GPs should have a bigger role in antenatal care

[LikeGarlicChicken]

Better confess straight off, I'm a retired GP. I couldn't agree more with this statement by The King's Fund. But the Gen.Sec. of the Royal College of Midwives says of GPs "....they must be able to demonstrate an up to date knowledge of the field...". Well Hello, Excuse me, who's the doctor here? I know I'm a bit reactionary and I still live in the world of "the doctor prescribes the treatment and the nurse carries it out", but really! The problem with midwives, from the beginning of time is that they have always thought of themselves as doctors in all but name. But it ain't so.
Yes I'm being a bit provocative here, but I always shared antenatal care with the midwife and I think this should always be the case. What does everyone think?

With my first I only saw my GP who had been my GP for the last four years. She was the GP I went to when I took the positive pregnancy test and she asked if she could continue with my care as she felt it would be useful for her and her students to deal with a straightforward pregnancy. There were midwives at the surgery who she consulted with on two occasions but she did all my antenatal appointments (except the scans), helped with my antenatal depression, referred me for physiotherapy for SPD, did my sweep and finally a few postnatal appointments. Occasionally I was poked by her students for an hour or two so they could learn about finding the position of the baby/bloodpressure etc.
I loved it at the time but am aware of the fact that this was very unusual and if I had had any serious problems I would have been referred to the midwife. My GP had just had a baby herself but I wouldnt have been happy doing this with any of the other GPs I have subsequently come across or with any other children.

With my second I had a midwife come to my house for every appointment as I was having a homebirth. This was my ideal of antenatal care and made me realise just how much information I missed out on the first time around and the midwife felt much more competent and in control.

StarlightMcKenzie

Goodness me

It's not and should never be about professionals 'elbowing' into anything.
That sort of territorial infighting between professionals makes me mad.

Surely it's about having some intelligent conversations between well-trained professionals with different skills to ensure that information is shared to ensure that mothers get the best care possible?

And its about mother's having choices.

We know that the vast majority of mums-to-be prefer midwife-led care - FACT.

However, the number of maternal deaths due to 'indirect' causes (heart disease, mental illness/suicide etc) that could have been prevented has doubled in 20 years - FACT.

GPs have a role to play, and if some are rubbish at it then something should be done.

'any other children of mine. Havent come across any child midwives yet!

I do think there should be better communication between GPs and M/ws. I've not worked in community but as a student saw big differences at different GP surgeries.

One surgery where there was a long term m/w there who was well known to the GPs had good communication. The women would have tended to see the GP first who tells them to book in with the m/w. The GP would write a letter to the m/w informing her that so-and-so was pg and detailing any medical facts about her that should be known.

Other surgeries especially the ones where its a different m/w every week didn't have the same communication. The m/w would just have a list of names of women who were attending the clinic but not know anything about them/if they had health conditions, etc. Obviously the women are able to tell the m/w at a booking appt about pre exisiting conditions and once past the booking appt there should be stuff written in the handheld notes but I can see how in such situations things can get missed, the m/w hasn't had chance to look up extra info/liase with GP if she feels she needs to. Not the GPs fault or the m/ws, but not a good situation.

I have a slightly different view, when having dd1 I had terrible boils in my underarms, severe ain, couldn't lift arms, couldn't move, so sore,crying all night etc saw midwife (I was midwifery led) she was really nice but reassured me it wasn't that bad, wouldn't recommend antibiotics/creams, wouldn't want to take a chance etc, saw doctor, couldn't believe how bad it was, got antibiotics, cream, finally got 2 weeks of relief before dd1 birth. While midwives are fantastic I feel that they can be a bit baby before woman.

For DC1 I had GP ante-natal checks only as there was no midwife at the surgery.

First GP I saw (supposedly with ante-natal care skills) had no idea what I meant by an anatomy/anomoly/20 week scan (not standard in my area then, but I wanted one due to family history of heart and kidney issues).

I had to explain to him it was normal in 90% of the UK and meant to be introduced to Glasgow asap. He mused outloud about why it was done at 20 weeks, oh, must be because of the abortion deadline, he said. When is that? 28 weeks, he asked? (This was the week it was in the news as the debate raged on lowering it from 24 weeks and parliament considered it).

Needless to say this didn't inspire confidence in me as a first timer, and though he wrote to the consultant and requested a scan for me I vowed never to see him again for an ante-natal appointment.

I made my next ante-natal appointments with another GP and she was excellent. Did all my checks monthly and was very helpful at referring me on when there were some concerns. Otherwise I just phoned the hospital triage and went in when required.

With DC2 I was under the care of a midwife clinic but saw different mw's every time, some excellent and some less than helpful. Again I attended the hospital for any major queries.

So for me it wasn't the role, GP or MW, that made the difference, but the professionalism, interest and knowledge of the individual.

The m/w should have referred you to the GP at that point. It wasn't a pregnancy/baby problem so she shouldn't be expected to know what antibiotics you need, plus she can't prescribe antibiotics. But if you were in that much pain she should have told you to see your GP.

Beyond my GP writing my referral letter (her response to me telling her I was pregnant was a look of shock & asking me "are you happy with that?"!!!!!!!!!) I never saw a doctor my entire pregnancy, apart from a non-pregnancy related matter and then the GP didn't even ask 'how's it going'? The weren't interested at all and I was fine with that if not a little bemused initially that they didn't want to know. I received specialist care from the MW's. I had the choice to go for some checkups with my GP but frankly they had been so uninterested & offensive, I choose to go to a birth centre & thus could opt for MW care throughout.

Don't GP's have enough to crack on with without getting involved in areas where they aren't necessarily required?

I imagine GP's would get involved with pregnancies with complications?

Starlight - same here. With my first pregnancy I saw 2 different midwives, once each, and the rest of the time I saw my GP for appointments. When I saw the GP for my 28 week appointment he told me to make my next one with the midwife - I went to reception and the earliest appointment they could give me with her was 36 weeks so I had a 32 week check up with the GP again (and by 36 weeks I had a three-week old baby anyway as it turned out).

And the midwife was only ever available from 10-12 on Tuesday mornings anyway, whereas I could make 8.30am appointments any day of the week with the GP so much more convenient when you're working.

Second pregnancy I saw the midwife once and made all my other appointments straight with the GP again, I just didn't see the point in even trying to see her.

Maybe I just had a good experience though - 3 of the GPs at our practice were happy to come out for home births for example.

I had shared care with both of my pregnancies, but the outcomes were very different.

The GPs involved were the same for both and their care was second to none. However they were female doctors and always made sure that I knew that my pregnancy and a good outcome was important to them. They also provided the 8 week check and have generally been brilliant.

The midwife team at Kingston for DD1's birth were awful, I felt like a problem to be got out the way as quickly as possibe. Never felt relaxed and in consequence had a horrible birth experience which scare me witless.

The midwife team for my second birth at West Middlesex (I changed hospitals as the care the first time was so awful), were great. I saw them a points throughout the pregnancy (so was proper shared care), and got to know them. They were brilliant. The GPs and midwives seemed to work as a real team. I think shared care, like I had with a good mix of input from midwives and GP is great.

Yes, sorry that last post was very patronising in retrospect, don't read the Guardian I promise!
I think the point was (as has been made by others) that for women with pre-existing medical problems, the GP has knowledge, plus they are better at dealing with non-obstetric complications arising through the pregnancy, e.g. depression etc.
I know this is a one-off random scenario but it just illustrates that better communication back to the GP from obstetrics would help - my friend had what was thought to be severe SPD, saw the midwife and an Obs registrar, and was just told to deal with it. She eventually went to to the GP just for a sick note-they knew about her past history of melanoma and referred her asap for XRays - metastatic cancer. I just meant that if communication between all health workers involved this may have been picked up earlier. Totally one off situation, but example of where better communication might have helped (I'm not saying any of them are better than the other, they just have different skills is all).

Although midwife and Obs registrer should have known about her past history of melanoma if a proper medical history had been taken at booking-in and they'd read her notes properly. So something went wrong with the existing process there.

But that is part of the problem isn't it. The inadequate history taking. Most cases of negligence I've read about come down to HCP (docs and others) not taking the time to get an adequate history.

I, myself, have had to forcefully give my history in the past but only because I know that it may be relevant.

Hmph. Sorry. Rant over.

Joined up care did not work for me. I had gp care because I had chosen a hospital in a different trust from my gp. The gp failed to notice red flag signs that would have led a midwife to refer me for a scan at 39 weeks. I was in latent stage labour for nearly a week but the local mws would not see me or check the heartbeat because I was not their patient. The gp told me to go to the hospital, who discharged me because I was not in established labour. The hospital told me to see the local mws (in the birth centre behind my house!) who, as I've said, would not see me at all.

Six days later dd was born by emcs. The surgeon told me that she could not have been born normally.

Had the gp and the midwives and the hospital been truly joined up, I might have been spared six days of painful contractions and not risked dd's health. She came out of it ok in the end.

So while I am neutral on gp led care, I am sceptical about whether antenatal care can ever be truly joined up.

Why is it wrong for midwives to say that GPs should demonstrate up to date knowledge of pregnancy and childbirth? Sounds a bit arrogant to me to just say "well I'm the Dr and you're the nurse and therefore I know best"... I personally haven't always been that impressed with the diagnostic abilities of GPs I have consulted. Isn't it possible that not all GPs, especially if they don't specialise in this area, are up to date with current research in antenatal and postnatal care. Jeez, you're a Dr not the fount of all knowledge, get over yourself.
By the way I am not a midwife with an axe to grind!

I have to say I was pretty appalled with my midwife care - I had high BP throughout my preg and was referred to Hospital where the care was superb. The local community midwife didn't seem to have much of a clue about pregnancy and high BP and she assumed it must be Pre eclamsia related. Tests confirmed this was not the case and infact a small kidney was the cause - not so serious lol! If I had chosen to give birth at the hospital she was working, I would have been put forwards for an elective ceserean (she insisted all the way through that I would have a cesarean because I am petite too!), but I chose a different hosiptal where I gave birth to my beautiful son last June 30th naturally ;-)
My BP was constantly monitored and I felt looked after with a team of professionals and doctors.
I would have prefered to have had a doctor I can see when needed some simple reassurance, instead of having to travel to the hospital miles away!!

This may be off the beaten track of OP but I think it is insulting that a couple of the midwives on here seem to consider themselves as better educated than nurses who are the "Drs handmaidens". I used to be a nurse prior to retraining in a completely different field. I completed a three year Nursing university degree and certainly valued my contribution within the multidisciplinary hospital team. I actually worked within the recovery unit of a hospital recovering post caesarian section women and worked very closely with the midwives. They were not trained to provide post anaesthesia care of unconscious and intubated patients and I was not trained in the specifics of post birth, ie palpating the woman's uterus and facilitating breastfeeding. Therefore we worked together and relied on each other's expertise. As a nurse I never considered myself as anyone's handmaiden although I did encounter that attitude from some old school arrogant medival consultants. I am a little disappointed that some midwives also seem to belittle their nursing colleagues as such.

Part of the problem with this debate is that there is no standard pattern of care in the UK - it varies by area, so we are all debating different things.

I am in a shared care area where about half of my appointments have been with my GP and half with the local midwifery team (potentially different MW each time). I don't imagine that the Kings Fund want more GP involvement that that. I have had a very straight forward pregnancy so far.

For every person who has had a useless GP, someone else has had an annoying MW. And much of this boils down to personal preference.

My GP seems much better able to tailor her communication style to my preferences, has an online booking system with appointments from 8.30 and has never rushed me through an appointment. She took my concerns about my work environment seriously (as she understood the nature of my job, which I don't think my MW did). She is located in my village, where as the MW are in a town 15min drive away.

On the other hand I have agreed to see just one of the MW (rather than pot luck) in the community team. She seems to suit me better than the others I have met, her clinics always run on time (which I am amazed by), she doesn't waste time lecturing me on things I have read/covered in NCT classes and is lovely.

The biggest issue I have with the shared care approach is that the communication between GP, MW and hospital has been poor, so I have had to chase up my blood test results to ensure that they have been circulated and interpreted. Whilst this has not proved to be a problem for me, I have known people go undiagnosed & eventually hospitalised as a result.

I think the drawback with GP is that, as doctors, they are trained to deal with illness. Pregnancy is not an illness.

I had an extremely risky pregnancy, and whereas I obviously needed and benefitted from the GP and consultant, it felt at times that they were treating a growing tumour rather than a foetus. I needed the MW to keep reminding me that most of what I was experiencing and feeling was very, very normal.

So yes, it all needs teamwork...

Prefer the system here in mainland Europe.

You go and see one gynaecologist/obstretician for all your care ... pre- and post-natal .. all scans/blood test carried out in her comfortable office 10-min drive from home. Bit of a wait but no hardship really.

She then oversaw my delivery (c-section in the end owing to breach) in hospital where she and her assistant were affiliated.

She provided both the up-to-date medical knowledge & experience/ plus latest equipment + the caring/motherly/continuity side of things

Yes I had to pay but 70% of cost was reimbursed by (obligatory) health insurance

Couldn't have been better frankly ...

Bootymum - sorry if my comments insulted you. It wasn't intentional, though reading my comments back I can see that it could be read that I was agreeing that nurses are a doctor's handmaiden. I wasn't, I was just trying to get the OP to realise that its midwives and not nurses that look after pregnant women and that midwives are autonomous.

Nurses may well be also, I know some are. I know some paed nurses who have done advanced training and are Advanced Practioners. Don't really know about nursing as a whole. I was certainly told as a student that midwives have more responsibility and are more involved in decision making than most nurses and that why we're on Band 6. But that may just have been a biased m/w lecturer that said that. I suppose I have always thought that nurses aren't as involved in decision making about treatment for their patients as their patients are ill and therefore need the Drs input in a way a pregnant/labouring woman won't 99% of the time. I'm sure there will be times when a nurse has the extra training/experience to make decisions but is that there for the majority of nurses as routinely as it is for midwives? Not meaning to be provocotive, genuinely interested.

Personally I liked my GP care but that was really because he was the only person who seemed to care about the whole of me, but I had 2 very complicated pregnancies after a first one which was fine.

I had a kidney problem in pregnancy (produced continual kidney stones). It was caused by pregnancy. The midwives said I should see the OB. The OB said he knew nothing about kidneys and I should see a urologist. The urologist said he knew nothing about pregnancy and I should see the OB or the midwife. I was in constant excruciating pain, and it was my GP who stepped in and found a specialist obstetric urologist hundreds of miles away who looked at all my notes and talked to me on the phone and looked at my scans and eventually found out what was going on. But it was my GP who organised it.

I lie, actually. The other person who saw me as a me and not an incubator was the pain control anaesthetist.

I think a GP can be very useful when things outside pregnancy are complicating issues. He was also the most helpful of all hcps when it came to dealing with my ante/post natal depression. And when he found out I had trained as a breastfeeding peer supporter and was feeding dd2, he got me to come in and do a presentation to all the practice staff (including receptionists etc) of normal breastfeeding, explaining what I was doing etc .....

He was great - shame we moved really as I haven't ever found another doctor I like as much (apart from fabulous dh of course, who is also a GP who comes home all clucky every time he does a postnatal check!)

Ime there are only 2 changes that should be brought to ante natal care in the UK:

• the guarantee of 3 routine scans during pregnancy (in the area where I lived only 2 scans were offered), as a 3rd scan in the 3rd trimester is vital to check on the health of the placenta and the efficiency of the umbilical cord.

• swab to detect gbs

Midwives are fine.