclampsia
• Early return to GP around two weeks post discharge.
• Wean hypertensive medication if still on them
• Regular blood pressure checks for three months
• If still hypertensive at three months postpartum, there is likely to be
underlying hypertension. Investigate for the cause.
• All patients with early pre-eclampsia should be screened for
antiphospholipid syndrome and be referred for obstetric physician review at
three months postpartum
• Recurrence risk
- early onset pre-eclampsia (<34 weeks): recurrence rate 25-65% (more
likely if underlying thrombophilia, connective tissue disease or renal
problems)
- late onset pre-eclampsia (>34 weeks): recurrence rate 5-7%
• Severity of disease is lower with subsequent pregnancies
If women have a history of pre-eclampsia and are considering a
subsequent pregnancy:
• Preconception counselling is helpful
• Preconception referral (or early referral in pregnancy) if she is likely to have
a high risk of recurrence and/or she has underlying disease
• Identify the ‘hidden’ pre-eclampsia – intra-uterine growth restriction in the
first pregnancy
In the next pregnancy
• Always record a first trimester blood pressure for comparison (blood
pressure routinely drops in the second trimester)
• Start calcium supplement (1.5gm calcium) and low dose aspirin (100 mg) in
the first trimester
• Low PAPP-A on the first trimester screen is associated with an increased
risk of pre-eclampsia
• Monitor more closely in late second and third trimesters
• Consider serial scans for intra-uterine growth restriction
• Cease aspirin at 36 weeks
41
Appendix 1 – Edinburgh Postnatal Depression Scale
(EPDS)
Ask the woman to mark the response that most accurately reflects how she
has felt in the last seven days for each of the questions.
The scoring is from 0-3 except in the questions marked with an * where the
scoring is reversed, i.e. 3-0. Add all of the scores together.
First 32
IN THE PAST 7 DAYS
Visit wks
1. I have been able to laugh and see the funny side of things
(0) As much as I could
(1) Not quite so much now
(2) Definitely not so much now
(3) Not at all
2. I have looked forward with enjoyment to things
(0) As much as I always did
(1) Rather less than I used to
(2) Definitely less than I used to
(3) Hardly at all
3. I have blamed myself unnecessarily when things go wrong*
(3) Yes, most of the time
(2) Yes, some of the time
(1) Not very often
(0) No, never
4. I have been anxious or worried for no good reason
(0) No, not at all
(1) Hardly ever
(2) Yes, sometimes
(3) Yes, very often
5. I have felt scared or panicky for no good reason*
(3) Yes, quite a lot
(2) Yes, sometimes
(1) No, not much
(0) No, not at all
SUBTOTAL
42
Note: The new National women-held Pregnancy Record EPDS does not
include scoring for individual questions.
First 32
IN THE PAST 7 DAYS
Visit wks
6. Things have been getting on top of me*
(3) Yes, most of the time I haven’t been able
to cope at all
(2) Yes, sometimes I haven’t been coping as well as usual
(1) No, most of the time I have coped well
(0) No, I have been coping as well as ever
7. I have been so unhappy that I have had difficulty sleeping*
(2) Yes, sometimes
(1) Not very often
(0) No, not at all
8. I have felt sad or miserable*
(2) Yes, quite often
(1) Not very often
(0) No, not at all
9. I have been so unhappy that I have been crying*
(1) Only occasionally
(0) No, not at all
10. The thought of harming myself has occurred to me*
(2) Sometimes
(1) Hardly ever
(0) Never
TOTAL
JL Cox, JM Holden, R Sagovsky (1987)
43
Appendix 2 – Perinatal Anxiety Screening Scale (PASS)
ERE
King Edward Memorial Hospital Med Rec. No: ..........................................................
H
BEL
Surname: .................................................................
PERINATAL ANXIETY SCREENING LA
FIX
Forename: ...............................................................
SCALE (PASS) F
A
Gender: ...................... D.O.B. ................................
 ANTENATAL  POSTNATAL DATE: ________________________
Weeks pregnant ______________ Baby’s age ______________
Over the past month, how often have you experienced the following? Please tick the response that most
closely describes your experience for every question.
Some Almost
Not at all Often
times Always
1. Worry about the baby/pregnancy 0 1 2 3
2. Fear that harm will come to the baby 0 1 2 3
3. A sense of dread that something bad is going to happen 0 1 2 3
4. Worry about many things 0 1 2 3

DO NOT WRITE IN BINDING MARGIN
PERINATAL ANXIETY SCREENING SCALE (PASS)

5. Worry about the future 0 1 2 3
6. Feeling overwhelmed 0 1 2 3
7. Really strong fears about things, eg needles, blood, birth,

0 1 2 3
pain, etc
8. Sudden rushes of extreme fear or discomfort 0 1 2 3
9. Repetitive thoughts that are difficult to stop or control 0 1 2 3
10. Difficulty sleeping even when I have the chance to sleep 0 1 2 3
11. Having to do things in a certain way or order 0 1 2 3
12. Wanting things to be perfect 0 1 2 3
13. Needing to be in control of things 0 1 2 3
14. Difficulty stopping checking or doing things over and over 0 1 2 3
15. Feeling jumpy or easily startled 0 1 2 3
16. Concerns about repeated thoughts 0 1 2 3
17. Being ‘on guard’ or needing to watch out for things 0 1 2 3

MR312.04
18. Upset about repeated memories, dreams or nightmares 0 1 2 3
KE458
12/15
Continued on Back
44 Page 1 of 2
KE458 HCHKEFMR312D.indd 1 15/12/15

KE458 HCHKEFMR312D FOB BLACK 3:52 PM
ERE
King Edward Memorial Hospital Med Rec. No: ..........................................................
H
BEL
Surname: .................................................................
PERINATAL ANXIETY SCREENING LA
FIX
Forename: ...............................................................
SCALE (PASS) F
A
Gender: ...................... D.O.B. ................................
Some Almost
Not at all Often
times Always
19. Worry that I will embarrass myself in front of others 0 1 2 3
20. Fear that others will judge me negatively 0 1 2 3
21. Feeling really uneasy in crowds 0 1 2 3
22. Avoiding social activities because I might be nervous 0 1 2 3
23. Avoiding things which concern me 0 1 2 3
24. Feeling detached like you’re watching yourself in a movie 0 1 2 3
25. Losing track of time and can’t remember what happened 0 1 2 3
DO NOT WRITE IN BINDING MARGIN

26. Difficulty adjusting to recent changes 0 1 2 3
27. Anxiety getting in the way of being able to do things 0 1 2 3
28. Racing thoughts making it hard to concentrate 0 1 2 3
29. Fear of losing control 0 1 2 3
30. Feeling panicky 0 1 2 3
31. Feeling agitated 0 1 2 3
Global Score
Reference:
Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., Page, A.C.
(2014).
The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of Women’s Mental
Health, DOI: 10.1007/s00737-014-0425-8
© Department of Health, State of Western Australia (2013)
Copyright to this material produced by the Western Australian Department of Health belongs to the State of
Western Australia, under the provisions of the Copyright Act 1968 (Commonwealth of Australia). Apart from any
fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written
permission of the Department of Psychological Medicine, Women and Newborn Health Service, WA Department
of Health. Please acknowledge the authors and the WA Department of Health when reproducing or quoting
material from this source.
Important Disclaimer:
All information and content in this Material is provided in good faith by the WA Department of Health, and
is based on sources believed to be reliable and accurate at the time of development. The State of Western
Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal
liability or responsibility for the Material, or any consequences arising from its use.
Page 2 of 2
45
KE458 HCHKEFMR312D.indd 2 15/12/15
KE458 HCHKEFMR312D BOB BLACK 3:52 PM
Appendix 3 – Care choices provided at KEMH
1. FAMILY BIRTH CENTRE (FBC) / MIDWIFERY GROUP PRACTICE (MGP)
Description
Healthy low risk women may self-refer or be referred by their GP.

Women are allocated to a primary midwife for their pregnancy, birth and
postnatal care.
If the primary midwife is unavailable, care will be provided by another midwife
within the Midwifery Group Practice whom the woman will have met previously.
If the woman needs to be transferred to the main hospital, the MGP midwife will
stay with the woman and provide care in collaboration with other health care
professionals as appropriate.
Exclusion criteria include: women who have had a previous caesarean section
or women with a BMI ≥ 30 at the time of booking.
For more information about the FBC, including exclusion criteria - click here
Pregnancy care Family Birth Centre MGP midwife
Antenatal and postnatal visits may occur within
the home.
Family Birth Centre (on-site at KEMH, access
Planned place of birth
located off Railway Parade)
Care provider during
Family Birth Centre MGP midwife.
labour and birth
Care provider following
Family Birth Centre MGP midwife.
the birth
Possible referrals of care To Antenatal Clinic (ANC) for pregnancy
complications.
To Labour and Birth Suite (L&BS) for birth
complications.
To postnatal wards for complications such as
infection, bleeding, feeding problems.
Transfer home 4 to 6 hours following birth if no complications.
Midwifery care at home Family Birth Centre MGP midwife until day 5
Family Birth Centre (08) 6458 1800.
Contact number Women will be given the mobile number of their
primary midwife.
46
Appendix 3 – Care choices provided at KEMH (cont.)
2. HOSPITAL MIDWIFERY GROUP PRACTICE
Description
Healthy low risk women are allocated to a primary midwife for their pregnancy,
birth and postnatal care. The antenatal visits and the birth will occur in the main
hospital at KEMH. If the primary midwife is unavailable, care will be provided by
another midwife within the Midwifery Group Practice whom the woman will have
met previously.
If the woman develops a complication, the MGP midwife will continue to care for
the woman in collaboration with other health care professionals as appropriate.
Pregnancy care Hospital MGP midwife sees the woman on Ward
4 at KEMH.
Antenatal and postnatal visits may occur within
the home.
Planned place of birth KEMH Labour and Birth Suite (L&BS)
Hospital MGP midwife.
labour and birth
Hospital MGP midwife +/- collaborative care as
required
L&BS staff if in Labour & Birth Suite longer than
the birth
4-6 hours
Postnatal ward midwife if transferred to the ward
Possible referrals of care To Antenatal Clinic (ANC) Red team for
pregnancy complications.
MFAU (Maternal Fetal Assessment Unit) if urgent
assessment required during pregnancy.
To postnatal wards for complications such as
infection, bleeding, feeding problems.
Transfer home 4 to 6 hours following birth if no complications.
Midwifery care at home Hospital MGP midwife until day 5
Midwifery Manager, Models of Care, through
KEMH switchboard
Contact number Phone (08) 6458 2222.
Women will be given the mobile number of their
primary midwife.
47
3. ANTENATAL CLINICS (ANC) - low risk
Description
Midwives provide care for women with low risk pregnancies in the Antenatal Clinic.
These clinics are available during normal clinic hours, Wednesday evenings and
Saturdays.
Pregnancy care Midwife sees the woman for antenatal visits at

KEMH and will refer to medical team if required.
Shared care with the woman’s GP is
encouraged.
If home visits are required, the Visiting Midwifery
Service (VMS) midwife will visit.
Care provider during L&BS midwife
labour and birth L&BS medical team
Care provider following Postnatal ward midwife
the birth Medical team
Possible referrals of care No referrals required
Transfer home Vaginal births from 4-6 hours.
Caesarean births from 24 hours.
Midwifery care at home VMS midwife visits daily until day five.
Clinical Midwifery Nurse Manager
Contact number (Ambulatory Services)
Phone (08) 6458 2222 page 3419
48
4. ANTENATAL CLINICS (ANC) - high risk
Description
The ANC has a team of doctors, midwives and other health professionals who care
for women who may have pregnancies with a high risk of complication.
• Maternal Fetal Medicine – pregnant women with complications in pregnancy
e.g. hypertension, heart disease, kidney disease, twin-to-twin transfusion,
congenital anomaly.
• Diabetes Service – women with pregnancies complicated by Diabetes.
• WANDAS – women with pregnancies complicated by alcohol and drug use.
• Adolescent Clinic – women who will give birth to their first baby before the age
of 18.
Pregnancy care Medical team at ANC.
After seeing the consultant, antenatal care can be
provided by the midwife, if the woman requests.
Shared care with the woman’s GP may be an
option for some appointments.
If home visits are required VMS midwife will visit.
Care provider during L&BS midwife
labour and birth L&BS medical team
Care provider following Postnatal ward midwife
the birth Medical team
Possible referrals of care Nil referrals required
Transfer home Vaginal births from 4-6 hours.
Caesarean births from 24 hours.
Midwifery care at home VMS midwife visits daily until day five.
Clinical Midwifery Nurse Manager (Ambulatory
Contact number
Services) Phone (08) 6458 2222 page 3419
49
5. Community Midwifery Program (CMP)
Description
Midwifery care provided for healthy women with uncomplicated pregnancies.

Clients suitable for CMP care must meet the inclusion criteria – click here
Pregnancy care Women are allocated a primary and support
midwife who will provide continuity of care
throughout pregnancy, birth and the postnatal
period.
Appointments occur at home and in clinics
CMP currently run clinics at the following places;
KEMH, Cockburn, Rockingham, Joondalup and
Kalamunda.
Referral to an obstetrician and/or GP during
pregnancy may be required.
Home (water birth may be an option)
Birth centre (FBC or Kalamunda)
Planned place of birth
Hospital (KEMH, Fiona Stanley, Armadale,
Rockingham)
Primary or support midwife.
labour and birth
Primary and support midwife.
the birth
Possible referrals of care To hospital for pregnancy, labour or postnatal
complications
Transfer home Variable depending on place of birth and any
complications.
Primary and support midwife will visit regularly
Midwifery care at home for 2-4 weeks postnatally dependent on each
woman’s individual needs
Contact number (08) 9301 9227
50
Appendix 4 – Important telephone numbers
Free-call for GPs anywhere in WA to obtain medical advice from a senior
staff member 1800 428 615.
Antenatal Clinic (08) 6458 1377
Antenatal Clinic Fax (08) 6458 1031
Clinical Midwifery Nurse Manager (Ambulatory Services) (08) 6458 2222 (Page 3419)
Breastfeeding Centre of WA (08) 6458 1844
Department of Obstetrics / Gynaecology (08) 6458 1382
Department of Psychological Medicine (08) 6458 1521
Diabetes Service (08) 6458 2163
Early Pregnancy Assessment Service (08) 6458 1431
Emergency Centre KEMH (24 hours) (08) 6458 1431
Family Birth Centre (08) 6458 1800
Genetics Services of WA (08) 6458 1683
Gynaecology Senior Registrar
(08) 6458 2222
(switchboard to page)
KEMH Switchboard (24 hours) (08) 6458 2222
Maternal Fetal Assessment Unit (24 hours) (08) 6458 2199
Maternal Fetal Medicine Service (08) 6458 2848
Obstetric Drug Information Service (7 days) (08) 6458 2723
Obstetric Senior Registrar
(08) 6458 2222
(switchboard to page)
Parent Education (08) 6458 1368
Pathology (08) 6458 2767
Pharmacy (08) 6458 2727
Physiotherapy (08) 6458 2790
Social Work (08) 6458 2777
Ultrasound Department (08) 6458 2700
Visiting Midwifery Service (08) 6458 1530
Women and Newborn Drug
(08) 6458 1582
and Alcohol Service (WANDAS)
51
Notes
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......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
52
The first edition of this booklet was produced in 2003 by the Shared Care Coordinating
Group, consisting of representatives from KEMH and the Perth Central Coastal Division of
General Practice. The booklet forms part of the “Shared Care Program at KEMH” initiated
in 2003 to meet the requirements of the “Policy Statement of the Joint Consultative
Committee on Obstetrics” of 4 February 2002. Metropolitan and rural divisions of General
Practice have been consulted on the implementation of this policy.
This booklet has been revised by KEMH with GP input and is up-to-date at the time of
publishing. These guidelines are also available on the Internet Website:
www.wnhs.health.wa.gov.au Health Professionals Manuals and Directories
Copies of this booklet can be obtained by contacting the Obstetric and Gynaecology
Clinical Care Unit on (08) 6458 1382.
This document can be made available

in alternative formats on request for
a person with a disability.
Compiled by: Obstetrics and Gynaecology CCU and KEMH Liaison GP

Produced by: Women and Newborn Health Service
Website: www.wnhs.health.wa.gov.au
© January 2003 WNHS 0062 Rev 6

Revised October 2016
W O M EN A N D N E WB OR N H E A LTH S E RV IC E
King Edward Memorial Hospital
374 Bagot Road Subiaco WA 6008
Telephone: (08) 6458 2222
Disclaimer: The advice and information contained herein is provided in good faith as a public service.
However the accuracy of any statements made is not guaranteed and it is the responsibility of readers to
make their own enquiries as to the accuracy, currency and appropriateness of any information or advice
provided. Liability for any act or omission occurring in reliance on this document or for any loss, damage
or injury occurring as a consequence of such act or omission is expressly disclaimed.
Copyright information - click here
Photos for illustration purposes only.
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Government of Western Australia

North Metropolitan Health Service

Antenatal Shared Care

Referring women to KEMH

Referrals for women requiring review within 7 days

Which general practitioners can provide shared care with KEMH?

Please Note: Frequent review of postcodes is undertaken taking into account

Requests for female practitioners

Woman/GP requests care at KEMH

Visit Encounter Provider

1st visit Confirm pregnancy and expected date of delivery. GP

24 weeks Routine assessment. Order 28 week investigations: full GP

Folate Dose Indication

Pregnancy is a time of increased iodine requirements for production of thyroid

Documentation and routine assessments

Early Pregnancy Assessment Service (EPAS)

Who may be referred?

Preterm birth (WA Preterm Birth Prevention Initiative)

Infectious diseases and immunisation in pregnancy

1. Initial routine investigations for each pregnancy at first antenatal visit

6. 36 weeks (KEMH will organise)

Group B streptococcus (GBS) infection

Hepatitis B – chronic carriers

Complications of obesity in pregnancy

Moderate risk factors for GDM:

Table of maternal age vs Down syndrome risk

Chance of having a live-born

2. Maternal serum screening (Triple Test)

NIPT may be employed in screening for aneuploidy in two ways:

Screening for Neural Tube Defects

The Maternal Fetal Assessment Unit

The Women and Newborn Drug and Alcohol Service

β Thalassaemia Trait β Thalassaemia major, Hb S/ β

High Risk Low Risk

1. Ethnic Background FBP FBP

Possible / confirmed Hb variant or Thalassaemia trait:

* Hb studies can be requested as an add-on to the FBP

Second and third trimester, postnatally – 625 IU (full dose vial).

How to obtain anti-D

Pathology request forms

Department of Psychological Medicine

Mother and Baby Unit

Recommended GP follow up for major post partum

Implications for future pregnancies

 ANTENATAL  POSTNATAL DATE: ________________________

Weeks pregnant ______________ Baby’s age ______________

1. Worry about the baby/pregnancy 0 1 2 3

2. Fear that harm will come to the baby 0 1 2 3

3. A sense of dread that something bad is going to happen 0 1 2 3

4. Worry about many things 0 1 2 3

PERINATAL ANXIETY SCREENING SCALE (PASS)

7. Really strong fears about things, eg needles, blood, birth,

8. Sudden rushes of extreme fear or discomfort 0 1 2 3

9. Repetitive thoughts that are difficult to stop or control 0 1 2 3

10. Difficulty sleeping even when I have the chance to sleep 0 1 2 3

11. Having to do things in a certain way or order 0 1 2 3

12. Wanting things to be perfect 0 1 2 3

13. Needing to be in control of things 0 1 2 3

14. Difficulty stopping checking or doing things over and over 0 1 2 3

Weeks pregnant Baby’s age