MATERNITY HOSPITAL IN THE HOME (M-HITH)

Education Presentation By Sabine Kahwati RM. EN.

Updated 08/05/2019

OBJECTIVES

• Background

• Key Aspects

• Midwifery Responsibilities: Women’s Services

• Midwifery Responsibilities: AMUM

• Midwifery Responsibilities: WHU

• Oxygen Saturation Screening

• Midwifery Responsibilities: M-HITH/MHC Coordinator

• Midwifery Responsibilities: M-HITH Daily Home Visit Activities

• Ward Clerk Responsibilities

• Clinical Practice Guidelines

• Additional Inclusion Criteria

• Summary

• References

BACKGROUND

• Evidence supports the early discharge from hospital of well mothers and term babies.

• When early discharge is supported with adequate follow-up home visits, maternal re-admissions and maternal depression are not statically different and breastfeeding rates are not statically altered (Brown et al. 2002, Goodwin et al. 2018 and Winterburn & Fraser, 2001).).

• The Women’s currently discharges well women and babies home after 24 hours, this includes instrumental births if there are no co-morbidities and women with PPH of less that 750mls.

• Monash Health transfers well women into M-HITH between 6-24 hours post birth.

• King Edward Memorial Hospital transfers well women and babies to home between 4-24 hours post birth.

M-HITH AT PENINSULA HEALTH

• Women who meet M-HITH criteria will be transferred home for care where they will receive 1-2 MHITH visits.

• They will then be discharged from M-HITH and followed-up by MHC as per our usual practice.

• M-HITH provides women with an additional layer of service and support at home between leaving the hospital and MHC visits.

• Over the coming weeks and months, PH will implement “same day” and “one day transfers” into M-HITH as a standard practice

that will apply to both primigravida and multigravida who fulfil the inclusion criteria and consent to accessing M-HITH service.

KEY ASPECTS

• M-HITH supports the early return of low risk mothers and babies to their own home with access to midwifery and medical support as an admitted patient.

• All women who are low risk, wish to go home before one midnight or after one midnight and consent to M-HITH should be referred to M-HITH.

• M-HITH does not apply to women who stay 2 midnights.

• M-HITH does not apply for women who “Discharge against medical advice.”

• Transfers that occur without a midnight stay are “same day transfers” and M-HITH may visit up to two times.

• Transfers that occur after one midnight are “one day transfers” and M-HITH may visit once.

• Women are transferred into M-HITH and remain a patient until discharged by M-HITH to MHC.

• Maternal ID labels must remain on and intact until discharge from M-HITH.

• If re-admission is required, women may be admitted direct to the WHU ward.

• Babies are discharged from WHU at time of maternal transfer and any neonatal re-admissions are via the Emergency Department.

KEY ASPECTS

• M-HITH may include the administration of medication as per HITH responsibilities, however as we anticipate only healthy women and babies will participate in M-HITH and that medications should not be required.

• 24 hour phone contact is available for M-HITH patients, between 8:00 and 16:00 the MHC coordinator will answer calls on the mobile phone number 0409 689 104 and between 16:00 to 8:00 the Inpatient AMUM will answer calls on 9784 8311.

• There is a new ward “Maternity HITH” access is via the spanner icon on Clover in your patient list. Please add to your existing lists. Add list flow: spanner>new>location>locations>FRANKSTON HOSPITAL>Frankston Hospital>Maternity Hospital in the Home>+>tick>finish>highlight>arrow over to list.

• Maternal and neonatal observations are required for 48 hours post birth.

MIDWIFERY RESPONSIBILITIES - WOMEN’S SERVICES

• Discuss M-HITH with women antenatally at the booking in appointment, 32 week visit and during antenatal appointments where appropriate. Please provide mothers with the M-HITH brochures if they are available.

• M-HITH is suitable for both primigravida’s and multigravida’s.

• Women having their first baby should be advised that they if they have an uncomplicated birth and are breast feeding well, that they can go home between 6-48 hours after a NVD.

• Women who have previously had a baby, an uncomplicated birth should be advised that they can return home between 6-24 hours after birth.

• After birth women who have risk factors may also be suitable for M-HITH services however, Midwifery and Obstetric clearance is required for maternal and neonatal conditions. Advise women that M-HITH will be discussed with them after delivery.

MIDWIFERY RESPONSIBILITIES- WHU AMUM’S

• Identify and assess patients that are suitable for M-HITH.

• Ensure there are midwives available for home visits. This requires liaising with M-HITH/MHC coordinator via phone or face to face.

• Keep the M-HITH/Inpatient Journey board up to date, include the black M-HITH “Pending” magnets to highlight potential transfers and the white M-HITH “Confirmed” magnets to highlight accepted transfers. This assists with the prioritisation of M-HITH transfers and assists the M-HITH/MHC coordinators when they visit the ward.

• Between 16:00 to 8:00 the Inpatient AMUM will answer calls. Phones should be attended and not diverted during these times. Phone contact is expected to be infrequent and should not affect work load.

• Re-admissions if required. Reasons for re-admissions should be discussed with Drs.

• Beds will not be held for M-HITH patients, it is expected that re-admission rates will be low.

• Complete handovers between M-HITH and WHU.

MIDWIFERY RESPONSIBILITIES - WHU

• Discuss M-HITH with women antenatally where appropriate, at the booking in appointment, 32 week visit (provide brochure if requested/available), during antenatal outpatient assessments and in the labour ward.

• Discuss transfers with AMUM, ensure there is a visit available and gain maternal consent.

• Complete the consent form for M-HITH in the maternal pathway, this requires Mother and Midwife to sign.

• Complete the M-HITH referral form in the maternal pathway for midwife to sign.

• Complete the Home Screening Tool, this is a new form for all maternal pathways, clinician to complete both sides.

• Complete the newborn examination and O2 saturations at or near to 6 hours post birth but no earlier that 4 hours post birth.

• Advise the Victorian Infant Hearing Screen Program that there is a M-HITH transfer pending so they can prioritise a check. If they are unavailable, please provide a “Sorry we missed you” and “Your baby’s hearing screen” brochure to mothers in the green book. These are located on the Hearing Screen office door in the hallway next to the main tea room.

• There are black M-HITH folders with white M-HITH appointment slips and universal M-HITH/MHC Home Care Check Lists. Please include BOS Summary, M-HITH appointment slip (white), BF and relevant information in green book when transferring. When providing the patient information to the Ward Clerks, please inform them that this is a M-HITH transfer so they can prioritise the transfer. The black folders are only to be used for M-HITH.

MIDWIFERY RESPONSIBILITIES -WHU

• Check maternal ID wrist labels and advise mothers that ID labels must remain on and intact until discharge from M-HITH.

• Maternal and Victor observation charts are included in transfer documentation. Maternal and neonatal observations are required for 48 hours post birth.

• Complete BOS summary, discuss with woman and place it in the green book.

• For the mother enter Discharge Destination to Home and Expected Home Care is Maternity HITH, enter same level of care as the Reason.

• For the baby, enter Discharge Destination to Home and Expected Care as DOM.

• Neonatal Pathways: Please complete as per the usual practice. Sign the discharge section on page 1.

• In the black M-HITH folder, there should be the following items only: M-HITH Checklist, Mother/Baby Identification Labels, Maternal and Neonatal pathways, Maternal and Victor observation charts.

• “Team” folders are black with a purple spine, if a women is in Team services, please use this folder for your referral information. Team women should be seen by Team midwives for M-HITH.

MIDWIFERY RESPONSIBILITIES –WHU HOME/COMMUNITY VISIT RISK SCREENING TOOL

• This tool is for every woman being discharged or transferred regardless of mode of birth.

• Caesarean section pathway will be updated shortly. Please ensure the new tool is inserted into pathway.

• Copies are located in dock 8 of the information wall in the inpatient midwifery station.

• Clinician to complete both sides of form and sign.

• It is for both M-HITH and for MHC.

• It replaces the old screening tool.

• Alerts to be checked on Clover under allergies.

• High Risk Accommodation list OTH-001 refers to housing risks, such as not fixed address, homelessness, couch surfing etc.

• We do not have access currently, housing issues are handed over.

• Risk of concerns must be noted and control measures discussed with AMUM.

• AMUM is the line manager and must approve control measures (interventions to reduce risk).

• Evidence of currency to be completed at transfer or discharge and by MHC or M-HITH midwife each visit.

• If tool not current, eg risk occurs, a new tool must be completed.

http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17836107\18348933\35799280.pdf

MIDWIFERY RESPONSIBILITIES –WHU MATERNAL EDUCATION

• On page 1 of the Maternal pathway, please ensure the following sections are complete:

• Tick M-HITH Referral

• Provide BFSS/BF drop in centre brochures and discuss.

• Medication for discharge.

• Educate women about normal feeding, signs of milk transfer, safe feeding in bed, demonstrate attachment, provide Safe Storage of EBM brochure.

• Discuss; signs of DVT, infection, peri/wound care, normal lochia, SIDS, BOS, green book, M-HITH, MHC.

• Advise follow-up appointments.

• Demonstrate AF and provide formula booklet if requested/required.

• We are transferring women to Hospital in the Home for care, you do not need to complete all the information on the first page or sign it, you are not discharging the women. M-HITH is able to complete the education.

• Include the white M-HITH appointment slip in the green book, all appointments are generally next day. Phone numbers on the slip are for M-HITH only, they are priority service numbers and apply for care given during M-HITH only.

MIDWIFERY RESPONSIBILITIES –WHU M-HITH REFERRAL/ADMISSION

• Please fully complete the M-HITH referral/admission in the Maternal Pathway.

• This is an important document required to obtain funding for the M-HITH service.

• All the requested information on this form must be filled in by the WHU midwife.

• Please do not write “see previous notes” or “see screening tool.”

• Referral source is the midwife referring.

• LMO is the woman's local medical officer or GP.

• Approximate length of treatment is how many visits.

MIDWIFERY RESPONSIBILITIES –WHU PATIENT CONSENT TO M-HITH

• Please ensure the patient consent form is complete.

• Patient must read document.

• Patient and midwife to sign.

• Patient to identify “self” as relationship to patient.

Patient to write own name

Patient to sign, write name and write “self” as relationship

Midwife to sign, write name, designation, date and time.

OXYGEN SATURATION SCREENING

• Safe Care Victoria recommends that oxygen saturation on neonates should be completed 24 hours after birth for optimal results.

• They advise that if required, early oxygen saturation testing can be completed at 6 hours post birth but no earlier than 4 hours post birth.

• Oxygen saturation screening prior to 24 hours may relate to transitional circulation and result in a false positive test.

• For infants discharged before 4 hours who pass the saturation screening test and have a normal newborn examination, no further screening is necessary.

• If an infant fails the oxygen saturation screen, please report it to your AMUM and the Paediatricians. A review may be required and a repeat or later oxygen saturation screening test.

https://bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/oxygen-saturation-screening-for-newborns

MIDWIFERY RESPONSIBILITIES- M-HITH/MHC COORDINATOR

• Discuss M-HITH availabilities with WHU and arrange M-HITH home visits.

• Transfer patient information between M-HITH and WHU and participate in handover with WHU AMUM.

• Report health concerns to WHU AMUM, Obstetric and Paediatric Drs.

• Enter the women onto the Don Nel system as next contact ‘M-HITH’ and add the day of the week as required.

• Discharge women from M-HITH to MHC on iPM. (Or with the Ward Clerks until access to iPM is arranged). Women will be ‘Discharged from M-HITH’ on iPM with ‘Further Care’ item to be identified as ‘Domiciliary Postnatal Care’. The midwife then documents the date and time of discharge from M-HITH on the Vaginal Birth Care-Map. A brief summary of any complications or investigations while on M-HITH will be recorded in the progress notes on the relevant day of the procedure in the Vaginal Birth Care-Map.

• Record subsequent Midwifery Home Care (MHC) visits on Don Nel as ‘DOM’

• Ensure that there is a completed referral and consent signed for every women accepted into M-HITH.

• Provide prepared black M-HITH folders to WHU.

MIDWIFERY RESPONSIBILITIES- M-HITH- DAILY HOME VISIT ACTIVITIES

Maternal and neonatal observations are required for 48 hours post birth.

• Advise women when M-HITH will cease and when MHC will commence, provide appointment time for MHC on the blue slip. Also educate women to use the MHC phone numbers after M-HITH.

• Report health concerns to M-HITH Coordinator and WHU AMUM, Obstetric and Paediatric Drs.

• Monitor vital signs for mother and baby as indicated per inpatient care map.

• Full maternal check head to toe assessment including perineal check, VTE risk, uterine involution, lochia and emotional and social wellbeing. Complete maternal and neonatal education in pathways.

• Breastfeeding assessment – including observation of breast-feed if possible to evaluate stage of onset of lactation, milk transfer, urine and bowel output of baby.

• Full neonatal check including general newborn behaviour, colour including jaundice check, any indication for paediatric referral.

• Education and support with breastfeeding, general self and newborn care which may include bathing, expressing breast milk, formula demonstration normal newborn behaviour and safety in the home.

• Transfer M-HITH documentation from the black M-HITH folders to the blue MHC folders.

• Complete the Home Screening Tool each visit. If there are changes to the risk factors ensure a new tool is completed.

WARD CLERKS

The Ward Clerk or Inpatient AMUM using iPM is to:

• Mother is ‘Transferred’ to the Maternity HITH ward ‘MHITH’ on iPM

• Baby is ‘Discharged’ home with ‘Further Care’ to be entered as – ‘Other Clinical/ Support services’ and ‘ General Practitioner’ (tick both options)

• Ward Clerk Admission/Discharge Book Names of Women transferred to M-HITH to be written on Discharge sheet in new M-HITH section at bottom of page. H-HITH patient information is placed in cream manila folders and then in the M-HITH basket for transfer to MHC located on the MHC trolley. Maternal and neonatal observation charts must be included for M-HITH patients. WHU midwives will place M-HITH documentation in the black transfer folders.

• Ward Clerks please prioritise M-HITH transfers.

• Referrals Close Antenatal referrals on iPM as per normal discharge process.

• Summary is to be sent to GP as per usual discharge process.

• Access to iPM is being arranged for M-HITH, until it’s completed, Ward Clerks may need to assist in patient discharges from M-HITH to MHC on iPM.

M-HITH GUIDELINE 1: ENSURE WOMAN MEETS CRITERIA CARE

For “SAME DAY” access to M-HITH:

• Woman is going home ‘same day’ (in and out prior to midnight) and may receive up to two M-HITH visits at home prior to discharge to MHC.

OR

For “ONE DAY” access to M-HITH:

• Woman is going home ‘one day’ after giving birth (in before midnight the first day and out before midnight the next day) and may receive one M-HITH visit at home prior to discharge to MHC.

M-HITH access is arranged around the midnights stayed, not the hours stayed in hospital. A women who has stayed one midnight can still receive a M-HITH referral if she is transferred to M-HITH before the second midnight.

M-HITH GUIDELINE 2: CRITERIA FOR M-HITH CARE

• Woman and baby have low risk for postnatal complications and do not require observations other than routine e.g Meconium exposure or GBS, post epidural observations (note following completion of observations for meconium, GBS with adequate antibiotic cover following paed review, or epidural mother and baby will be suitable for one day M-HITH).

• Note: Women who have had an epidural may be transferred after 12 hours and may be suitable for same day or one day transfer.

• Midwife or medical staff agree the woman is suitable for M-HITH.

• Woman consents to M-HITH.

• Staff availability to visit the following day.

• Midwife completes the M-HITH admission and consent and circles M-HITH on the Vaginal Birth Care-Map.

• Woman is not discharged on iPM and retains her patient ID label.

• Baby examination completed.

• M-HITH is ideal for low risk women however women may also access M-HITH in the following circumstances after consultation with AMUM/Drs:

• Women who have an epidural in labour may be suitable for M-HITH after 12 hours post the epidural catheter removal provided they have voided within 6 hours and: -Epidural catheter insertion site must be viewed. -Must have documented return of lower limb function (tone, power, sensation, strength). -Must have had an uncomplicated epidural insertion. -Dural/intrathecal insertion must stay until reviewed by anaesthetics/acute pain service. Please document information in the maternal pathway.

• Infants with meconium stained liquor require 24hr observations and may qualify for “one day transfer”

(Peninsula Health Management of Meconium Stained Liquor Clinical Practice Guideline, 2016).

• Women with GBS positive swab that have adequate intrapartum antibiotic prophylactic cover require 48hr observations, however may qualify for “one day transfer” after 24 hrs if they are 38 or more weeks gestation, have had 4 or more hours of antibiotic intrapartum prophylaxis, if other discharge criteria is meet and there is a person able to comply fully with instructions for home observations will be present. (Peninsula Health Group B Streptococcus Clinical Practice Guideline, 2017).

• Women who are stable GDM on Diet require 24hr BGL’s, x3 infant BGL’s above 2.6mmol/l and may qualify for “one day transfer” (Peninsula Health Diabetes in Pregnancy Clinical Practice Guideline, 2017).

• Women who are stable GDM on Insulin require 48hr BGL’s, x3 infant BGL’s above 2.6mmol/l, can complete and document their own BGL’s for 48hrs post birth. They may qualify for “one day transfer” after Obs review.

• PPH <750mls with stable observations, may qualify for “one day transfer” after Ob’s review.

WOMEN WHO MAY ALSO BE SUITABLE FOR M-HITH

M-HITH GUIDELINE 3: ON IPM (INPATIENT MANAGEMENT SYSTEM)

There is a new MHITH ward on iPM active now that you can add to your ward list. The Ward Clerk or Inpatient AMUM using iPM is to:

• Mother is ‘Transferred’ to the Maternity HITH ward ‘MHITH’ on iPM

• Baby is ‘Discharged’ home with ‘Further Care’ to be entered as – ‘Other Clinical/ Support services’ and ‘ General Practitioner’ (tick both options)

• Ward Clerk Admission/Discharge Book Names of Women transferred to M-HITH to be written on Discharge sheet in new M-HITH section at bottom of page. Referrals Close Antenatal referrals on iPM as per normal discharge process.

• Summary is to be sent to GP as per usual discharge process.

M-HITH GUIDELINE 4: BOS

• Complete BOS Discharge Summary and

• Mother - Enter ‘Discharge Destination’ to ‘HOME’ and Expected Home Care is ‘Maternity HITH.’ Enter ‘same level of care’ as reason.

• Baby - Enter ‘ Discharge Destination’ to ‘Home’ ‘Expected Home Care’ is ‘DOM’

M-HITH GUIDELINE 5: HANDOVER

• The midwife in Women’s Health Unit (WHU) will hand over to the Midwifery Home Care (MHC) coordinator, who will enter the women onto the Don Nel system as next contact ‘M-HITH’ and add the day of the week as required.

• Women under M- HITH will remain on the WHU journey board until discharged to MHC. Women with a ‘same day discharge’ will receive 2 M- HITH visits prior to discharge to MHC. Women with a ‘one day discharge’ (overnight stay) will receive one M-HITH visit prior to discharge to MHC.

• After each M-HITH visit, the Maternal and Neonatal clinical pathways will be returned to the MHC basket on the WHU ensure continuity of care and facilitate documentation after hours should the woman phone the WHU Inpatient AMUM with any care concerns.

M-HITH GUIDELINE 6: M-HITH CARE REQUIREMENTS

M-HITH care requirements: Minimum daily visits are required in the initial 48hrs from birth to monitor physical, emotional and social wellbeing of the mother and her baby. This should include, but is not limited to:

• Vital signs for mother and baby as indicated per inpatient care map

• Full maternal check head to toe assessment including perineal check, VTE risk, uterine involution, lochia and emotional and social wellbeing

• Breastfeeding assessment – including observation of breast-feed if possible to evaluate stage of onset of lactation, milk transfer, urine and bowel output of baby.

• Full neonatal check including general newborn behaviour, colour including jaundice check, any indication for paediatric referral.

• Education and support with breastfeeding general self and newborn care which may include bathing, expressing breast milk, formula demonstration normal newborn behaviour and safety in the home.

• The visiting M-HITH midwife will report any maternal or neonatal concerns to the Obstetric or Paediatric medical staff via the MHC coordinator between 0800-1600hrs and to the WHU Inpatient AMUM 1600-0800hrs.

M-HITH GUIDELINE 7: M-HITH MIDWIFE REPORTING CONCERNS PATHWAY

M-HITH GUIDELINE 8: WOMEN IN M-HITH REPORTING CONCERNS PATHWAY

• Women will be advised that they can contact the MHC coordinator on 97842601 or 04090689103 with any concerns between 0800-1600hrs. The MHC coordinator will determine if the woman requires an additional home visit (if one has already occurred that day). Alternatively, the woman may be invited to hospital for review.

• Women will be advised that after business hours 1600-0800hrs they should call the WHU Inpatient AMUM phone (9784 8311) for triage and assessment. Women who require physical review will be asked to present to the WHU and not the emergency department.

• Women who require readmission are to be admitted directly to WHU and not via the emergency department.

• Babies who require review and possible readmission are required to present via the emergency department.

M-HITH GUIDELINE 9: DISCHARGE FROM M-HITH

• Women will be ‘Discharged from M-HITH’ on iPM with ‘Further Care’ item to be identified as ‘Domiciliary Postnatal Care’. The midwife then documents the date and time of discharge from M-HITH on the Vaginal Birth Care-Map. A brief summary of any complications or investigations while on M-HITH will be recorded in the progress notes on the relevant day of the procedure in the Vaginal Birth Care-Map.

• Record subsequent Midwifery Home Care (MHC) visits on Don Nel as ‘DOM’

SUMMARY

• All women who are low risk, wish to go home before one midnight or after one midnight and consent to M-HITH should be referred to M-HITH.

• Women who stay 2 midnights do not meet M-HITH inclusion criteria.

• Any women wishing to be transferred into M-HITH that have risk factors must be reviewed by our Obstetric Team and/or Paediatrics.

• M-HITH does not apply for women who “Discharge against medical advice.”

• Transfers that occur without a midnight stay are “same day transfers” and M-HITH may visit up to two times.

• Transfers that occur after one midnight are “one day transfers” and M-HITH may visit once.

• Women in M-HITH are admitted patients and maternal ID labels must remain on and intact until discharged from M-HITH.

• If re-admission is required, women may be admitted direct to the WHU ward.

• Babies are discharged from WHU at time of maternal transfer and any neonatal re-admissions are via the Emergency Department.

• Maternal and neonatal observations are required for 48 hours post birth.

• Clinical judgement should be used to refer and clear women for M-HITH. If you have concerns, please discuss individual circumstances with your AMUM and Dr’s.

REFERENCES

• Brown S, Small R, Argus B, Davis PG, & Krastev A. (2002). Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database of Systematic Reviews, Issue 3. Art. No: CD002958. DOI:10.1002/14651858. CD002958https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002958/full#

https://www.cochrane.org/CD002958/PREG_early-postnatal-discharge-from-hospital-for-healthy-mothers-and-term-infants

• Safer Care Victoria (2018). Oxygen saturation screening for newborns. Victorian Agency for Health Information, Victoria State Government. https://bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/oxygen-saturation-screening-for-newborns

• Goodwin L, Taylor B, Kokab F, & Kenyon S. (2018). Postnatal care in the context of decreasing length of stay in hospital after birth: The perspective of community midwives. Midwifery, volume 60, 36-40. DOI: 10.1016/j.midw.2018.02.006 https://www.midwiferyjournal.com/article/S0266-6138(18)30036-6/fulltext

• Winterburn S & Fraser R. (2001). Does the duration of postnatal stay influence breast-feeding rates at one month in women giving birth for the first time? A randomized control trial. Journal of Advanced Nursing Volume 32, Issue 5. DOI: 10.1046?j.1365-2648.200.01586.xhttps://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2648.2000.01586.x

• Peninsula Health - Clinical Practice Guideline - Diabetes in Pregnancy http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17862791\17863542\28849721.pdf

• Peninsula Health - Clinical Practice Guideline - Epidural Analgesia in Labour http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17862791\17863542\34961110.pdf

• Peninsula Health - Clinical Practice Guideline - Group B Streptococcus http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17862791\17863542\28853739.pdf

• Peninsula Health - Clinical Practice Guideline - Home/Community Visiting - Staff Safety http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17836107\18348933\35799280.pdf

• Peninsula Health - Clinical Practice Guideline - Management of Meconium Stained Liquor (MSL) http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17862791\17863542\21625893.pdf

• Peninsula Health - Clinical Practice Guideline - Maternity hospital in the Home http://prompt.phcn.vic.gov.au/Search/download.aspx?filename=17862791\17863549\44011836.pdf

REFERENCES