Early Booking in Pregnancy First Trimester... · EARLY BOOKING IN PREGNANCY - FIRST TRIMESTER April 2018 Page 1 of 20 This map was published by MidCentral District. A printed version

EARLY BOOKING IN PREGNANCY - FIRST TRIMESTER April 2018 Page 1 of 20

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Early Booking in Pregnancy – First Trimester Obstetrics and Gynaecology > Antenatal care > Early Booking in Pregnancy

Pasifika Hauora Māori Updates to this care

map

Information resources

for providers

Information for women

& families/whānau

Pre-conception care in

general practice

Confirmation of

pregnancy and initial Refer to LMC if not screening/referral by registered already

GP Team or LMC

Risk assessment

Screening - domestic

violence

History and

examination

Screening - gestational

diabetes

Referral to support

services

Medication review

and prescribing

supplements

Screening for

chromosomal

abnormalities

Mental

Health

Diet and

exercise

Advise and support

smoking cessation

Alcohol and substance

misuse during

pregnancy

Nausea and vomiting

Provide the following

supporting information

Employment and

pregnancy

Exposure to infectious Travel and pregnancy

diseases

Care map information

History of pre-

eclampsia

Refer for specialist

consultation

Indications, immediate

referral to hospital

Referral to Mental

Health Service



1. Care map information

In Scope:

• pre-conception care

• confirmation of pregnancy

• first trimester screening

Out of Scope:

• pregnancy termination

• pregnancy counselling

• miscarriage

2. Information for women & families/whānau

General Information:

• 'Your pregnancy'

• Choices for Childbirth

• Guide to Eligibility for Publicly Funded Services

• '5 things to do in the first ten weeks' (MDHB publication)

• Call 0800 MUM2BE

• Find your midwife

• Pasifika Maternal and Child Health Coordinator :

• supports and cares for Pasifika mothers and children

• navigates health system with clients

• reduces barriers and increase access to health and other services

Screening in Pregnancy:

• Antenatal Blood Tests

• HIV testing in pregnancy: Part of antenatal blood tests

• Antenatal screening and testing for Downs Syndrome and other conditions - in pregnancy

• Screening During Pregnancy: Your choice

Smoking Cessation:

• Yes you can!

Nutrition:

• Food safety: Avoiding listeria

• Eating for Healthy Pregnant Women

• Folic Acid and Neural Tube Defects (including Spina Bifida)

• Central PHO Clinical Dietitian Service

• Nutrition and referral for Green Prescription (Sport Manawatu)

• Severe Nausea and Vomiting in Pregnancy

Alcohol:

https://www.maternity.org.nz/product/choices-for-childbirth.htmlhttp://www.health.govt.nz/new-zealand-health-system/eligibility-publicly-funded-health-services/guide-eligibility-publicly-funded-health-services-0http://www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/Let%27s%20Talk%20About%20Health%20Issue%2016.pdfhttps://www.findyourmidwife.co.nz/http://www.centralpho.org.nz/OurServices/PacificHealth.aspxhttps://www.maternity.org.nz/screening-during-pregnancy.htmlhttp://www.centralpho.org.nz/node/81http://www.sportmanawatu.org.nz/green-prescription/https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Severe%20Nausea%20and%20Vomiting%20in%20Pregnancy%20Brochure.pdf



• Alcohol and Pregnancy: When you drink so does your baby

Disease/Infection:

• Hepatitis B: Information for Pregnant Women

• Rubella and Women

Early Pregnancy Antenatal Classes:

• Barnados 'Bump to Babies' Education Programme (Manawatu, Horowhenua, Tararua)(programme is free)

• Parents Centre Childbirth Education Classes (Palmerston North) (NB: fee associated)

Mental Health:

• Perinatal Mental Health information and referral

3. Information resources for providers

Primary Maternity Services Payments:

The maternity services payments are claimed by authorised doctors, midwives and specialists to reimburse them for all maternity

related-services. New Zealand women are not charged for their maternity care. The Primary Maternity Services Notice 2007

Guide outlines the terms and conditions for payment to a maternity provider for providing primary maternity services. The Minister of

Health has approved the 2016 amendment to the Primary Maternity Services Amendment Notice 2007. The amendment implements

the Budget 2015 increase of two percent applied to the fees in the Notice for certain modules of care provided by Lead Maternity

Carers (LMCs). The Ministry has published the Amendment Notice in the New Zealand Gazette. The Amendment Notice came into

force on 1 March 2016. The implementation date for this amendment is 1 July 2015.

Referral Guidelines:

Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines):

• the above guideline provides Lead Maternity Carers (LMCs) with information about the categories of referral, referral pathways

and criteria on which LMCs should advise women that a referral is warranted

Alcohol and Pregnancy:

The following tools and resources are intended to support health professionals in advising women about the consequences of

alcohol use in pregnancy, identifying at-risk drinking and supporting women to stop drinking when pregnant or planning pregnancy:

• hazards of alcohol use by pregnant women and women of reproductive age - encourages health professionals to ask women

about their alcohol use and advise them not to drink alcohol if they are pregnant or planning a pregnancy

• ABC Alcohol for Pregnancy - provides a practical, three-step guide to help primary care health professionals address alcohol

use in pregnancy in their conversations with women

• Pregnant? Trying? Don't drink - a short pamphlet health professionals can give to women as part of a conversation about

alcohol use in pregnancy

Smoking and Pregnancy:

Strongly recommend that all pregnant women who smoke use a stop-smoking service to help them stop; and make a referral as

appropriate:

• the Stop Smoking Support pathway lists local stop smoking services and referral information

Mental Health:

• Perinatal Mental Health information and referral

Other:

• Barnardos 'Bumps to Babies' Service across MidCentral (July 2016)

http://www.barnardos.org.nz/bumps-babieshttp://www.parentscentre.org.nz/palmerston-north/childbirthed/default.asphttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Perinatal%20Mental%20Health%20Referral%20Guide__2381.pdfhttp://www.health.govt.nz/system/files/documents/pages/referral-glines-jan12.pdfhttp://www.health.govt.nz/system/files/documents/pages/referral-glines-jan12.pdfhttps://gazette.govt.nz/notice/id/2016-go660?noticeNumber=2016-go660http://www.health.govt.nz/system/files/documents/pages/referral-glines-jan12.pdfhttp://alcohol.org.nz/sites/default/files/documents/Hazards%20of%20alcohol%20use%20while%20pregnant.pdfhttp://alcohol.org.nz/sites/default/files/documents/ABC%20Alcohol%20and%20Pregnancy-Final.pdfhttp://alcohol.org.nz/sites/default/files/images/ALC1030%201%200%20Alcohol%20and%20Pregnancy%20A4_F.PDFhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Perinatal%20Mental%20Health%20Referral%20Guide__2381.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Barnardos%20Bumps%20to%20Babies%20Service%20across%20MidCentral.pdf



4. Updates to this care map

Interim Update: June 2018:

• Where a woman is not settling with conservative means, clinicians are guided to consider rehydration through POAC or for

more severe cases to follow the 'Nausea and Vomiting in Pregnancy' pathway.

This pathway has been updated in line with consideration to evidenced based guidelines.

First Publication Date: 2017

5. Hauora Māori

Māori are a diverse people and whilst there is no single Māori identity, it is vital practitioners offer culturally appropriate care when

working with Māori Whānau. It is important for practitioners to have a baseline understanding of the issues surrounding Māori health.

This knowledge can be actualised by (not in any order of priority):

• acknowledging Te Whare Tapa Whā (Māori model of health) when working with Māori Whānau

• asking Māori clients if they would like their Whānau or significant others to be involved in assessment and treatment

• asking Māori clients about any particular cultural beliefs they or their Whānau have that might impact on assessment and

treatment of the particular health issue (Cultural issues)

• consider the importance of whānaungatanga (making meaningful connections) with their Māori client / Whānau

• knowledge of Whānau Ora, Te Ara Whānau Ora and referring to Whānau Ora Navigators where appropriate

• having a historical overview of legislation that has impacted on Māori well-being

For further information:

• Hauora Māori

• Central PHO Māori Health website

6. Pasifika

[Pasifika co-ordinator]

Pacific Cultural Guidelines (Central PHO) 6MB file

Our Pasifika community:

• is a diverse and dynamic population:

• more than 22 nations represented in New Zealand

• each with their own unique culture, language, history, and health status

• share many similarities which we have shared with you here in order to help you work with Pasifika patients more effectively

The main Pacific nations in New Zealand are:

• Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu

Acknowledging The FonoFale Model (pasifika model of health) when working with Pasifika peoples and families.

Acknowledging general pacific guidelines when working with Pasifika peoples and families:

• Cultural protocols and greetings

http://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Te%20Whare%20Tapa%20Wha.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Cultural%20Issues.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Wh%C4%81naungatanga.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Whanau%20Ora%2C%20Te%20Ara%20Whanau%20Ora%20and%20Navigators.pdfhttp://www.centralpho.org.nz/CollaborativeClinicalPathways/HauoraMaori.aspxhttp://www.centralpho.org.nz/OurServices/M?oriHealth.aspxhttp://www.centralpho.org.nz/OurServices/PacificHealth.aspxhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Pacific%20Cultural%20Guidelines%20(Central%20PHO).pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Fonofale%20model.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Cultural%20Protocols%20and%20Greetings.pdf



• Building relationships with your pasifika patients

• Involving family support, involving religion, during assessments and in the hospital

• Home visits

• Contact information

Pasifika Health Service - Better Health for Pasifika Communities:

• the Pasifika Health Service is a service provided free of charge for:

• all Pasifika people living in Manawatu, Horowhenua, Tararua and Otaki who have long term conditions

• all Pasifika mothers and children aged 0-5 years

• an appointment can be made by the patient, doctor or nurse

• the Pasifika Health Service contact details are:

• Palmerston North Office - 06 354 9107

• Horowhenua Office - 06 367 6433

• service brochure

Additional resources:

• Ala Mo'ui - Pathways to Pacific Health and Wellbeing 2014-2018

• Primary care for pacific people: a pacific health systems approach

• Tupu Ola Moui: The Pacific Health Chart Book 2004

• Pacific Health resources

• List of local Maori/Pacific Health Providers

• Central PHO Pacific Health website

7. Pre-conception care in general practice

Education to improve pre-conception health should be viewed as a routine part of primary care for all women of

reproductive age.

Consider asking all women of reproductive age a single question about pregnancy risk or intent:

• encourage women to think about the right time and circumstances to consider pregnancy and prescribe effective contraception

until this is desired

• provide education about modifiable risks during pregnancy such as smoking, alcohol intake and drug use

• provide education on how a pregnancy may be best achieved

Pre-conception consultation

A pre-conception discussion could include [1]:

• an initial question about pregnancy risk or intent: do they wish to become pregnant, and when?, are they taking precautions to

prevent the risk of becoming pregnant?

• a review of personal aspects of health that may have an impact on fertility and pregnancy, e.g. weight, diet, long-term

conditions, medications, environmental exposures and psychosocial issues

• a review of current contraception

If the woman wishes to conceive, further actions include:

• discussion about the fertile phase of the menstrual cycle and optimal timing and frequency of intercourse

• prescription of folic acid - this is recommended at least four weeks before conception and for the first twelve weeks of

pregnancy

• checking of immunity status for rubella and varicella (chicken pox)

• ensuring that cervical smears are up to date and considering if a STI check is required

• checking that long-term medications are appropriate and safe

• highlighting the issues regarding intake of caffeine, alcohol and other drugs and recommending avoidance

http://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Building%20relationships%20with%20pacific%20patients.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Family%20support_Religion_Healing_Hospital.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Home%20visits.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Contact%20info.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Womens%20Health/Early%20Pregnancy/Pasifika%20Health%20Final%20Pamphlet%202017%20(003)%20(2).pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Womens%20Health/Early%20Pregnancy/ala-moui-pathways-to-pacific-health-and-wellbeing-2014-2018-jun14-v2.pdfhttp://www.health.govt.nz/publication/primary-care-pacific-people-pacific-and-health-systems-approachhttp://www.health.govt.nz/publication/tupu-ola-moui-pacific-health-chart-book-2004http://www.health.govt.nz/our-work/populations/pacific-health/pacific-health-resourceshttp://www.centralpho.org.nz/CollaborativeClinicalPathways/HauoraMaori.aspxhttp://www.centralpho.org.nz/OurServices/PacificHealth.aspxhttp://www.bpac.org.nz/BPJ/2011/april/preconception.aspx



• encouraging smoking cessation if applicable

• discussing good nutrition, e.g. a well balanced diet which also optimises iron and calcium

• giving general advice regarding personal health care and potential teratogens in early pregnancy such as avoiding x-rays and

foods that may be contaminated with listeria

• giving advice about when and where to attend in early pregnancy

• giving advice about dental care to ensure no periodontal disease

It is important to explain that conception may not be achieved immediately. In general, consider referral for evaluation of

fertility for women aged under 35 years who have not conceived after 12 months and for women aged over 35 years who

have not conceived after six months.

Preconception care for men:

Pre-conception care for men should include advice about [1]:

• maintaining a healthy weight - a BMI of greater than 29kg/m² may reduce sperm health

• safe levels of alcohol intake - more than two standard drinks every day has been shown to reduce sperm quality

• smoking cessation - smoking is known to reduce sperm count and motility and to increase the number of abnormal sperm

• drug use - marijuana, cocaine and anabolic steroids have all been shown to reduce the number and quality of sperm

• medications that may affect the quality and quantity of sperm, e.g. calcium channel blockers, corticosteroids, sulphasalazine,

cimetidine

• avoiding activities that increase the temperature of the testes, although there is limited evidence to support a direct effect on

sperm quality, e.g. tight underwear, hot baths, laptops on knees

• optimising the number of ejaculations - optimal sperm quality (in number, morphology and motility) is highest when there is two

to three days between ejaculations. Lower rates of pregnancy are found if the time interval between ejaculations is greater than

three days

• considering reducing workplace and recreational exposure to chemicals that may impair the quality of sperm such as

pesticides and organic solvents in products such as paint strippers, decreasers and glues

8. Confirmation of pregnancy and initial screening/referral by GP Team or LMC

Confirmation of Pregnancy

In order to confirm pregnancy, calculate expected date of delivery (EDD) by last menstrual period (LMP). If the woman experiences

irregular periods or if LMP is unknown, refer the woman for a dating scan. When a woman becomes pregnant, it is recommended

that she receives a range of standard investigations. A first antenatal screen is required even if the woman is considering termination

of pregnancy.

Initial Screening

The 'first antenatal screen' may be requested by the GP at the first appointment when pregnancy is confirmed, and the results later

forwarded to the chosen Lead Maternity Carer (LMC). Tests included in the first antenatal screen include:

• complete blood count

• HbA1c

• blood group and antibody screen

• rubella antibody status

• syphilis serology

• hepatitis B serology

• HIV

It is important that the woman has enough information to assist them in deciding whether to have any of the above tests. The

National Screening Unit provides detailed information about the various testing that is available during pregnancy and for newborns.

Routine laboratory tests during pregnancy

Provide information on Lead Maternity Carer (LMC) availability and complete the early pregnancy assessment form .

http://www.bpac.org.nz/BPJ/2011/april/preconception.aspxhttps://www.nsu.govt.nz/pregnancy-newborn-screeninghttp://www.bpac.org.nz/BT/2011/July/pregnancy.aspxhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Child%20Health/Early%20Booking%20in%20Pregnancy/Early%20Pregnancy%20Assessment%20Form.pdf



Provide antenatal information package including information on:

• antenatal screening, including risk and benefits of the screening tests

• the right to decline a test

early pregnancy antenatal classes:

• Barnados 'Bump to Babies' Education Programme (programme is free):

• Horowhenua/Otaki:

• 6 week antenatal classes in Levin and Otaki as well as working directly with pregnant teens in the Waiopehu College Teen

Parent Unit

• Dannevirke/Taraua:

• 6 week antenatal or weekend block classes in both Pahiatua and Dannevirke

• Feilding:

• 6 week antenatal classes in Feilding

• Palmerston North:

• six week or weekend block classes in Palmerston North as well as working with Te Aroha Noa in Highbury to provide a more

flexible pregnancy and early parenting service to meet the needs within this community

• Barnardos 'Bumps to Babies' Service across MidCentral (July 2016)

• Parents Centre Childbirth Education Classes (Palmerston North) (NB: fee associated)

• diet and exercise advice/referrals - refer to Central PHO Clinical Dietitian Service

• nutrition and referral for Green Prescription (Sport Manawatu)

• information for management of nausea, vomiting and other symptoms

It is also important to discuss the availability and purpose of screening throughout the pregnancy:

• First Trimester combined screening

Available if the woman is less than 14 weeks pregnant. This option combines the results of a blood test from the woman and a

nuchal translucency (NT) ultrasound scan with other information, such as the woman's age and weight, to give a risk result.

• Second Trimester combined screening

Available if the woman is 14-20 weeks pregnant. This option combines the results of a blood test from the woman, with other

information, such as their age and weight to give a risk result.

Women that present >13 weeks gestation:

Arrange antenatal assessment and refer woman to an LMC urgently. If appropriate, provide woman with information about second

trimester maternal serum screening. This is a blood test which is best taken between 14 and 18 weeks of pregnancy but can be

taken up to 20 weeks.

9. Indications, immediate referral to hospital

Refer woman urgently if experiencing any of the following:

• significant PV bleeding

• pelvic pain

• urinary retention

10. Refer to LMC if not registered already

http://www.barnardos.org.nz/bumps-babieshttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Barnardos%20Bumps%20to%20Babies%20Service%20across%20MidCentral.pdfhttp://www.parentscentre.org.nz/palmerston-north/childbirthed/default.asphttp://www.centralpho.org.nz/node/81http://www.sportmanawatu.org.nz/green-prescription/



Complete early pregnancy assessment form - print and provide copy to woman and advise she gives copy to chosen LMC

Lead Maternity Services:

Provide information on LMC availability:


Lead Maternity Care Services

The Lead Maternity Carer (LMC) model of primary maternity care is the cornerstone of the maternity service. All other services fit

in around this model so that the woman experiences a seamless maternity service that meets her individual needs, whatever these

might be.

The majority of LMCs are now midwives. Whilst most GPs no longer provide LMC services, there is still a role for general practice in

providing continuity of care for women with healthcare problems during pregnancy and effective pre- and post-natal care for patients

in the practice.

Resources:

• '5 things to do in the first ten weeks' (MDHB publication)

• Call 0800 MUM2BE


11. History of pre-eclampsia

Assess risk factors for pre-eclampsia:

• major risk factors for pre-eclampsia include:

• previous pre-eclampsia requiring delivery before 37 weeks or with haemolysis, elevated liver enzymes, and/or low platelets

(HELLP) syndrome

• predisposing medical conditions:

• autoimmune e.g. systemic lupus erythematosus, scleroderma, anti-phospholipid syndrome

• chronic hypertension

• diabetes type I and II

• any chronic kidney disease

• women with risk factors have a risk of pre-eclampsia of about 20%

• all women with major risk factors for pre-eclampsia require specialist consultation [3] as per Guidelines for Consultation with

Obstetric and Related Medical Services

Guidance regarding the use of low-dose aspirin in the prevention of pre-eclampsia in high-risk women:

• low dose aspirin (LDA) - 100mg enteric coated tablet of aspirin is recommended once daily with food, commenced before 16-20 weeks reduces the risk of pre-eclampsia in women with major risk factors

• it is recommended that LDA is prescribed by the General Practitioner or the obstetric service wherever possible

• initiation of LDA treatment is recommended at 12 weeks and discontinued at 36 weeks

• at the specialist consultation calcium, which also reduces the risk of pre-eclampsia in women at high risk, may be prescribed

Contraindications to low dose aspirin (rare in women of reproductive age):

• previous peptic ulcer

• asthma induced by non-steroidal anti inflammatory drugs

• allergy to aspirin

Role of Calcium:

A decision regarding a recommendation for calcium supplementation is to be made at the time of specialist consultation in women

with major risk factors, and the prescription provided by the obstetrician at that time.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Child%20Health/Early%20Booking%20in%20Pregnancy/Early%20Pregnancy%20Assessment%20Form.pdfhttp://www.findyourmidwife.co.nz/http://www.midcentraldhb.govt.nz/Publications/AllPublications/Documents/Let%27s%20Talk%20About%20Health%20Issue%2016.pdfhttp://www.findyourmidwife.co.nz/http://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdfhttp://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdfhttp://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf



Refer to the Guidance produced by the New Zealand Committee of The Royal Australian and New Zealand College of Obstetricians

and Gynaecologists (RANZCOG) and the New Zealand College of Midwives (NZCOM) regarding the use of low-dose aspirin in the

prevention of pre-eclampsia in high-risk women for more information.

12. Risk assessment

Check for previous pregnancy-related complications that require specialist care:

• perinatal mental health conditions

• three or more consecutive miscarriages, or a mid-trimester loss

• neonatal death or stillbirth

• retained placenta on more than one prior occasion

• previous antenatal or postpartum haemorrhage on at least two occasions

• haemolysis, elevated liver enzymes and low platelet count (HELLP syndrome), severe pre-eclampsia or eclampsia

• pre-eclampsia requiring pre-term delivery and/or medication - may include moderate pre-eclampsia

• previous congenital anomaly

• previous intrauterine growth restriction, or large-for-gestational-age (LGA) infant (greater than 95th centile) - a customised

growth chart will be generated for later use in pregnancy:

• previous baby weighing less than 2.5kg or more than 4.5kg

• rhesus isoimmunisation or other significant blood group antibodies

• uterine surgery including caesarean section, myomectomy, or cone biopsy

Assess for the following, as women with any of these pre-existing conditions usually require additional care:

• cardiovascular disease (CVD), renal, and endocrine disorders, e.g. diabetes

• haematological disorders

• autoimmune disease

• epilepsy requiring anticonvulsants

• malignant disease

• severe asthma

• cystic fibrosis

• substance misuse, including alcohol misuse

• HIV or hepatitis B virus (HBV) infection

• obesity

• family history of genetic disorder

• female genital mutilation (FGM)

Assess risk factors for pre-eclampsia

Assess risk factors for small for gestational age

Assess venous thromboembolism risk

Perform mental health assessment

Chronic hypertension:

• most women with pre-existing (chronic) hypertension will have mild to moderate hypertension, blood pressure (BP) less than

160/110mmHg, and are at low risk of pregnancy complications

• the role of antihypertensive treatment in pregnant women with mild to moderate hypertension is uncertain:

• if the woman is not taking any antihypertensive treatment, consider close monitoring

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Low-dose%20aspirin%20for%20treating%20pre-eclampsia%202015.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Assess%20risk%20factors%20for%20pre-eclampsia.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/RCOG%20-%20IUGR.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Assess%20venous%20thromboembolism%20risk.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Perform%20mental%20health%20assessment.pdf



• if antihypertensive medication is continued during pregnancy, it is advisable to switch to one that is recommended for use

during pregnancy - in particular, angiotensin-converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists

must be stopped

Presence of the following factors may indicate that the woman requires additional support or consideration:

• suicidal ideation

• lack of social support

• substance misuse

• age 40 years and over

• teenage pregnancy

• obesity - body mass index (BMI) more than 30kg/m²

• underweight - BMI less than 18kg/m²

• more than four previous pregnancies

• past or current domestic violence

• smoking

• recent arrival as a migrant

• asylum seeker or refugee status

• difficulty speaking or understanding English

• poverty

• homelessness

• post traumatic stress disorder

13. Screening – domestic violence

Screen for Domestic Violence:

• be alert to the symptoms or signs of domestic violence

• give women the opportunity to disclose domestic violence in a secure environment

• consider that pregnancy may be a risk factor for domestic violence

Screening Questions could include:

• has anyone in your family kicked, punched, scratched or physically hurt you in the past year?

• does anyone in your family put you down, make you feel small, make you feel like you are walking on egg shells?

• has anyone made you do something sexual that you didn't want to do?

• have you any concerns regarding a previous spouse?

14. Refer for specialist consultation

One of the major risk factors for pre-eclampsia is previous pre-eclampsia before 37 weeks or with haemolysis, elevated liver

enzymes, and/or low platelets (HELLP) syndrome. All women with high risk factors for pre-eclampsia require specialist consultation

as per the Guidelines for Consultation with Obstetric and Related Medical Services.

Refer to Ambulatory Care via email ([email protected]) or fax to (06) 350 8499 [may use 'early pregnancy

assessment form' here]

15. History and examination

Obtain patient history, including:

http://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf



• basic patient information, including occupation, to allow a risk assessment of working during pregnancy

Obstetric history:

• parity and gravida

• history of past pregnancies and deliveries

• complications during pregnancy

• intra-partum and post-partum complications

Medical history:

• medical, surgical history

• family history, including psychiatric illness and mood disorders

• previous mental illness

• allergies

Social history:

• alcohol, smoking and drug history

• domestic violence screen

• age and ethnicity of both biological parents

• consider history of genital mutilation

Undertake basic examinations, including [1]:

• calculate body mass index (BMI)

• blood pressure (BP)

• urinalysis

• any other relevant examinations, depending on history

16. Screening – gestational diabetes

Gestational Diabetes [2]

Gestational diabetes affects 5 - 8% of pregnant woman and is associated with hypertensive disorders, macrosomia, shoulder

dystocia, increased rate of caesarean delivery and the development of maternal diabetes later in life:

• every pregnant women should be offered glycated haemoglobin (HbA1c), as a routine part of booking antenatal blood

tests before 20 weeks - this will identify women with probable undiagnosed diabetes or prediabetes and will help identify

women at high risk of developing gestational diabetes

• women with an HbA1c 50 mmol/mol should be referred directly to a service that specialises in diabetes in pregnancy (go to

Diabetes - Pregnancy pathway) as these women have probable undiagnosed diabetes

• women with an HbA1c of 41-49 mmol/mol should be offered a two-hour, 75g oral glucose tolerance test (OGTT) at 24-28 weeks

- these women are considered at an increased risk of gestational diabetes

17. Referral to support services

Support Services:

1. Perinatal Mental Health Services

2. Pāruru Māwai is a team of people involved in maternity or childcare who meet regularly around families who may need

extra support:

• information brochure

http://www.health.govt.nz/publication/diabetes-pregnancyhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Parura%20Mowai%20Brochure.pdf



3. Family Start is an intensive home visiting programme that focuses on improving children’s growth and health, learning

and relationships, family circumstances, environment and safety:

• referral guide

• information brochure

• referral form

4. Whānau Ora Navigation Service

Whānau Ora Navigator / Kaiwhakārāra work alongside Whānau to identify their aspirations, strengths and chosen pathway using

the Te Ara Whānau Ora pathway. They support Whānau by providing coaching, advocacy and brokerage services:

• more information and referral

5. Pasifika Maternal Child Health Service

For Pasifika Mothers and Children aged 0-16 years:

• help with health & wellness

• eczema and asthma

• immunisations

• diet & nutrition

• pregnancy/breastfeeding support

• birth control

• help pregnant mums find a midwife or Lead Maternity Carer (LMC)

• cervical screening

• more information and referral

18. Medication review and prescribing supplements

Medication Review

Questions about the safety of medicines in pregnancy arise when a pregnant woman is already taking an established treatment, or

when a new medicine is being considered to treat a condition that occurs during pregnancy. An accurate list of medicines, doses and

frequency of doses should be obtained from women in the pre-conception stage. This list should include all prescription medicines

as well as complementary medicines (over the counter medicines, herbal medicines, vitamins and minerals) and recreational drug

use. It is important that the risks and benefits of all medicines are assessed and medicine adjustments made to safer alternatives as

part of the planning process.

The medicine's Safety Data Sheet usually contains some information about use during pregnancy but this is often insufficient to

guide decision making. If the medicine is known to be teratogenic in humans or contraindicated in pregnancy this should be clearly

stated in the data sheet. The level of information required will depend on the clinical context. For more complex scenarios, the first

step may be to contact a specialist for advice about on-going management; e.g. a woman with depression or epilepsy.

For more routine questions, there are a number of quick reference resources available which provide useful guidance:

• the New Zealand Formulary

• Christchurch Drug Information (Clinical Pharmacology)

• Prescribing Medicines in Pregnancy (Therapeutic Goods Authority - Australia)

• Medsafe provides information on current safety concerns and updates to data sheets.

Drugs can have harmful effects on the embryo or fetus at any time during pregnancy. It is important to bear this in mind when

prescribing for a women of child-bearing age or for men trying to father a child. During the first trimester drugs can produce

congenital malformations (teratogenesis), and the period of greatest risk is from the third to the eleventh week of pregnancy. The

New Zealand Formulary classifies drugs according to the Australian categorisation system for prescribing medicines in pregnancy. A

database provides specific guidance on prescribing medicines during pregnancy.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/family-start-referral-guide.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Plunket%20Family%20Start%20brochure.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Plunket%20FamilyStart%20Referral%20Form.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/General%20Cancer%20docs/MC/Te%20Tihi%20Whanau%20Ora%20Navigation%20Service.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/General%20Cancer%20docs/MC/Pasifika%20Health%20Service%202016.pdfhttp://www.nzformulary.org/http://www.druginformation.co.nz/pregnancy.htmhttps://www.tga.gov.au/prescribing-medicines-pregnancy-databasehttp://www.medsafe.govt.nz/profs/datasheet/dsform.asphttps://www.tga.gov.au/prescribing-medicines-pregnancy-database



Prescribing Supplements

The following supplements are recommended for all women:

Folic acid:

• folic acid 0.8mg daily (if not already started)

• folic acid 5mg daily if any one of the following applies:

• if past history of neural tube defects

• family history of neural tube defects

• currently prescribed antiepileptic medication

Iodine:

Requirements for iodine increase in pregnancy due to a marked change in thyroid function. It is recommended that pregnant women

consume 150mcg per day of potassium iodide to prevent deficiency.

Vitamin D:

During pregnancy, women at higher risk of becoming deficient in vitamin D are those who:

• have darker skin - this includes many women from Africa, the Indian subcontinent and the Middle East as well as some Maori

and Pasifika women

• completely avoid sun exposure for religious, personal or medical reasons; for example, women who are covered by veils

and clothing over the whole body because they have had skin cancer, skin damage from the sun or are on photosensitising

medications

• have liver or kidney disease, or are on certain medications (e.g. anticonvulsants) that affect vitamin D levels

In general, testing of asymptomatic pregnant women is not recommended. Supplements should be prescribed based on the risk of

vitamin D deficiency (as identified above). Supplementation is not recommended when hypercalcaemia, hypervitaminosis D or renal

osteodystrophy with hyperphosphataemia is present. Care should be taken when considering supplementation in the presence of

atherosclerosis or cardiac function impairment, hypersensitivity to vitamin D, renal function impairment, or sarcoidosis.

19. Screening for chromosomal abnormalities

First trimester combined screening

This occurs between 9 and 13 weeks, 6 days and women have the option to have combined screening for chromosomal

abnormalities, including Down Syndrome. This gives a more accurate screening result than a scan on its own:

• blood test MSS1 - (9-13 weeks, 6 days) and measures the pregnancy associated plasma protein-A (PAPP-A) and beta human

chorionic gonadotrophin (BhCG)

• nuchal translucency screening (scan 11-13 weeks, 6 days) - measures the thickness of the fluid filled space at the base of the

baby's neck

Second trimester maternal serum screening (MSS2):

• blood test (14-20 weeks) - tests four different substances in the woman's blood

Information for pregnant women to help them make an informed decision about optional screening and testing for Down Syndrome

and other conditions

20 Mental Health

Specialist Perinatal Mental Health Service

In considering what community support may be helpful think about:

• practical support



• social support

• family support

• parenting support

• cultural support

• emotional support

• counselling and/or psychotherapy for specific issues:

• grief

• abuse

• trauma

• loss

• self esteem

• helplines:

• plunket

• health line

• listening agencies: • samaritans

• lifeline

GP services are the ideal point of health care contact for a woman and/or family as they are the key providers of primary care.

In the first instance, for women with mild-moderate mental health concerns, they can instigate appropriate treatment (consulting

with PMHS if necessary), refer if needed to secondary and tertiary services; and provide a point-of-contact for discharge letters/

arrangements. This allows integrated care to be delivered between services.

21. Diet and exercise

Diet and Exercise:

• all pregnant women should be weighed and have their weight recorded at routine antenatal appointments

• all pregnant women should be offered information covering the role of a healthy, balanced diet, body weight and exercise,

including advice to be physically active for at least 30 minutes per day, most days of the week (New Zealand Physical Activity

Guideline, 2001)

• all pregnant women should be advised on avoiding excessive weight gain throughout their pregnancy (Ministry of Health, 2014)

• recreational exercise such as swimming or brisk walking and strength conditioning exercise is safe and beneficial

• the aim of recreational exercise is to stay fit, rather than to reach peak fitness

• if women have not exercised routinely they should begin with no more than 15 minutes of continuous exercise, three times per

week, increasing gradually to daily 30-minute sessions

• if women exercised regularly before pregnancy, they should be able to continue with no adverse effects

• explain to those women who would find this level of physical activity difficult that it is important not to be sedentary, as far as

possible. Encourage them to start walking and to build physical activity into daily life, for example, by taking the stairs instead of

the lift, rather than sitting for long periods

• the healthy lifestyle message should continue after birth

There are certain foods that need to be avoided during pregnancy; some may harm an unborn baby, while others can make pregnant women feel unwell, which can be difficult to cope with whilst pregnant. Refer to the Food Safety Chart for guidance.

Healthy Weight Gain in Pregnancy:

Achieving optimal weight gain during pregnancy is associated with improved outcomes for the mother and the baby regardless of the

mother's existing body mass index (BMI). Excessive gestational weight gain (GWG) increases maternal risk for:

• pre-eclampsia

• gestational diabetes

• caesarean section

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Food%20Safety%20Chart.pdf



• weight retention postpartum with associated long-term health consequences

All women of childbearing age should have their weight and height measured and documented and body mass index (BMI)

calculated as part of routine pre-pregnancy clinical practice and advice should be given that is consistent with the Weight

Management Guidelines for Adults

22. Advise and support smoking cessation

Advise and support smoking cessation

• pregnant women expect clear, honest and non-judgemental communication about smoking

• there is often a higher uptake of cessation support during pregnancy

• strongly recommend that all pregnant women who smoke use a stop-smoking service to help them stop; and make a referral as

appropriate:

• the Stop Smoking Support pathway lists local stop smoking services and referral information

• continue to offer smoking cessation support throughout the pregnancy to all pregnant women who continue to smoke

• postnatal relapse is common in women who stop smoking during pregnancy. These women may benefit from referral to a stop-

smoking service around the time of the birth to help them remain smoke free.

Key message is: "...when you smoke, your baby smokes..."

When a pregnant woman smokes, two individuals are exposed to the substances in tobacco smoke, the smoker and the unborn

child. Smoking increases the woman's risk of:

• miscarriage

• bleeding

• waters breaking earlier (as a result the unborn baby may be born with an infection)

• premature birth

• baby dying just before or after birth

• baby dying from sudden unexpected death of an infant (SUDI)

• baby being growth restricted rather than normal weight

Second hand smoke - it is important to involve the entire family. Woman are able to minimise exposure to secondhand smoke by:

• making the home and car completely smoke-free

• encouraging family and friends to go outside if they want to smoke

• avoiding, where possible, environments where other people have been or are smoking

• encouraging any smokers that the woman lives with to get help to quit

Use of patches, gum and lozenges

Pregnant and breastfeeding woman can still use nicotine patches, gum and lozenges. These products expose the foetus to lower

levels of nicotine than from smoking and there is no exposure to the other toxic components of tobacco smoke. Prescription tablets

that assist with smoking cessation are not recommended during pregnancy.

23. Alcohol and substance misuse during pregnancy

Alcohol during pregnancy

Drinking alcohol during any stage during pregnancy can affect the development of the unborn baby. The most extreme consequence

of alcohol affecting the fetus is a miscarriage or stillbirth.

In other cases, the baby can be born with significant permanent effects.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/healthy-weight-gain-in-pregnancy-record-lmc-quick-reference-guide-jun14.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/healthy-weight-gain-in-pregnancy-record-lmc-quick-reference-guide-jun14.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/healthy-weight-gain-in-pregnancy-record-lmc-quick-reference-guide-jun14.pdfhttp://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking



Drinking alcohol during pregnancy can result in one or more of a spectrum of disabilities (physical, psychological, behavioural),

which are described by the umbrella term of fetal alcohol spectrum disorder (FASD). Some of the more severe outcomes can include

growth deficits, facial malformations, and brain and central nervous system disorders [2]. It is important to avoid making assumptions

about drinking behaviour based on a women's socioeconomic status, education or ethnicity, as alcohol use during pregnancy

crosses all socioeconomic, educational and ethnic boundaries. There are however, some groups of women for whom it is particularly

important to ask about alcohol use during their pregnancy. These include:

• women with a history of risky drinking and who have an unplanned pregnancy

• women who already have a child with FASD

• women who have FASD themselves

The following three-step process can be used as an intervention guide when working with women who are planning a pregnancy or

who are pregnant:

1. Ask about alcohol use, and record and assess the level of alcohol consumption

2. Advise about not drinking alcohol if a woman is planning to be, or is, pregnant and explain why

3. Assist women to stop drinking alcohol while pregnant, and arrange referrals to addiction treatment services for those

who are unable to stop.

Alcohol can affect a developing baby throughout pregnancy including before a woman knows she's pregnant. There is no

known safe amount and no known safe time to drink during pregnancy.

Referral to Alcohol Cessation Services

Alcohol Drug Helpline - 0800 787 797

• available 10am - 10pm seven days per week

• an information, referral and intervention service that offers free, confidential information, help and

support

National Addictions Treatment Directory

• contains a regionalised database of all addiction treatment and advice services available in New Zealand

• provides information on how to access, and the referral process for, each service, including self-help groups

24. Nausea and vomiting

Nausea and vomiting in pregnancy:

• usually resolves completely within 16-20 weeks gestation:

• 90% of cases resolve by 16 weeks

• incidence of hyperemesis gravidarum is around 0.5-2% of pregnancies

• is not usually associated with poor pregnancy outcome

Management of nausea and vomiting:

• advise:

• rest and drinking little and often

• eating small, frequent meals high in carbohydrate and low in fat - cold meals may be more easily tolerated if nausea is smell-

related

• eating plain biscuits about 20 minutes before getting up

• avoiding any foods or smells that trigger symptoms

• avoiding drinking cold, tart, or sweet beverages

• provide information about self-help and non-pharmacological treatments

• the following treatments have been found to be effective for reducing symptoms:

http://www.health.govt.nz/system/files/documents/publications/alcohol-pregnancy-practical-guide-health-professionals.pdfhttp://alcoholdrughelp.org.nz/Directory/



• P6 (wrist) acupressure

• antihistamines (promethazine, prochlorperazine, metoclopramide)

• ginger

• vitamins B12 and B6 (consider toxicity of B6)

If not settling with conservative means, consider rehydration through POAC (see Acute Rehydration in Adults pathway). For more

severe cases, refer to Nausea and Vomiting in Pregnancy pathway.

Advise seeking urgent medical advice if:

• very dark urine, or no urination for more than 8 hours

• abdominal pain or fever

• severe weakness or feeling faint

• vomiting blood

• repeated, unstoppable vomiting

• inability to keep down food or fluids for 24 hours

Discourage use of over-the-counter (OTC) remedies (e.g. herbal remedies, multivitamins, pyridoxine) as their safety and

efficacy has not been established during pregnancy. Other common pregnancy related symptoms during pregnancy

include:

• dyspepsia and reflux

• constipation

• varicose veins

• vaginal discharge

• backache

• urinary incontinence

• pelvic pain

Hyperemesis gravidarum:

• defined as fluid and electrolyte disturbances or nutritional deficiency from intractable vomiting developing early in pregnancy

• consider thromboprophylaxis

• usually requires hospital admission

Management of hyperemesis gravidarum:

• refer to Gynaecology Clinic for MidCentral

• refer to ED for Whanganui

25. Referral to Mental Health Service

Specialist Perinatal Mental Health Service (SPMH) four box referrer’s guide and contact details.

27. Employment and pregnancy

There are a number of entitlements through different government agencies that can make the balancing of family and work life

easier:

• parental leave fact sheet

• flexible working arrangements

• rest and meal breaks

• special leave of up to 10 days can be taken by a mother before maternity leave for reasons connected with pregnancy (e.g.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Perinatal%20Mental%20Health%20Referral%20Guide__2381.pdfhttps://www.employment.govt.nz/workplace-policies/productive-workplaces/flexible-work/benefits-rights-and-responsibilities/https://www.employment.govt.nz/hours-and-wages/breaks/rest-and-meal-breaks/



antenatal checks) - this type of leave is unpaid

28. Exposure to infectious diseases

Exposure to infectious diseases

Influenza

• flu injection is safe to be given at any stage of pregnancy or when breastfeeding

• funded during pregnancy (available from 1 April each year)

• offers passive immunity to baby in the first six months when most vulnerable

• decreases likelihood of low birth weight

Whooping Cough

• immunisation is strongly recommended for pregnant woman for each pregnancy; it is recommended that partners and family

members/friends are immunised particularly if they will be in close contact with the newborn

• Tdap between 28-38/40 weeks

• provides passive immunity to baby in the first six months when most vulnerable

Measles

• live vaccine

• not given in pregnancy

• avoid pregnancy for one month after vaccination given

• safe to be given to breastfeeding woman

• if not immune, and exposure occurs during pregnancy, offer HNIG within 6/7 through Infectious Disease Specialist/Paediatrician

Chicken Pox

• every effort should be made to confirm the diagnosis in the suspected positive contact and assess significance of exposure

• exposure or symptoms in the final two weeks pregnancy should always be discussed with a specialist

Zika Virus

• pregnant women who become infected with Zika can transmit the disease to their unborn babies, with potentially serious

consequences

• there is no vaccine for Zika virus - the best way to prevent infection is to avoid being bitten

• pregnant woman should consider delaying travel to an affected area

• all men who have travelled to a Zika-affected area should abstain from sexual activity (oral, vaginal, or anal) or use condoms for

the duration of the pregnancy, even if they do not have symptoms

29. Travel and pregnancy

Pregnancy and Travel

Pregnancy is not a barrier to air travel for healthy woman with uncomplicated pregnancies. Air travel is generally the safest in the

second trimester. Airlines have individual policies on pregnant passengers and in some cases, the woman's Lead Maternity Carer

(LMC) may be required to provide written verification that the woman is fit for travelling:

• Air New Zealand

• Virgin Australia

• Qantas Airways

http://www.bpac.org.nz/BPJ/2012/April/influenza.aspxhttp://www.bpac.org.nz/BPJ/2014/April/pertussis.aspxhttp://www.bpac.org.nz/BPJ/2014/September/measles.aspxhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Womens%20Health/Early%20Pregnancy/Management%20of%20pregnant%20women%20exposed%20to%20varicella%20or%20zoster.pdfhttp://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/zika-virushttp://www.bpac.org.nz/BPJ/2011/december/travellers.aspxhttp://www.airnewzealand.co.nz/special-assistance-travelling-when-pregnanthttp://www.virginaustralia.com/au/en/plan/special-needs-assistance/flying-while-pregnant/http://www.kidsonaplane.com/qantas-flying-with-children-policy/#Mother



Early Booking in Pregnancy – First Trimester

Provenance Certificate

Overview

Overview | Editorial methodology | References | Contributors | Disclaimers

This document describes the provenance of MidCentral District Health Board’s Early Booking in Pregnancy – First Trimester pathway.

This localised pathway was last updated in October 2017.

One feature of the “Better, Sooner, More Convenient” (BSMC) Business Case, accepted by the Ministry of Health in 2010, was the development of 33 collaborative clinical pathways (CCP).

The purpose of implementing the CCP Programme in our DHB is to:

• Help meet the Better Sooner More Convenient Business Case aspirational targets, particularly the following:

o Reduce presentations to the Emergency Department (ED) by 30%

o Reduce avoidable hospital admissions to Medical Wards and Assessment Treatment and Rehabilitation for over-65-year-olds by 20%

o Reduce poly-pharmacy in the over-65-year-olds by 10%

• Implement a tool to assist in planning and development of health services across the district, using evidence-based clinical pathways.

• Provide front line clinicians and other key stakeholders with a rapidly accessible check of best practice;

• Enhance partnership processes between primary and secondary health care services across the DHB.

To cite this pathway, use the following format:

Map of Medicine. Medicine. MidCentral District View. Palmerston North: Map of Medicine; 2014 (Issue 1).

Editorial methodology

This care map was based on high-quality information and known Best Practice guidelines from New Zealand and around the world including Map of medicine editorial methodology. It has been checked by individuals with front-line clinical experience (see Contributors section of this document).

Map of Medicine pathways are constantly updated in response to new evidence. Continuous evidence searching means that pathways can be updated rapidly in response to any change in the information landscape. Indexed and grey literature is monitored for new evidence, and feedback is collected from users year-round. The information is triaged so that important changes to the information landscape are incorporated into the pathways through the quarterly publication cycle.



References

This care map has been developed according to the Map of Medicine editorial methodology. The content of this care map is based on high-quality guidelines and practice-based knowledge provided by contributors with front-line clinical experience. This localised version of the evidence-based, practice- informed care map has been peer-reviewed by stakeholder groups and the CCP Programme Clinical Lead.

1 http://www.bpac.org.nz/BPJ/2011/april/preconception.aspx

2

Ministry of Health. 2014. Diabetes in Pregnancy: Quick reference guide for health professionals on the screening, diagnosis and treatment of gestational diabetes in New Zealand. Wellington: Ministry of Health. http://www.health.govt.nz/publication/diabetes-pregnancy

3

Ministry of Health. 2012. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). Wellington: Ministry of Health. http://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf

Contributors

MidCentral DHB’s Collaborative Clinical Pathway editors and facilitators worked with clinical stakeholders such as front-line clinicians and pharmacists to gather practice-based knowledge for its care maps.

The following individuals have contributed to this care map:

• Cheryl Benn, Regional Midwifery Director/LMC (Secondary Care Clinical Lead)

• Dawn Jacobs, LMC, MidCentral DHB

• Linda Findlay, LMC, Whanganui

• John McMenamin, GP, Whanganui

• Rashmi Singh, GP, MidCentral (Primary Care Clinical Lead)

• Ray, Project Director, Collaborative Clinical Pathways, Health Care Development (Editor)

Disclaimers

Clinical Board Central PHO, MidCentral DHB

It is not the function of the Clinical Board Central PHO, MidCentral DHB to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness and completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date.
http://www.bpac.org.nz/BPJ/2011/april/preconception.aspxhttp://www.health.govt.nz/publication/diabetes-pregnancyhttp://www.health.govt.nz/system/files/documents/publications/referral-glines-jan12.pdf