The Capability Framework for Victorian maternity and newborn services delineates the role of each maternity and newborn service in the metropolitan, regional and rural areas.  It describes the services required at each level of care and the relationships with other maternity and newborn services within the context of state wide services.

The role of this protocol is to articulate the referral of clients from Level 1, 2, 3 and 4 services in the antenatal outpatient setting and to facilitate the back transfer of those clients in a timely manner in the postnatal period. 

• The consultation, referral and transfer processes to the antenatal clinic are clearly articulated to ensure all key stakeholders are aware of their role in the process.
• All woman are transferred back to their referring health service as soon as safely possible after birth.

Levels of care – Refer Capability framework for Victorian Maternity and Newborn Services 2019

Ballarat Health Services (BHS) Maternity Unit, as a Level 5 service, is the main obstetric referral service for the rural health services in the Grampians region and is responsible for:

• Establishing links with surrounding Level 1, 2, 3, and 4 health services regarding consultation, referral and patient transfer
• Establish links with Level 6 health services including PIPER regarding consultation, referral and patient transfer
• Accepting appropriate transfers from Level 1, 2, 3 and 4 services
• Accepting appropriate convalescent transfers from Level 6 services
• Ensure formal communication procedures with all services.

PIPER - Paediatric Infant Perinatal Emergency Retrieval.

• Obstetric complications which occur during pregnancy and are outside of the local capability framework for pregnancy and birthing care (see Capability framework for Victorian Maternity and Newborn Services 2019)
• Postnatal mothers and babies who are appropriate for back transfer to their local health service

• Obstetric risk factors/complications requiring Level 6 pregnancy care (see Capability framework for Victorian Maternity and Newborn Services 2019)

• This protocol is a guide for clinicians however each case must be assessed individually by the lead care provider at BHS to determine suitability of care.

In the Antenatal Period

• All emergency antenatal transfers must be discussed with PIPER (1300137650)
• Identify those women who are referred to BHS Antenatal Clinic from level 2, 3 or 4 maternity services in the region and apply the appropriate model of care
• Identify those women who will birth at BHS and are appropriate for back transfer to their local health service in the postnatal period (early if possible).  Ensure appropriate entry in electronic record and also discuss with the woman and her significant others.

In the Postnatal Period

• Identify and assess those women and newborns appropriate for back transfer to their local health service in the postnatal period

Criteria for postnatal transfer to level 2, 3 or 4 maternity services:

• No variations or complications from the intrapartum and immediate postnatal period that might impact on postnatal care.
• Maternal and neonatal observations within normal range in the initial 4 hours following birth.
• A woman who has had a normal pregnancy, vaginal birth (including assisted vaginal birth) and postnatal period (early transfer >4 hours).  Caesarean section may consider transfer after 24-48 hours if mother and baby are stable.
• Public patient.

Mode of transport:

• To be determined and approved by the medical practitioner

Exclusion criteria for back transfer:

Maternal

• Febrile / suspected maternal infection
• Persistent hypertension / eclampsia
• Haemorrhage > 1000mls
• Low haemoglobin (Hb) of 100g/L and/or symptomatic
• Thrombophlebitis or thromboembolisim
• Uterine prolapse
•  Pre-existing medical conditions requiring treatment (e.g. diabetes)
• Urinary retention requiring medical intervention
• Concern regarding psychological condition
• Severe perineal trauma requiring close monitoring and follow-up (e.g. 3^rd or 4^th degree tear)
• Perinatal death
• Current history of drug and/or alcohol use (e.g. effects on neonate)

Infant

• Apgar < 7 at 5 minutes
• <37 weeks gestational age
• Infant weight <2500g (may be negotiated with receiving health service)
• Less than 3 vessels in umbilical cord
• Jaundice < 24 hours or suspected pathological jaundice after 24 hours
• Unstable blood sugar levels
• Temperature instability
• Confirmed or suspected sepsis
• Excessive moulding and/or cephalhaematoma
• Abnormal findings on physical examination
• Excessive bruising, abrasions, unusual pigmentation and/or lesions
• Birth injury/trauma requiring monitoring and/or investigation
• Congenital abnormalities
• Abnormal heart rate pattern
• Abnormal cry
• Persistent abnormal respiratory rate and/or pattern
• Persistent cyanosis or pallor
• Bile stained vomiting
• Infection of umbilical stump site
• Feeding problems
• Suspected or actual seizure activity