65,000

Goodfellow Symposium, Auckland March 09

What is
your role?

Section 88 Primary
Maternity Services Notice
2007

www.moh.govt.nz/maternity
Or
0800 252464
 Non-LMC first trimester
services (DB10)

Informing the woman regarding her
options for choosing a LMC
Aims to encourage

Providing appropriate information
continuity of GP and education about screening and
involvement in the offering referrals to a provider for the
appropriate screening tests
care of women.

Providing written information
including screening test results and
relevant health information

Non-LMC first trimester Non-LMC first trimester

services services

Pregnancy care and advice
$110

Care and advice if threatened or
actual miscarriage.
$150 if threatened
miscarriage or planning

Assessment care, and advice termination
provided in relation to a
termination of pregnancy
One fee claimed per
woman per enrolling PHO

Urgent pregnancy care

(DB12 &13)
General Practioners can register to
access free secure information about
referral to DHB services.

$40 normal hours

Most DHB services on Healthpoint have
GP specific information that can only be

$60 out of hours viewed once a registered GP has signed in.

Per visit
www.healthpoint.co.nz


Blood tests In any programme there is an irreducible

Swabs minimum of false positive and
false negative results.

Scans Thus, there is the potential to cause harm
during screening.

Physical

Life Style False reassurance – False negative
Raised anxiety – False positive
Dr Graham Parry 2008

Five Standard tests

Polycose

Glucose Tolerance Test

Maternal Serum Screen 1 & 2

HIV

Despite what we are doing

there is no decrease in numbers of T21 babies born
But an increase in diagnostic tests

How important is Down syndrome to the woman?

Do they know what Down syndrome is?

“Maternal age is not a sufficient
screening test by itself.

Do they want screening?
Women should not be referred for invasive
diagnostic tests

Cultural aspects
based on maternal age alone”
July 2008

Source: Dr Graham Parry SAMCL presentation

2008
 Serum, Urine & Ultrasound Screening Study 2003

Maternal Serum Screening test in the 1st trimester

Results show that it is now possible (MSS1) taken between 9 and 11 weeks. Costs $120
to obtain a high level of detection
(8 or 9 out of every 10 affected pregnancies)
Nuchal Translucency (NT) Scan by an accredited
With a false-positive rate (1–2%) practitioner @ 11 weeks & 3 days – 13 weeks & 6 days

For women who present for the first time in the
MSS2 test in the 2nd trimester taken between 14 and
second trimester, 18 weeks. Free
the quadruple test (MSS2) is the test of choice,

Positive result >1 in 300 → offer amniocentesis or
Wald et al First and second trimester antenatal screening for Down’s syndrome: the results of the Serum, Urine
and Ultrasound Screening Study (SURUSS). Health Technology Assessment 2003; Vol. 7: No. 11 CVS

All Pregnant women to be offered

With treatment transmission is
HIV test
< 1% to unborn child

Document decline or accept in notes

Without treatment transfer rate is
approximately up to 30%

Failure to offer may be see as failure to

NZ has no reported cases of vertical
transmission of HIV in women treated identify risk (section 88) & lead to:
in pregnancy Medical misadventure by ACC Breach

To treat women already infected and
of the H&D code
prevent ongoing infection to others
Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008 Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008

Anticipate approx 10 confirmed HIV +ve

women in Auckland

Result phoned to requestor by laboratory

Phone Community HIV team for advice

before giving result

Inform woman of result face to face

Source: Tracey Senior Antenatal HIV Co-ordinator CMDHB 2008 Source: Donna Raymond Antenatal HIV Co-ordinator ADHB 2008
 Dealing with confirmed
HIV +ve result Gestational Diabetes Mellitus (GDM)

All information on complicates 5-8% of all pregnancies in
www.healthpoint.co.nz New Zealand.

Community HIV Team
Universal screening is recommended

located @ Auckland City
Hospital
Early Polycose or GTT instead of
Polycose for those with several risk

Mon-Fri 9-5 09 375 7077 factors
Source: GDM in New Zealand technical report, March 2007

Previous GDM

Glycosuria at booking

Polycystic ovary disease

HbA1c is recommended
Source: Susan Duckmanton, Diabetes Midwife Specialist, Tall Poppies article 2006 Source: Susan Duckmanton, Diabetes Midwife Specialist, Tall Poppies article 2006

Combined Risk Factors Combined Risk Factors

Requiring GTT Requiring GTT

Age over 30
Previous Macrosomic baby &
shoulder dystocia.

Obesity

Unexplained still birth, pre-

Family Hx – Especially maternal mother eclampsia, pre-term birth

High Parity
Chronic hypertension

Source: Susan Duckmanton, Diabetes Midwife (CMDHB) Source: Susan Duckmanton, Diabetes Midwife Specialist, Tall Poppies article 2006
 Chlamydia
Gonorrhoea
Group B Strep
Trichomoniasis
Bacterial Vaginosis

Early trans-abdominal USS

to detect gestational age from 6
As required: Growth, Fetal
weeks onwards lie, Placental position,
Biophysical profile (BPP)

Nuchal Translucency (NT)
@ 11/40 + 3 – 13 /40+ 6

Customized growth charts

Anatomy 18-20 weeks
available at:
www.gestation.net

“Pre-eclampsia can progress to a life

threatening situation in, on average
two weeks from diagnosis.”
Previous pre-eclampsia

Risk assessment is required early in
Multiple pregnancy

pregnancy

Underlying medical conditions:

Offer referral before 20 weeks for
specialist input to their antenatal care
if they have one of the following:
Presence of antiphospholipid
antibodies
The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community. The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community.
Milne et al BMJ 2005; 330; 576-580 Milne et al BMJ 2005; 330; 576-580

24 hour collect is the

First Pregnancy
most reliable

≥10 years since last baby

Protein creatinine ratio

Age ≥40 levels ≥30mg/mmol on

Body mass index ≥35
random urine

Family history of pre-eclampsia

The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community. Milne et al BMJ The pre-eclampsia community guideline: how to screen for and detect onset of pre-eclampsia in the community.
2005; 330; 576-580 Milne et al BMJ 2005; 330; 576-580

The prevalence of smoking in women of childbearing

age (15-39years) ranges from 26-29%.

The rates vary significantly across ethnic groups, with

Maori rates between 39-61%,

Pacific between 27-47%,
and Pakeha, 22-27%.

Source: New Zealand Smoking Cessation Guidelines 2007 pg 21 Data from 2006

Risks Principles
Fertility SUDI / Asphyxia ↑200%

Dose effect applies:
less smoking, less risk
Placenta Small for dates ↑200%

Unborn baby Stillbirth ↑100%
Becoming smokefree

Ectopic pregnancy ↑90% at any time in
Pregnancy pregnancy reduces the
Preterm Labour ↑70%
New born baby Placenta Previa ↑60%
risk

Breast feeding Placental ↑60%
Becoming smokefree

Abruption
Infant Care Choices in the first trimester
Cleft Lip ↑35% almost reverses the risk.
Young Child Miscarriage ↑25%
Professional Practice Infertility ↑25%

Early intervention is
Source: Education for Change, Safe Start 2008 best
Source: Personal communication A/Prof L McCowan courtesy of Education for Change, Safe Start 2008

Nicotine breaks down more quickly in
International pregnancy so higher NRT doses may be needed
Recommendations: to achieve smokefree success
Benefits of NRT far
NRT removes harmful exposure to carbon
outweigh the risks monoxide and the 4000 other chemicals
of smoking during

NRT relieves cravings, has a slower delivery and
pregnancy
www.nzgg.org.nz is less addictive than smoking
Source: Education for Change, Safe Start
2008 Source: Dempsey et al Vol 301, Issue 2 594-598, May 2002. Courtesy of Education for
Change, Safe Start 2008

Body Mass Index

Women of a normal BMI who put on more than
(weight in kgs ÷ height in ms²)
16kgs during pregnancy have an increased rate
Not perfect … but the easiest in context
of:

Preeclampsia

Failed induction

Large for gestational age

Source: Tomasina Stacey, Presentation at NZCOM conference ,Auckland, September 2008

Source: Tomasina Stacey, Presentation at NZCOM conference ,Auckland, September 2008

Measure height to get an accurate BMI 2

1.8
1.6

BMI >30 Advise a weight gain of <6kg 1.4
1.2
RR

1

Weigh at each visit to monitor 0.8
0.6
0.4

The baby’s movements may “change” 0.2
towards the end of the pregnancy BUT 0
BMI <20 BMI 20- BMI 25- BMI 30- BMI >35
they should NOT “slow down” 24.9 29.9 34.9

Tomasina Stacey, September 2008

Personal communication T. Stacey Feb 2009

Stillbirth

Neonatal death Pregnancy is a

Large for gestational age time of

Small for gestational age high risk.

Shoulder dystocia Violence often

Congenital abnormality begins or

Reduced rate of escalates in
breastfeeding pregnancy.
Source: Tomasina Stacey, Presentation at NZCOM conference ,Auckland, September 2008 Ministry of Health 2001

POLICE 111
Levels of referral 1 & 2

CYFS (Children) 0508 FAMILY The LMC may recommend or
must recommend to the woman

VICTIM SUPPORT 0800 VICTIM
that a consultation with a
specialist is warranted.

WOMEN’S REFUGE 09 378 1893
Level 3

PREVENTING VIOLENCE in The LMC must recommend to the
woman that the responsibility for
the HOME (PVH) 0508 DVHELP
her care be transferred.

<20 weeks Gynecology

Guidelines for consultation
available @
>20 weeks Obstetric

www.moh.govt.nz/moh. If in doubt – CALL

nsf/indexmh/maternity- “We’re friendly”
section88notice
The more information you can
send with the woman the better
- especially copies of scans

Concealed pregnancy

Appears to be 35-36 weeks
pregnant

Epileptic taking one medication

No seizures for 2 years now

Pre-pregnancy BMI of 16 and
has gained little weight

Dr Graham Parry

Dr Vivien Wong

Tracey Senior & Donna Raymond – Antenatal HIV
co-ordinators

Susan Duckmanton – Diabetes Midwife

Lesley Dixon – New Zealand College of Midwives

Dr Lesley McGowan

Tomasina Stacey – Research midwife

Stephanie Cowan – Change for our children (formerly
Education for Change)

Clare Kirby – Midwife Educator