Clinical Programme

The 20-year old Monash Medical Centre has a most modern purpose-built neonatal facility. The entire floor on level 5 is dedicated to obstetric and neonatal care. Of the 5000 annual births at the Monash Medical Centre a high proportion are from high risk pregnancies referred for management, the estimated annual livebirth population served by Monash Medical Centre being 20,000-25,000. We have the major responsibility of providing tertiary neonatal care to the Southern Health Care Network in the State of Victoria. There are three other NICUs in the State: two in maternity hospitals and one in a children's hospital. About 1,000 neonates per year are admitted to the 50-bed Monash Neonatal Unit which has a floor area of about 1000 sq. metres (Appendix 1). Over 200 neonates receive assisted ventilation annually. Although the majority of admission are from inborn deliveries, the Monash Medical Centre admits outborn neonates from within the State via the Newborn Emergency Transport Service (NETS). Prof. Yu has been representing Monash Medical Centre on the NETS Advisory Committee of the Health Department of Victoria since 1977. A selective and preferential referral pattern of sick neonates to Monash Medical Centre from many paediatricians in the community and country areas, has already been established. The Growth and Development Clinic was established in 1979 by Prof. Yu to assess the long-term outcome of high-risk survivors (Appendix 2). It helps study infant development, determine the cause of disability and identify early those families in need of special assistance.

Monash Medical Centre is a general hospital with the University Departments of Obstetrics and Gynaecology as well as of Paediatrics on site. The obstetric and paediatric services have about 100 beds each. In the Monash University Department of Paediatrics, the senior academic staff have developed clinical and research programmes which contribute significantly to the department's perinatal-neonatal expertise. Dr Andrew Ramsden is in charge of the neonatal intensive care and follow-up programmes, Prof. Wei Cheng co-ordinates the neonatal paediatric surgical service. All have a substantial academic and research record. Unlike stand-alone NICUs in maternity hospitals, a full range of subspecialty paediatric services are available for the comprehensive care of the preterm or critically-ill neonate, including cardiology, nephrology, neurology, genetics etc. within the Department of Paediatrics. Unlike stand-alone NICUs in children's hospitals, comprehensive perinatal intensive care for the mothers, fetus and neonate can be provided within the one institution.

EDUCATION PROGRAMME

The Neonatal Critical Care Nursing Course (Appendix 3) has to date graduated over 150 specialists in neonatal nursing who at present can be found working in several Australian states, New Zealand and several countries in SE Asia. A number of nursing postgraduate students came sponsored by their own institutions or funded by scholarship, including several from Hong Kong, Malaysia and Singapore, and one from Beijing, China, who was awarded a United Nations Development Programme Scholarship for postgraduate studies at the Monash Neonatal Unit. Currently, this course is being run as a Graduate Diploma of Nursing (Neonatal Care), Centre for Graduate Studies in Clinical Nursing, Monash University.

In 1980, a postgraduate training programme was established for young paediatricians who wish to work as neonatologists (Appendix 4). The Monash Neonatal Unit offers postgraduate training which is accredited by the Royal Australasian College of Physicians to Advanced Trainees in Neonatal/Perinatal Medicine. In addition to Australian medical graduates, our neonatal programme has offered the opportunity for postgraduate neonatal training to 117 overseas medical graduates from 33 countries including Bangladesh, Belgium, Brunei, Canada, China, Egypt, Germany, Hong Kong, India, Indonesia, Iran, Japan, Kenya, Korea, Kuwait, Macau, Malaysia, Mauritius, New Zealand, Nigeria, Oman, Pakistan, Philippines, Poland, Saudi Arabia, Singapore, Sri Lanka, Switzerland, Taiwan, Thailand, United Kingdom, and the U.S.A. (Appendix 5). Over half of these overseas medical graduates were funded independently, being recipients of scholarships from their own universities or hospitals or governments, WHO, APSSEAR, AIDAB and NHMRC. A number of these neonatologists are now leading the development of perinatal-neonatal services in other Australian states or within their own countries.

Senior medical and nursing personnel from the Monash Neonatal Unit have also been invited as guest speakers and lecturers at conferences, postgraduate courses, universities and hospitals both within Australia and abroad. Over 180 overseas sponsored invitations for Prof. Yu have come from 38 countries: Belgium, Brazil, Brunei, Canada, China, Egypt, Fiji, France, Germany, Hong Kong, India, Indonesia, Iran, Ireland, Israel, Italy, Japan, Kenya, Korea, Macau, Malaysia, Nepal, New Zealand, Pakistan, Philippines, Poland, Portugal, Saudi Arabia, Singapore, South Africa, Spain, Sri Lanka, Taiwan, Thailand, The Netherlands, United Arab Emirates, United Kingdom and the USA.

In addition to bedside and other informal teaching activities in the Monash Neonatal Unit, regular neonatal-perinatal educational sessions are held in Monash Medical Centre:

* Neonatal Teaching. On a weekly basis, one-hour lectures or group discussions are conducted by neonatologists for neonatal medical and nursing staff to improve their theoretical knowledge in neonatology and understanding of clinical practices within the Monash Neonatal Unit.

* Neonatal Meeting. On a weekly basis, neonatal topics and protocols are reviewed are presented for discussion. Including is a monthly Neonatal Journal Club, and a monthly review of neonatal deaths from the previous month with the pathologists. Consultants, registrars and outside specialists speak in these one-hour sessions attended by neonatal medical and nursing staff.

* Paediatric Teaching. On a twice weekly basis, paediatric topics including neonatal ones, are reviewed systematically over the year. Consultants from different paediatric subspecialties lecture in these one-hour sessions which are open to all paediatric staff.

* Paediatric Meeting. On a weekly basis, an one-hour paediatric seminar is held at which a neonatal topic is sometimes chosen.

* Paediatric Journal Club. On a weekly basis, current journals are reviewed systematically, including papers on neonatology. These sessions are open to all paediatric medical staff.

* Paediatric X-ray Meeting. On a weekly basis, interesting x-rays from paediatric and neonatal patients are reviewed with the radiologists.

* Obstetric-Neonatal Meeting. On a weekly basis, the obstetric staff meets with the neonatal staff to discuss high-risk pregnancies, their obstetric managment, intrapartum care and neonatal outcome.

* Perinatal Mortality Meeting. On a monthly basis a panel of obstetricians, neonatologists, pathologist, geneticist and epidemiologist review all stillbirths and neonatal deaths.

* Research Meeting. Weekly meetings of special interest groups involved in perinatal research meet at the hospital. These are run by the staff from the IRD. These are open to neonatologists and neonatal registrars.

* Fetal Diagnostic Meeting. A quarterly meeting is held in which interesting congenital malformations diagnosed in utero or after birth are selected for review in a meeting attended by obstetricians, geneticists, pathologists, neonatologists and neonatal and registrars.

RESEARCH PROGRAMME

There has been a strong emphasis on clinical research which is directly relevant to improving medical care for preterm or sick infants. Based on work carried out in the Monash Neonatal Unit, 133 articles have been accepted for publication in North America and Europe, 103 articles in Australia and 91 articles in Asia (Appendix 6). In addition, over 250 abstracts have been published based on scientific papers presented at various international and national conferences.

The book Respiratory Disorders in the Newborn was the first one written by Prof. Yu; it was published by Churchill Livingstone in 1986. Prof. Yu and Assoc/Prof. Adamson were editors of the book Perinatal Medicine published by the Australian Perinatal Society in 1986. Prof. Yu and Prof. Carl Wood from the Department of Obstetrics and Gynaecology were editors of the book Prematurity published by Churchill Livingstone in 1987. All the contributors to the book were staff members of Monash Medical Centre or Monash University, thus confirming the uniqueness of the combined expertise this university has in perinatal-neonatal medicine. Prof. Yu and Assoc/Prof. MacMahon were editors of the book Intravenous Feeding of the Neonate published by Edward Arnold in 1992. Prof. Yu was the editor of Pulmonary Problems in the Perinatal Period and their Sequelae which was published by Bailliere Tindall in 1995, senior editor of Textbook of Neonatal Medicine which was published by Hong Kong University Press in 1996, and editor of The Extremely Tiny Baby published by WB Saunders in 1996. Prof. Yu co-authored Selected Topics in Neonatal Intensive Care with Prof. Hans Monintja of the University of Indonesia, and this was published by the University of Indonesia Press in 1997. Prof. Yu has been on the editorial board of the Australian Paediatric Journal (1982-86), Early Human Development (1986-89), Paediatric and Perinatal Epidemiology (1986-89), Bioethics (1987-89), Journal of Neonatology (1993-) and is an Associate Editor of Early Human Development and Guest Editor of Acta Paediatrica Sinica and Seminars in Neonatology.

In addition to external funding for postgraduate trainees which contributed significantly to research activities in the Monash Neonatal Unit, research funds obtained directly from applications submitted to peer-reviewed, competitive research grant agencies and awarded to our Consultants are listed in Appendix 7. This has provided interrupted support for research activities since 1981.

The Senior Registrar and Registrars are offered the opportunity to be involved in perinatal-neonatal research during the course of their postgraduate clinical neonatal training. This can take the form of retrospective data analysis utilising our perinatal and follow-up database from extremely preterm infants or a prospective clinical study can be planned. Collaborative research involving the Monash Neonatal Unit and the IRD includes laboratory investigations in the fetus and newborn of regional cerebral blood flow and oxygenation, pulmonary circulation and lung mechanics, high frequency oscillation, cardiovascular dysfunction, and gastrointestinal blood flow and nitric oxide. The clinical roster of the Registrars allows breaks of up to 7 days. Those wishing to spend a proportion of their free time in research activities will be given every encouragement and support. Many Registrars have successfully completed basic research studies at the IRD or conducted useful clinical research in the Monash Neonatal Unit during the course of their clinical appointment. Several continued on to full-time research in the second/third year to pursue a MD or PhD degree supported by a Monash University scholarship. Consequently, based on research work carried out by our postgraduate trainees in the Monash Neonatal Unit, over 80 scientific publications have been published in refereed medical journals and over 170 papers have been accepted for presentation at national or international medical conferences.

PERINATOLOGY PROGRAMMES AT MONASH

Department of Obstetrics and Gynaecology

The pioneering work of Prof. Carl Wood in the Department of Obstetrics and Gynaecology has led to development of fetal monitoring techniques to evaluate fetal health at late stages of pregnancy. The hormonal control of pregnancy and parturition are new areas of research brought to the department by the appointment of Prof. David Healy to the Chair of Obstetrics and Gynaecology. Additional research activities include analyses of placental function, particularly in relation to high-risk pregnancies such as pre-eclampsia. The recent appointment of Prof. Robert Burrows as Professsor of Maternal and Fetal Medicine will further enhance the clinical, educational and research collaboration in perinatal-neonatal medicine at Monash University.

Ritchie Centre for Baby Health Research

A substantial part of the perinatal research effort of the Monash Medical Centre was initially started at the CEHD. Research interests of members of the CEHD span the areas of human infertility and conception, embryonic development, uterine function, fetal growth, organ function at birth, birth defects and physiological problems in the first year of life. Studies focus firstly on normal developmental processes: fertilisation, preimplantation embryo development and differentiation, implantation organ formation and growth, and the acquisition of complex co-ordinated activity in organ systems. Secondly, there are investigations of pathological conditions of development such as infertility, teratology, spontaneous abortion, prematurity, persistent pulmonary hypertension of the neonate, respiratory distress syndrome, periventricular haemorrhage and leukomalacia, necrotising enterocolitis and SIDS. A central theme of this work is the desire to improve and develop new techniques for human in vitro fertilisation (IVF), develop new and sensitive models for the identification of embryotoxic and/or teratogenic drugs and chemicals, develop alternative tests for genetic abnormalities such as Down Syndrome, improve prevention and treatment for respiratory, cardiovascular, gastrointestinal and neurological disorders in the neonate, and suggest ways of recognising infants at risk of SIDS and to aid in devising ways to prevent it.