APPENDIX I

GUIDELINES FOR CONSULTATION WITH

OBSTETRIC AND RELATED SPECIALIST MEDICAL SERVICES

1.0 PURPOSE OF GUIDELINES

This document provides guidelines for best practice based on expert opinion and available evidence. It is the intention that the guidelines be used to facilitate consultation and integration of care, giving confidence to providers, women and their families.

For the purpose of these guidelines, referral to specialist services includes both referral to Secondary Maternity or to a specialist, as defined in this Notice.

It is intended that these guidelines should be reviewed at two yearly intervals.

2.0 CIRCUMSTANCES WHERE GUIDELINES MAY BE VARIED

The guidelines acknowledge that General Practitioners, General Practitioner Obstetricians and Midwives have a different range of skills. The guidelines are not intended to restrict good clinical practice. There may be some flexibility in the use of these guidelines:

(a) The practitioner needs to make clinical judgements depending on each situation and some situations may require a course of action which differs from these guidelines. The practitioner will need to be able to justify her/his actions should she be required to do so by their professional body.

It is expected that the principles of informed consent will be followed with regard to these guidelines. If a woman elects not to follow the recommended course of action it is expected that the practitioner will take appropriate actions such as seeking advice, documenting discussions and exercising wise judgement as to the ongoing provision of care.

(b) It is also recognised that there may be some circumstances where the requirement to recommend consultation places an unnecessary restriction on experienced practitioners, particularly where there is no immediate access to specialist services. The individual practitioner can come to an appropriate arrangement with the specialist.

It is agreed that, in accordance with good professional practice, a practitioner must record in the notes the reasons for the variation from the guidelines.

3.0 TIMING OF REFERRALS

Referral to a specialist should occur in a timely manner.

The gestational age is defined as the number of completed weeks, as determined by the LMP, ultrasound estimation or clinical assessment. For example, a baby is 24 weeks from 24 weeks 0 days until 24 weeks 6 days.

4.0 REFERRAL PROCESS

Referral for most of the criteria will be to an Obstetrician and, for those listed under Services Following Birth, to a Paediatrician. However, in some instances, particularly those criteria involving associated medical conditions, a referral to another Specialist such as a Physician, Anaesthetist, Surgeon, Paediatrician, Infectious Diseases Specialist or Psychiatrist, may also be appropriate or be more appropriate. For some situations a multidisciplinary team will be necessary. Many of the criteria under Labour and Birth and Paediatric Services will require both Obstetrician and Paediatrician.

It is recognised that referral to a woman’s usual General Practitioner may be appropriate in some circumstances. However these guidelines refer specifically to Specialists.

There are some particular circumstances, for example twins, where clinically the specialist needs to be responsible for care but the primary practitioner is very important.

5.0 LEVELS OF REFERRAL

These guidelines define three levels of referral and consequent action:

Level 1
The Lead Maternity Carer may recommend to the woman (or parents in the case of the baby) that a consultation with a specialist is warranted given that her pregnancy, labour, birth or puerperium (or the baby) is or may be affected by the condition. Where a consultation occurs, the decision regarding ongoing clinical roles/responsibilities must involve a three way discussion between the specialist, the Lead Maternity Carer and the woman concerned. This should include discussion on any need for and timing of specialist review. The specialist will not automatically assume responsibility for ongoing care. This will depend on the clinical situation and the wishes of the individual woman.

Level 2
The Lead Maternity Carer must recommend to the woman (or parents in the case of the baby) that a consultation with a specialist is warranted given that her pregnancy, labour, birth or puerperium (or the baby) is or may be affected by the condition. Where a consultation occurs, the decision regarding ongoing clinical roles/responsibilities must involve a three way discussion between the specialist, the Lead Maternity Carer and the woman concerned. This should include discussion on any need for and timing of specialist review. The specialist will not automatically assume responsibility for ongoing care. This will depend on the clinical situation and the wishes of the individual woman.

Level 3
The Lead Maternity Carer must recommend to the woman (or parents in the case of the baby) that the responsibility for her care be transferred to a specialist given that her pregnancy, labour, birth or puerperium (or the baby) is or may be affected by the condition. The decision regarding ongoing clinical roles/responsibilities must involve a three way discussion between the specialist, the Lead Maternity Carer and the woman concerned. In most circumstances the specialist will assume ongoing responsibility and the role of the primary practitioner will be agreed between those involved. This should include discussion about timing of transfer back to the primary practitioner.