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Introduction: Hypertensive disorders of pregnancy (HDP) affect up to 10% of all pregnancies annually and are associated with an increased risk of maternal and fetal morbidity and mortality. This guideline represents an update of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) guidelines for the management of hypertensive disorders of pregnancy 2014 and has been approved by the National Health and Medical Research Council (NHMRC) under section 14A of the National Health and Medical Research Council Act 1992. In approving the guideline recommendations, NHMRC considers that the guideline meets NHMRC's standard for clinical practice guidelines., Main Recommendations: A total of 39 recommendations on screening, preventing, diagnosing and managing HDP, especially preeclampsia, are presented in this guideline. Recommendations are presented as either evidence-based recommendations or practice points. Evidence-based recommendations are presented with the strength of recommendation and quality of evidence. Practice points were generated where there was inadequate evidence to develop specific recommendations and are based on the expertise of the working group., Changes in Management Resulting From the Guideline: This version of the SOMANZ guideline was developed in an academically robust and rigorous manner and includes recommendations on the use of combined first trimester screening to identify women at risk of developing preeclampsia, 14 pharmacological and two non-pharmacological preventive interventions, clinical use of angiogenic biomarkers and the long term care of women who experience HDP. The guideline also includes six multilingual patient infographics which can be accessed through the main website of the guideline. All measures were taken to ensure that this guideline is applicable and relevant to clinicians and multicultural women in regional and metropolitan settings in Australia and New Zealand., (© 2024 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Problem: Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models., Background: Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice., Aim: This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women., Methods: A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis., Findings: Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care., Discussion: Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible., Conclusions: Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Midwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow., Background: It is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services., Aim: We aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings., Methods: Data were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework., Findings: Good quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes., Discussion: Midwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework., Conclusion: The QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: Antenatal corticosteroids (ANC) reduce mortality and morbidity in preterm babies, but prescription practices vary., Aims: To assess obstetricians' compliance with the recommendations of the Australian and New Zealand clinical practice guidelines on use of ANC., Materials and Methods: An anonymous online questionnaire was distributed to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Results: All respondents reported prescribing an initial course of ANC according to the guidelines if preterm birth at 28 weeks' gestation was expected within 24 or 72 h. However, 22% reported prescribing ANC even if birth was not expected within seven days. This was reported more often by practitioners not using adjunct tests to predict preterm birth (14% vs 69%; P < 0.001). An initial course of ANC at ≥35 weeks was prescribed by 52% of respondents. However, 93% reported prescribing ANC at ≥35 weeks prior to elective caesarean section. Repeat courses of ANC were prescribed by 76% of respondents. Of these, 89% reported prescribing repeat courses beyond the guideline recommendations at ≥33 weeks and 29% exceeded the recommendations on number of repeat courses., Conclusions: For infants born at <35 weeks, current ANC prescribing patterns in Australia and New Zealand are consistent with the guideline recommendations and result in high rates of administration in this group. However, administration of ANC to groups where benefits have not been demonstrated is commonly reported. Adherence to the guideline recommendations would decrease ANC exposure to babies for whom there is no strong evidence of benefit., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Purpose: The objective of this systematic integrative review is to identify, summarise and communicate the findings of research relating to tools that measure maternal satisfaction with continuity of maternity care models. In so doing the most appropriate, reliable and valid tool that can be used to measure maternal satisfaction with continuity of maternity care will be determined., Design and Methods: A systematic integrative review of published and unpublished literature was undertaken using selected databases. Research papers were included if they measured maternal satisfaction in a continuity model of maternity care, were published in English after 1999 and if they included (or made available) the instrument used to measure satisfaction., Results: Six hundred and thirty two unique papers were identified and after applying the selection criteria, four papers were included in the review. Three of these originated in Australia and one in Canada. The primary focus of all papers was not on the development of a tool to measure maternal satisfaction but on the comparison of outcomes in different models of care. The instruments developed varied in terms of the degree to which they were tested for validity and reliability., Conclusion: Women's satisfaction with maternity services is an important measure of quality. Most satisfaction surveys in maternity appear to reflect fragmented models of care though continuity of care models are increasing in line with the evidence demonstrating their effectiveness. It is important that robust tools are developed for this context and that there is some consistency in the way this is measured and reported for the purposes of benchmarking and quality improvement., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: In 1989, the first major state-wide report into maternity services, known as the Shearman Report after its author, was released in New South Wales, the most populous state in Australia., Aim: This paper reflects upon the report and tracks the progress of five of its key recommendations. The recommendations are still some of the major issues facing maternity services across the country. These are: community-based maternity care, rural maternity services, hospital visiting rights for privately practising midwives, obstetric intervention, and midwifery continuity of maternity care., Findings: In some ways, much has changed in 25 years including the terminology used in the report, the importance of midwifery continuity of care and the woman-centred nature of many services. However, in other ways, there is still a long way to go to address these major issues. Despite more than a quarter of a century, many recommendations have not been fulfilled, especially access to care in rural areas, rates of obstetric intervention, and the issue of visiting rights for privately practising midwives which has gone backwards., Conclusion: A continued and renewed effort is needed to ensure that the forward thinking recommendations of the Shearman Report are ultimately realised for all women and their families., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Prior to and throughout the twentieth century, biomedical understandings of health predominated. Australian obstetrician and gynaecologist, Professor Derek Llewellyn-Jones responded to frustrations with the limitations of this narrow approach from both within and beyond the medical profession. His pioneering research, education and writings re-conceptualised the discipline as encompassing the social and psychological contexts and profoundly influenced women's own understanding of their health and the practice of obstetrics and gynaecology. The biopsychosocial model has replaced biological determinism and is now pervasive in education and clinical practice in many parts of the world. Widespread acceptance of the model has until now been associated with under-recognition of the importance of biology. Recent findings from epigenetics and neuroscience are enabling integration of body, mind and society and enhanced understanding and practice of psychosomatic obstetrics and gynaecology.

Background: Understanding immigrant women's experiences of maternity care is critical if receiving country care systems are to respond appropriately to increasing global migration. This systematic review aimed to compare what we know about immigrant and non-immigrant women's experiences of maternity care., Methods: Medline, CINAHL, Health Star, Embase and PsychInfo were searched for the period 1989-2012. First, we retrieved population-based studies of women's experiences of maternity care (n = 12). For countries with identified population studies, studies focused specifically on immigrant women's experiences of care were also retrieved (n = 22). For all included studies, we extracted available data on experiences of care and undertook a descriptive comparison., Results: What immigrant and non-immigrant women want from maternity care proved similar: safe, high quality, attentive and individualised care, with adequate information and support. Immigrant women were less positive about their care than non-immigrant women. Communication problems and lack of familiarity with care systems impacted negatively on immigrant women's experiences, as did perceptions of discrimination and care which was not kind or respectful., Conclusion: Few differences were found in what immigrant and non-immigrant women want from maternity care. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women's understanding of care provision and reducing discrimination.

This article argues that the continuing reluctance on the part of professional and bureaucratic bodies in Australia to provide for and support planned attended homebirth for low-risk women is unfounded according to the research evidence. It also suggests that such lack of support might be encouraging some planned but intentionally unattended homebirths to occur in Australia, particularly as in recent years there appears to have been an increase in popularity in freebirth (or do-it-yourself homebirth). The article calls for RANZCOG and Australian state health departments to support planned attended homebirth for low-risk women in the face of what is now a considerable amount of evidence showing its safety, when compared with unplanned homebirth and hospital birth. The article raises a number of challenging issues for obstetricians, midwives and managers or planners of maternity services.

Objectives: To assess obstetric outcomes of different models of antenatal care., Methods: The study was historical cohort analysis of population birth data of 67,675 singleton births delivered in all public hospitals in Sydney South-west. Maternal and neonatal outcomes were compared for different models of antenatal care received. The care was provided within the hospitals in doctor's clinic, midwives' clinic, birth centre, or by a team of midwives in the caseload midwifery. In the non-hospital settings, the care was provided by private obstetricians or by the general practitioner (GP) as part of the GP Shared Care program. The data for those women who received no antenatal care were also analysed., Results: This study provided information that the obstetric outcomes were very similar regardless of whether a woman received her antenatal care in the midwives' clinic, the birth centre, under the GP Shared Care program or in the doctor's clinic in Sydney South-west hospitals., Conclusions: This study provides evidence for the view that different models of maternity care can be provided with good outcomes.

The Performance Indicators for Coding Quality (PICQ) is a data quality assessment tool developed by Australia's National Centre for Classification in Health (NCCH). PICQ consists of a number of indicators covering all ICD-10-AM disease chapters, some procedure chapters from the Australian Classification of Health Intervention (ACHI) and some Australian Coding Standards (ACS). The indicators can be used to assess the coding quality of hospital morbidity data by monitoring compliance of coding conventions and ACS; this enables the identification of particular records that may be incorrectly coded, thus providing a measure of data quality. There are 31 obstetric indicators available for the ICD-10-AM Fourth Edition. Twenty of these 31 indicators were classified as Fatal, nine as Warning and two Relative. These indicators were used to examine coding quality of obstetric records in the 2004-2005 financial year Australian national hospital morbidity dataset. Records with obstetric disease or procedure codes listed anywhere in the code string were extracted and exported from the SPSS source file. Data were then imported into a Microsoft Access database table as per PICQ instructions, and run against all Fatal and Warning and Relative (N=31) obstetric PICQ 2006 Fourth Edition Indicators v.5 for the ICD-10- AM Fourth Edition. There were 689,905 gynaecological and obstetric records in the 2004-2005 financial year, of which 1.14% were found to have triggered Fatal degree errors, 3.78% Warning degree errors and 8.35% Relative degree errors. The types of errors include completeness, redundancy, specificity and sequencing problems. It was found that PICQ is a useful initial screening tool for the assessment of ICD-10-AM/ACHI coding quality. The overall quality of codes assigned to obstetric records in the 2004- 2005 Australian national morbidity dataset is of fair quality.

Obstetric haemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome. The aim of this study was to assess facilities relevant to major obstetric haemorrhage management in all units in Australia and New Zealand that offer operative obstetric services. The questionnaire was divided into ten sections: demographics, facilities, staffing, policies and guidelines, drugs, procedures, equipment, point of care testing, availability of O negative blood and free comments. Responses were received from 240 (76.4%) of the 314 hospitals surveyed (187 public and 53 private). One hundred and nine units (45%) had fewer than 500 deliveries per year Distances to referral facilities were frequently very large. Of the 90 hospitals (38.1%) without an onsite blood bank, 12 did not have a supply of blood for emergencies. Half of all units (n=121) had on-site intensive care or high dependency facilities and 72.9% (n=175) had an on-site cardiac arrest team. Only 58.8% of units (n=141) had a written haemorrhage protocol. Findings are presented in the context of other literature, including evidence-based guidelines. Haemorrhage responds well to appropriate treatment, although careful preparation and anticipation of problems is required. In our region geographical factors and different systems of healthcare complicate provision of obstetric services. Where facilities are limited, women should be offered antenatal transfer to a larger centre.

Strict control of blood glucose levels should be pursued before conception and maintained throughout the pregnancy (glycohaemoglobin [HbA(1c)] level as close as possible to the reference range). Before conception: high-dose (5 mg daily) folate supplementation should be commenced; oral hypoglycaemic agents should be ceased; and diabetes complications screening should take place. Management should be by a multidisciplinary team experienced in the management of diabetes in pregnancy. Blood glucose monitoring is mandatory during pregnancy, and targets are: fasting 4.0-5.5 mmol/L; postprandial < 8.0 mmol/L at 1 hour; < 7 mmol/L at 2 hours. A first trimester nuchal translucency (possibly with first trimester biochemical screening with pregnancy-associated plasma protein A and beta-human chorionic gonadotropin) should be offered. Ultrasound should be performed for fetal morphology at 18-20 weeks, if required, for cardiac views at 24 weeks and for fetal growth at 28-30 and 34-36 weeks. Induction of labour or operative delivery should be based on obstetric and/or fetal indications. Level 3 neonatal nursing facilities may be required and should be anticipated when birth occurs before 36 weeks, or if there has been poor glycaemic control. Insulin requirements fall rapidly during labour and in the puerperium. At this time, close monitoring and adjustment of insulin therapy is necessary.

The present paper briefly describes a growing trend in continuing professional development (CPD) for medical practitioners, examines some recent published contributions related to professionalism in medicine and describes the theoretical platform of a CPD framework based on medical professionalism that has been developed for use in a variety of medical specialties. The work arises from a project funded by The Commonwealth Department of Health and Ageing and conducted by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on behalf of the Committee of Presidents of Medical Colleges. Overall, the aim of the project was to design and develop a framework that can be considered 'best practice' in the field of medical specialist CPD, and which could be applicable to a wide variety of medical specialties and practice environments. The project was informed by available literature in areas such as the ways in which medical practitioners learn and the effectiveness of CPD, as well as consultations with a variety of stakeholders in the health-care field, including medical boards, medical defence organisations, health complaints organisations, specialist medical colleges and practising specialists. Overwhelmingly, the primary purpose of specialists participating in ongoing CPD was, according to the project consultations conducted, the maintenance, development and improvement of skills that enable consumers of healthcare to be confident of the level of care that they receive. Coupled with the need to recognise CPD as contributing to the wider context of professional practice, the resulting framework is underpinned by a theoretical platform based on the concept of medical professionalism. It is this theoretical platform, which articulates the nature of and responsibilities associated with the practice of specialist medicine, that enables a CPD framework to be constructed that can accommodate a wide range of specialist disciplines and practice settings, while also framing ongoing education expectations from the viewpoint of a range of stakeholders, rather than a single perspective; that of practitioners themselves.

Objective: To assess obstetricians' current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus., Design and Participants: National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus., Outcome Measures: Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines., Results: 523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission., Conclusion: There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.

The attitudes of Australian practitioners working in clinical genetics and obstetrical ultrasound were surveyed on whether termination of pregnancy (TOP) should be available for conditions ranging from mild to severe fetal abnormality and for non-medical reasons. These were compared for terminations at 13 weeks and 24 weeks. It was found that some practitioners would not facilitate TOP at 24 weeks even for lethal or major abnormalities, fewer practitioners support TOP at 24 weeks compared with 13 weeks for any condition, and the difference in attitudes to TOP between 13 weeks and 24 weeks is most marked for pregnancies which are normal or involve a mild disorder. It is argued that a fetal abnormality criterion for late TOP is inconsistently applied, discriminatory and eugenic. Four possible moral justifications for current practice are examined, each of which would require significant changes to current practice. I argue in favour of a maternal interests criterion for any TOP.

Objective: To develop an effective and practical self-administered obstetric audit program for use by clinicians within their own practice., Setting: The private and public practices of specialists in provincial practice., Sample: Two periods of 3 months in each Fellow's practice, separated by a period of 3 months to allow for data review, resulting in the review of management of 6708 singleton births., Methods: All provincial Fellows in active practice in Australia in early 1998 were invited to take part in a voluntary 'quality cycle' obstetric practice audit. The data from the first 3 month period was fed back to participating Fellows for review before a second 3-month audit period was undertaken., Results: One hundred and twenty provincial Fellows were invited to take part; 62 registered for the study, 58 commenced the project, and 52 completed the entire cycle. 60.1% of the 6708 women studied laboured spontaneously, 25.8% had labour induced, and 14.1% had elective Caesarean sections. 87.8% of the 5759 women who laboured gave birth vaginally. There was little change in the incidence of intervention in labour between the first and second study periods., Conclusions: It is possible to design a worthwhile self-administered clinical audit in obstetric practice with which specialists in full-time practice can cope and which provides useful personalised feedback for the specialist.

Objectives: To describe the obstetric profile and perinatal mortality of Pacific Island-born women giving birth in New South Wales (NSW) and assess risk factors associated with the high perinatal death rate previously noted in this immigrant group., Method: Retrospective cohort study based on the Midwives Data Collection in NSW from 1990 to 1993. Births to 5,034 Pacific Island-born women were compared with births to 256,843 Australian-born women., Results: Pacific Island-born women had fewer teenage pregnancies and were of an older age and higher parity. They were more likely to be married or in a de facto relationship and to present for antenatal care later in the pregnancy. The proportion of low birthweight and preterm birth was similar in the two groups but Pacific Islanders had a higher perinatal mortality rate (14.6/1,000 vs. 10.3/1,000, RR = 1.42, 95% CI = 1.13-1.54). Even at normal and high birthweights, infants of Pacific Island-born women were at greater risk of perinatal death. After adjusting for maternal factors (marital status, insurance status, parity and maternal age) Pacific Islanders were 30% more likely to have a perinatal death (OR = 1.30, 95% CI 1.07-1.54)., Conclusions: Further analyses of the causes of perinatal death in Pacific Island-born women are needed so appropriate interventions can be implemented., Implications: The need for the design and evaluation of culturally specific services aimed at improving antenatal care attendance in Pacific Islanders is emphasised. Conventional risk assessment may not adequately predict adverse perinatal outcomes in all populations.

Objective: To describe the types of antenatal services in NSW maternity hospitals and examine the views of midwives and obstetricians about who can provide adequate routine antenatal care., Measurements: A mail-out questionnaire to nursing unit managers (NUMs) explored the types of antenatal services available in their hospitals. The questionnaire for 196 midwives and 114 obstetricians asked whether they believed six provider/service types could provide adequate antenatal care either alone or in conjunction with an obstetrician., Findings: 80% of hospitals had GPs providing antenatal care, 53% had obstetricians and 3% had visiting midwives; 33% had a public antenatal clinic, 28% a shared care program with GPs and 26% midwives' antenatal clinics. Midwives were more likely than obstetricians to rate the following as able to provide adequate care alone: hospital antenatal clinic (4.7 times more likely); independent midwife (42.9x); and community midwives as an outreach hospital service (17x). Obstetricians were 8.2x more likely than midwives to rate private obstetricians as being able to provide adequate care. Midwives were more likely to perceive that independent midwives (24.7x more likely) and community midwives as an outreach hospital service (15.3x more likely) were able to provide adequate care either alone or in conjunction with an obstetrician., Conclusion: Most NSW hospitals have GPs providing care, but midwives' clinics and independent midwives are less available. While midwives and obstetricians hold similar beliefs about GPs providing care, substantial differences emerged about the midwife's role. Such disparity in opinion may be central in providing options and consistency in care for women.

Obstetrics is one of the most demanding yet rewarding disciplines required of rural general practice although rising medical indemnity fees combined with medico-legal interest in this discipline make the current rural generalist obstetricians a threatened species. These factors, plus the difficulty generalist registrars have in obtaining good procedural training in this specialist field make obstetric practice less than attractive for future rural general practitioners. This article provides a brief overview of rural obstetric practice from the perspective of a rural generalist obstetrician with 18 years experience. Case studies are used to highlight the challenges of this field.

This paper presents a number of documents developed at State and Territory Government level including the 'Shearman Report' concerning the strategic planning of obstetrical services. The papers are presented in chronological order. The aims, objectives and implementation arising from the reports are discussed including the mechanism by which the various studies were undertaken. The author acknowledges the existence of the many other reports relating to strategic planning for obstetrical services which were not able to be discussed due to the constraints of the presentation.

Objective: To investigate the perceptions of patients about delivery of their babies., Method: One hundred and forty four out of 200 surveyed women answered consumer orientated questions before and after delivery., Results: They were on the whole satisfied with antenatal classes (there seemed to be a need for more information in the form of an on-the-ward postnatal class), disliked the practice of perineal shaves (but did not object to enemas or rupture of membranes) and felt they had adequate analgesia (although not for after-pains or the discomfort of haemorrhoids in the puerperium). Women who intend to deliver in the more (western) conventional positions are less likely to be disappointed. Women expressed the desire to be more actively involved in some aspects of delivery such as cutting the cord, putting the baby to the breast and being alone with partner and baby immediately after delivery. Cardiotocography (CTG) is more reassuring than frightening. A "Birthing Room" is seen as a satisfactory alternative to home delivery.

A microcomputer is used directly by the clinician, immediately after delivering a baby, to produce a summary letter to the referring physician and for the case notes. The programme is easy to use, and accepted by a wide range of medical users. In addition to producing a summary, the information is added to the obstetric data base, which may be interrogated by a computer novice. The system is now used to produce yearly obstetric audits of the Queen Victoria Medical Centre.