Midwife Led Care

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Midwife Led Care

• DOMINO Midwifery
• Rotunda Hospital

Fiona Hanrahan Oct 08
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DOMINO Midwifery
Part 1 Who we are. Part 2 Where we came
from. Part 3 What do we do. Part 4 Where do
we do it. Part 5 How do we do it.
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• July 2005 DOMINO team established.
• Remit
• Book 300 women per year (2007, 436,2008 420)
• Low Risk
• Living in D7 and D11
• Community based care
• Establish referral pathways with other
  professionals
• Care at all stages of pregnancy, birth,
  postnatal period

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The Team
7 Clinical Midwife Specialist (CMS) 1 CMM3
Providing cover 24hrs a day 7 days a
week. Rotation to night duty.
Clinical Midwife Specialist

• Specially focused knowledge and skills
• Major clinical focus
• Assessment
• Planning
• Delivery
• Evaluation (NCNM 2007)

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Our Speciality? LOW RISK!
More about the definition of low risk later
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The Beginning..
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Background

• 2002/3 Rotunda Hosp responds to the following
  reports
• People of Finglas and their health (2003)
• The report of the mother and infant care scheme
  review (1997)
• A plan for Womens Health (1997)
• Report of the Commission on nursing (1998)
• Factors that influence the recruitment and
  retention of midwives and
• nurses in the Dublin Maternity Hospitals (2003)

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1996 WHO concludes Midwives are the most
appropriate and cost effective professionals to
give care to women during a normal pregnancy and
birth 1998 Commission on Nursing Midwifery
offers practitioners a unique opportunity for
autonomous practice in the provision of health
care to women
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DOMINO model of Midwife led care

• Lead professional
• Autonomous practitioner
• Expert in normal pregnancy birth and
  puerperium
• Recognises deviation from normal
• Makes appropriate referral

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Example of partnership working
Steering Group
members included

• Directors of Public Health Nursing
• GPs
• Obstetricians
• Paediatricians
• Senior management team
• Hosp Midwives
• Practice development Midwife
• Hosp depts I.e. IT, Med records, Labs, MSW

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Philosophy of Midwifery Care
To ensure that Midwifery care is provided in
partnership with women their partners and
families. To promote the concepts of choice,
continuity and control for women during this life
changing time. To offer care that is holistic,
effective and sensitive to the individual needs
of women. To utilise the best available evidence
in our care. To protect the normal physiological
processes of pregnancy, birth and the postnatal
period. To recognise and promote breastfeeding
as the best start in life for babies.
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• Objectives for the DOMINO service are to provide
• care tailored to the individual womans needs.
• information and choice of care for women.
• midwifery care to low risk women from our
  catchment area.
• Holistic continuous care for women in
  partnership with
• Midwives and other health providers I.e. Gps
  and PHNs.
• Practice based on sound evidence with on going
  evaluation/audit.

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Lets talk about RISK
Does lack of medical/surgical history mean a
woman is low risk?

• Exclusion criteria concentrates on measurable
  definable risk
• For example
• Prev LSCS Excluded
• Multiparity gtP5 Excluded
• Anaemia lt 10gms Excluded
• Previous stillbirth Excluded

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• Common traits amongst the women with DOMINO
• Average age 19 (gt18 under care of teen M/W)
• Living with parents, often sharing bedrooms
• Out of full time education
• High level of unemployment
• History of Rx depression
• Not unusual to have lost sibling to
  drugs/suicide/violence
• Family members/boyfriend in prison
• Smokes cigarettes
• Use of non prescription drugs (coke, weed,
  speed)
• Drinks alcohol (Wicked and Fat Frogs)
• Varied diet. chipper, pizza, Chinese, kebab!!!

No identifiable medical or surgical risk factor
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Meet Sally Age 25. Left school
at 14 yrs. Living in social housing. Already has
6 children ( 2 dogs 3 cats, 1 terrapin 1
rabbit) Finds she is pregnant again.
DOMINO midwife hears from friend of Sallys about
the pregnancy. Phones, leaves messages, calls
around to the house, leaves a note.
Finally makes contact with Sally. She is already
29wks. She is in complete denial. She is alone.
Her booking haemoglobin is 6.2grms
Sally is outside the criteria for Midwifery led
care
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• Through negotiation and consultation with
  Obstetricians
• GP, MSW, PHN and other agencies.
• Sally booked with DOMINO.
• Admitted for iron infusion
• MSW provided support and links to young mothers
  programme
• Antenatal visits provided in Sallys home.
• Sally cared for during labour and birth by
  DOMINO M/W
• Requested to be discharged home 12hrs after
  birth
• Home postnatal visits providing care, support
  and advice
• PHN involvement
• Local support groups involved

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• DOMINO team aim to achieve
• Women booked and first visit by 14wks
• Full attendance for antenatal care
• greater awareness of harmful effects and reduced
  use of
• Cigarettes
• alcohol
• non prescription drugs
• improved detection and management of
  complications
• PET and PIH
• IUGR and SFD
• Gestational diabetes
• Cholestasis

We encourage attendance at DOMINO run classes or
we offer One to One sessions in the womans home.
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Emotional well being

• Women and their partners are supported by
  midwives during
• pregnancy.
• Women feel confident and prepared for birth.
• Women have a sense of optimism about their
  childs future.
• Parents are aware of ongoing support services
  available to them.
• Women are aware of signs of postnatal depression
  and know how
• to connect with services.
• Women are linked to PHN services earlier where
  concern exists.

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Welcome to Wellmount Health Centre
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Access to DOMINO service

• Live within catchment area i.e. D7 and D11
• Have minimalrisk factors at booking.

Referral to DOMINO Service

• Self referral
• Word of mouth
• GP referral
• Via Hospital clinics

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Antenatal care

• Booking visit offered
• Home
• Hosp

• Scans and blood tests
• As per routine for low risk women

• Antenatal care
• GP visits
• Community clinics
• Home visits

• Antenatal classes
• Provided by DOMINO team
• Small groups 6-8 women
• Evening classes

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Referral to Hospital services

• Midwife to Midwife referral
• Day care unit
• GTT
• Ultrasound
• Psychology services
• Lactation

• Other Hosp Services
• Physiotherapy
• Social Work

If complication resolves return to DOMINO!

• Medical referral
• Registrar
• Consultant
• Specialists clinics
• Emergency Room

OR
Transfer to Obstetric care
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Labour and Birth

• Contact DOMINO midwife
• Stay at home in early labour
• Deliver in the Rotunda
• Care in labour with DOMINO Midwife
• Philosophy of protecting normal physiological
  birth
• Respecting and supporting choice

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Postnatal Care
Hospital care

• Minimum 6hr stay.
• Mother postnatally well.
• Paed examination of newborn.

• Breastfeeding
• Promotion
• Protection
• Respect

• Community care
• Home visits up to 7 days.
• Care advice and support.
• Health promotion.

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Thank you for your attention.
Questions and comments