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Antenatal and postnatal care: whose job is it anyway?

Gavin Young
MA MB BS FRCGP DRCOG
GP Principal
Temple Sowerby Medical Practice
Cumbria

In a statement in April 1996, the UKCC said: "Antenatal care should be provided by a practising midwife who is supervised by the local supervisor of midwives". A practice nurse (PN) who has qualified as a midwife (MW) is not a practising MW unless she has notified her intention to continue practising with the local supervising authority. In a "Dear Colleague" letter in May 1996, the UKCC also acknowledged that: "There may be situations in which the involvement of a practice nurse in an aspect of care is appropriate. To pretend that such instances do not happen or to state that they must not happen would be unrealistic."
Where does this leave the PN? Clearly a PN can take a blood pressure (BP) and do urinalysis just as well on a pregnant woman as on a nonpregnant woman. The problem lies in the interpretation of the result. A BP recording of 130/85mmHg would not normally cause alarm, but if this BP is found at 28 weeks in a woman whose BP at the start of pregnancy was 110/60mmHg, it should.
Similarly, proteinuria found at 30 weeks might be because of urinary tract infection (UTI), but sending off an MSU (midstream urine) may lead to a dangerous delay in picking up on pre-eclampsia. The situation would worsen if the PN felt pleased to find that the MSU showed no white cells or bacterial growth. This negative result in the face of proteinuria at 30 weeks is very alarming. Any task requiring a skill specific to MWs rather than nurses, such as assessing uterine size, should not be undertaken by a PN unless she is also a practising MW.

Preconception care
Many women seek advice about contraception and pregnancy from PNs, who are in an ideal position to provide care at this time. Topics that should be discussed include:

    * Folate supplements.
    * Timing of stopping contraception.
    * Rubella immunity.
    * Smoking.
    * Alcohol.
    * Chronic disease (eg, hypertension).
    * Drugs, such as the pros and cons of continuing anticonvulsants.

There is not space to discuss these matters in detail, but it is useful to point out their importance, especially in certain groups of women, for example women with diabetes, where pre- and postconception glycaemic control is very important.
Preconception clinics have not been a huge success. However, the practice could advertise that it offers preconception advice. The impact of such care will always be limited - one-third of babies in UK are not planned. Male health is also important - evidence suggests that sperm quality is affected by, for instance, heavy drinking. But men rarely attend for preconception advice!

Antenatal care
AN care has been likened to trying to find a needle in a haystack: a huge amount of effort with little chance of finding anything, or worse, not finding some very important needles. Anyone who has provided AN care will recognise this - the perfect maternity record with no problems encountered until the mother presents with an intrauterine death at 41 weeks; or the woman with normal BP readings and no proteinuria throughout pregnancy and when last seen at 26 weeks, then sudden development of fulminating pre-eclampsia at 29 weeks.
AN care fails many of Jugner and Wilson's criteria for good screening tests.(1) We need more research into what aspects of AN care are effective, who should provide such care, where and how often. Until recently it was assumed that AN care was "a good thing", with very little evidence to support such an assumption.
I do not wish to be too nihilistic; some aspects of AN care are important. Most women still consult their GPs to confirm pregnancy. hCG (human chorionic gonado-tropin) testing sticks should be ­available in all practices (and in all GPs' bags to help detect ectopic pregnancies when called to visit young women with abdominal pain).
The first attendance after pregnancy is confirmed is important, and whoever does it should allow plenty of time. You will need to discuss:

  • Date of LMP (last menstrual period)/cycle ­regularity and degree of certainty. At least one in five pregnancies has some first-trimester bleeding. This ­frequently leads to dating errors, or the assumption on the woman's (and doctor's and nurse's) part that she cannot be ­pregnant. If in doubt do a hCG test, but remember it may be ­negative for two to three weeks after conception.
  • Availability of AN screening tests (eg, nuchal lucency for Down's syndrome). This is best done at around 11-12 weeks, and if not discussed early the opportunity will be missed. Many GPs (and even more PNs) are probably not sufficiently ­knowledgeable to provide advice about these tests, in which case early referral to a MW (or in a minority of cases, an obstetrician) is essential. Serum screening (double/triple/quadruple/Bart's test) for Down's syndrome may be available in your area. Again this must be done at a specific gestation time (usually around 16 weeks). It is usual now to arrange an early scan to date the pregnancy accurately. The most accurate dating scans are done at around 12 weeks, but that may turn out to be too late for nuchal lucency testing.
  • BP recording in early pregnancy is important and should be put on the woman's pregnancy record. As the woman-held record is usually started by the MW, it may be helpful for the GP to see the woman after the MW has started the record to enter such data and provide background ­information. Better still, allow the MW access to the woman's GP notes. If your area doesn't use the national maternity record, persuade them to do so - mistakes are less likely to happen if we all write in the same set of notes.
  • Early weight measurements matter. A body mass index under 15 or over 35 is a significant risk factor.
  • The GP may be the only person to have any record of past pregnancies and therefore has a responsibility to ensure that those who need to know get to know - shoulder dystocia during a previous birth is a good example.

A great majority of women do not see an obstetrician in pregnancy, and quite rightly so. However, some should, such as those with diabetes. Others need early referral to a MW. This does not (or should not) mean the end of GP involvement if the woman wishes for some GP input and the GP feels competent to provide it.
Later AN care is mainly focused on looking out for pre-eclampsia and checking fetal growth. We are not very good at this. A very thorough study of AN care in Aberdeen showed that the majority of term babies under the tenth centile for weight were not detected before birth.(2) On top of that, for every woman who was correctly picked up as having a small baby, 2.5 women were told their baby was small when it wasn't. Although using a tape measure for symphysial fundal height brings some objectivity, it hasn't been shown to improve outcomes.(3) Neither have kick charts. This is a pity as they gave the mother some sense of caring for her baby. However, they didn't work and caused maternal anxiety and guilt.
If a woman reports less movement it must be taken seriously, although it is common in late pregnancy. Though Doppler umbilical artery studies are no use as a screening test, they are useful in high-risk groups (eg, diminished movements). Despite widespread use, antenatal cardiotocographs (CTGs) and biophysical profiles from ultrasound have not been shown to be of benefit.
Pregnancies going beyond 42 weeks have poorer outcomes as time progresses. Women should be referred for an obstetric opinion at term plus 10 days.

Care at birth
The care a good MW provides in labour is perhaps the most intense caring any human provides for another. If you as a GP or PN get a chance to attend a home birth, go, even if you are just an observer. The role of the GP at home birth is discussed elsewhere.(4)

Postnatal care
In the past there was much redundant postnatal activity, such as measuring the fundal height. Now most care is in the form of emotional support. However, babies can get dangerously jaundiced, can fail to gain weight, and mothers can get pulmonary emboli. These can be missed if postnatal care becomes just a chance to chat. Successful breastfeeding, especially for first-time mothers, requires encouragement. Contraception needs discussing - unless a woman is breastfeeding it is possible to conceive before the six-week postnatal check. Postnatal depression can occur before six weeks but is more common after, and good health visitors are very alert to this.

Conclusion
PNs have only a very small part to play after conception. Most AN and postnatal care is now carried out by MWs. It was not the intention of the Changing childbirth report to exclude GPs from pregnancy care,5 nor do I believe it is in the best interests of women that family doctors should have no knowledge or experience of caring for women during and after pregnancy. GPs should discuss with women and MWs individually what care is best for that woman. The proposed new GP contract makes no mention of maternity care - a pity.
Remember that your major role will be to provide advice and support in the hope that women can enjoy their pregnancy, birth and their baby despite being surrounded by ever-growing causes for worry.

References
1. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: WHO; 1968.
2. Hall M. MacIntyre S, Porter M. Antenatal care assessed. Aberdeen: Aberdeen UP; 1995. p. 30.
3. Neilson JP. Symphysis fundal height measurement in pregnancy (Cochrane review). In: Cochrane Library, Issue 1. Oxford: Update Software; 2002.
4. Young G. GPs and home births.The Diplomate 1996;3(2):114-48.
5. Department of Health. Changing childbirth: report of the expert maternity group. London: HMSO; 1993.

Resources
Royal College
of Midwives
W:www.rcm.org.uk
Royal College of General Practitioners
W:www.rcgp.org.uk