Midwifery Care

Christine Doogan

Endorsed Midwife. Midwife Prescriber. Registered Nurse.

I am an experience registered nurse and midwife having worked in various settings and areas of Australia since gaining my General Nursing Registration in 1982.
I completed my General Nurse training at the Warrnambool Base Hospital and went on to work and study in Melbourne where 
I completed my grad year and Intensive Care Nursing course. From there I ventured to Western Australia to work in community health in Leonora.
I returned to Victoria to complete my Midwifery qualification in 1991 before returning to Western Australia where I worked with the Royal Flying Doctor Service for 5 years before settling in to gain experience as a Midwife in various country and city hospitals both in WA and QLD over the next 15 years.
I studied at Griffith University in 2015 to gain my qualification as an Endorsed Midwife before commencing in Private Practice in January 2016.
Whilst working in Private Practice I am also employed in the Hospital system to maintain my currency and skills in an acute Midwifery setting.
I will provide comprehensive, individualised care throughout your pregnancy, and continue to provide support from your discharge from Hospital unitl 6 weeks after the birth of your baby.
You birth at your chosen hospital.
All care I provide is in accordance with the "National Midwifery Guidelines for Consultation and Referral", and relevant state legislation.

ABOUT US

Post-natal Schedule of Care

AIMS: 
Promote recovery from the labour and birth
            Promote emotional, psychological and physical wellbeing
Provide health education and advice - promote sound infant care; successful adaption to motherhood; effective mother-baby interaction
            Monitor the progress of the postpartum woman
            To detect complications in a timely manner and make appropriate referral for specialist care



Week 1
Mother
Review Birth – mode of delivery, post-natal progress, estimated blood loss; GBS status; Meconium liquor; perineum; wounds
Physical assessment
Vital signs as required
Check involution of fundus; lochia loss; passing of clots; when is it abnormal??
Check breasts for engorgement, signs of mastitis
Check Nipples for grazes, cracks, thrush     
Perineal care – check for healing
Wound care if required
* Pain relief requirements
* Voiding – sensations of full bladder, complete emptying; S&S of UTI
* Bowel habits – strategies to avoid constipation; check haemorrhoids
* Legs – assess for DVT
Psycho/social Assessment
Sleep patterns – mother and baby
Social supports; financial/housing; support at home; care of other children; home environment
Discuss feelings around the birth outcome
* Formula feeding – preparation, volume required;
* Breast feeding - frequency; maintaining supply; contraceptive effect of B/F; assistance with positioning and attachment as required
* Post-natal exercises including care of back, pelvic floor; ergonomic work surfaces at home; low impact exercises
* Avoid swimming/bathing/using tampons until 6week check
* SIDS – reinforce safe sleeping; smoking; drug taking
* Injections – follow-up for Anti-D, pertussis, MMR, Flu vaccine
* Discuss contraception
* Child Health Nurse Service / GP progress report

Baby

Review birth status of baby – APGARS; resuscitation required; Birth weight; feeding; weight loss/gain;
Skin – colour, bruising, integrity, nevi
Head – shape, symmetry, fontanelle. Discourage prop feeding
Chest - movement, shape; Heart rate and sounds; respiratory rate and work of breathing, lung sounds; nipples and breast tissue
Abdomen – shape and size; umbilicus and cord care, bowel sounds; bowel movements
Genitalia – testes descended, vaginal discharge – avoid using talc
Musculoskeletal – Tone, reflexes, dimples, malformations, check hips
* Activity/behaviour patterns/hearing/sight
* Weight, head circumference, length
* Number of wet and dirty nappies; transition stools
* Establishing day/night routines
* Thirst Vs Hunger
* Settling strategies

Weeks 2-5
Mother
* Fundal height – involution continuing, Lochia reducing/stopped; ongoing pain management
* Ongoing breast care; demand feeding; nipple care; S&S of nipple thrush, mastitis, engorgement
* Monitor for Post-natal depression – complete EPDS
* Discuss resumption of sex and contraception. Vaginal dryness.
* Reminder on continuing pelvic floor exercises; back care; Bowel and bladder patterns;
* Wound care as required

Baby
* Weigh at each visit; cord care; meeting developmental milestones; hearing/sight; activity/muscle tone;
* Sleeping patterns / Feeding patterns
* Output


Follow up as required with Paediatrician; Physio; Continence nurse; Diabetes educator


Week 6

* Care as above
* Blood tests – FBC, Iron studies, random BSL; Vit D, Thyroid levels and GTT as required.
* Refer to GP for ongoing care; PAP smear if required; contraceptive implants; family planning; haemorrhoids, varicose veins
* Infant immunisations – first vaccinations can be given at >6 weeks of age
* Refer to Child Health Nurse for ongoing infant care and advice – feeding, sleep, growth, developmental milestones. 
Antenatal Schedule of Care
NHMRC endorsed National Antenatal Guidelines
1st Visit
* Confirm Pregnancy - last menstrual period; pregnancy test; expected date of confinement.
* Clinical assessment: BP, Wt., BMI, physical assessment,
* Comprehensive history: medical, family history, obstetric Hx, physical, social and emotional aspects of health. Domestic violence issues
* Psychosocial assessment – Edinburgh Post-natal depression score (EPDS).
* Current medications; Allergies
* Arrange dating scan if indicated.
* Arrange screening/booking bloods and urine. 
* Counsel and recommend STI screening
* Discuss alcohol consumption, smoking, exposure to 2nd hand smoke, social drugs use.
* Discuss folate, Vit D and iron supplements, OTC medications including herbal preparations.
Avoid Vit A and foods at risk for listeria / salmonella
* Discuss morning sickness, back care, diet, exercise, minor pregnancy discomforts
* Offer Flu vaccine
* Counsel and offer 1st trimester screening for Downs: blood tests at 10 weeks and USS at 12 weeks
* Identify women who may need additional care – higher risk.
* Care pathway – what happens and when, blood tests, screening tests

8 - 12 weeks
* Review, discuss and record test results.
* Review pregnancy discomforts. Back care, exercise, morning sickness, modifiable risk factors – smoking, alcohol, drug use, diet
* Discuss model of care /collaborative arrangements
10 weeks - 1st trimester screening test
12 weeks – Nuchal fold scan

14 - 16 weeks
* Review, discuss and record 1st trimester screening results
* Referral to birthing hospital
* Commence National Woman-held Pregnancy Record
* Early GDM screening for high risk women: BMI>30, >35yrs, Previous GDM, family Hx of diabetes, unexplained still birth, raised BP, previous birth defect, previous baby >4.5kg, Ethnicity risk groups: Indigenous Australians, pacific islanders, Maori, SE Asian, African, Hispanic
* Discuss and arrange anatomy scan at 18-20 weeks

At each appointment – recommended schedule of care.
                Weight
                BP
                Urinalysis
                Fundal Height
                Foetal heart rate
                Foetal movements

20 - 22 weeks
* Booking visit at birthing Hospital
* Foetal growth and development
* Encourage attendance at Antenatal classes
* Exercising – including abdo and pelvic floor, low impact, swimming, walking, musculo-skeletal health
* Nutrition and supplements – Iron, Vit D, Avoid Vit A and foods at risk for listeria / salmonella
* Smoking/alcohol/social drug use
* OTC medications including herbal preparations
* Discuss anatomy scan result – check position of placenta
* Complete National Woman Held Pregnancy Record (NWHPHR) including booking BP, BMI, EPDS, blood results, scan results etc
* Give request form for GGT and 28/40 bloods (24-28 weeks)
* Discuss consents in back of NWHPR – Hep B, Vit K, NNST
* Discuss foetal movements – timing, normal wake/sleep patterns

24 Week visit
Routine care
* Discuss when to present to hospital – Bleeding, pain, SROM
* Discuss need for Anti-D if Neg blood group
* Request for 28/40 bloods – FBP, GTT, Iron studies, Group and antibody screen if Neg blood group, repeat Chlamydia testing if previously positive or high risk

28 Week visit
Routine Check – Reiterate previous education including smoking, drugs, hospital presentation
* Discuss 28/40 blood results – refer to Diabetic educator if required
* Counsel and consent for Anti-D, Pertussis vax, flu vax
* Discuss signs of pre-eclampsia
* Discuss when to present to hospital – Bleeding, pain, SROM, reduced foetal movements
* Education classes

31 Week visit
Routine check
* Discuss Braxton Hicks; Breasts and possible milk production starting
* Discuss signs of pre-eclampsia – headaches, visual disturbances
* Discuss signs of early labour
* Discuss birthing – pain relief options, labour ward environment, support people – number of people restrictions, closed in shoes, music, own pillow, clothing,
* Breast feeding preparation
* Reinforce classes – hospital tour
* Domestic violence issues

34 week visit
* Routine check – Review plan of care, identify increased risk pregnancies
* Repeat EDPS. Discuss PND
* Discuss GBS and provide request form for 36/40 bloods – FBC, Iron Studies,
* Reinforce education on pre-eclampsia, when to present to hospital, decreased foetal movements
* After-hours access to Birth Suite
* Signs of early labour vs Braxton hicks. Birth Plan – pain relief options
* Ensure baby is cephalic – refer to Dr if still breech
* Measurement – below or above cm=gestation – refer to Dr
* Repeat U/S as indicated for low lying placenta and foetal growth
* 2nd Anti-D as required

36 week visit
Routine check
* Ensure bloods and GBS swabs results are recorded
* Review birth plan and consents for Hep B and Vit K, need for MMR, PAP smear postnatal
* Education on newborn care. Preparation at home.

38 week visit
* Discuss after birth care and facilities – early discharge – VMS, private practising Midwives, CHN, GP follow up, Lactation consultant, and other community groups
* Education on the management of early labour at home.
* Reinforce Birth suite support people – contact phone numbers
* Discuss prolonged pregnancy management options

40 week visit
Routine check
* Elective IOL, GDM and elective C/S – start expressing EBM
* Discuss non-medical methods for inducing labour – including nipple stimulation, stretch and sweep
* Dr apt for 1 week
* Book IOL for T+10