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Pregnant woman with complications refuses to see midwife and demands to see you

Three GPs share their approach to a practice problem

case history

Lisa is pregnant for the second time; her last pregnancy was straightforward and she seems well. When she came to tell you she was pregnant again, she told you she didn't like the practice midwife and wanted you to provide all her antenatal care. You explained that GPs are no longer contracted to provide this, and she duly went off for her booking bloods and scan.

She is now 35 weeks and has come to see you requesting another check-up. Her blood pressure is slightly up, and she has oedematous ankles. She hasn't seen the midwife during the pregnancy, and when you remonstrate with her she says she won't bother with any more checks and will just go straight to the delivery suite when the time comes.

Dr Zoe Rogers

'I would explore why she did not get on with the practice midwife'

Doing work for nothing is a hot potato at the moment but what matters here is the care of the patient. I would try to rescue the doctor-patient relationship before it totally breaks down. I would ask Lisa if we can start again. I would try to explore why she did not get on with the practice midwife and suggest that I look into finding an alternative one. In my experience, midwives work in teams and another midwife could probably provide Lisa's care, although she may need to go to another practice or to the hospital for her appointments.

For today, the most important thing is to establish if Lisa needs urgent care for her raised blood pressure and swollen ankles. It may be that remonstrating with me has put her blood pressure up! I would recheck her blood pressure when she has calmed down and check her urine as well as examining her abdomen. I would check there have been no previous problems in this pregnancy recorded in her maternity record. If she needs an urgent assessment for her blood pressure and swelling, I would refer her to the on-call obstetric team. If she seems well, I would ask her to leave things with me. I would then speak to the practice midwife and explain the problem. I would ask if it is possible for Lisa to see a different midwife. If no alternative midwife is available, I would be willing to provide her care; after all this is only going to be weekly checks for the next four weeks or so. Lisa must understand that she will need to go to hospital if any complications arise. Personally I enjoy providing antenatal care; it gives a good opportunity to get to know a pregnant woman before her baby is born. This then helps with postnatal care and any problems with the baby's health. If Lisa is not willing to go along with my suggestions then I will need to explain to her that missing antenatal checks may put her life and that of her baby in danger. I believe that as long as Lisa has capacity to make the decision, she is free to choose not to follow the care that health professionals suggest. I would, however, check this with my defence organisation and make careful notes.

Dr Alex Williams

'The safety and care of mother and unborn child are paramount'

This is a familiar situation that I have faced myself, although most pregnant women now seem to see the midwife exclusively and I feel a very valuable bonding between the GP and the family is lost. But that is another debate.

In this situation the safety and good care of the mother and her unborn child are paramount. The situation is in danger of escalating out of control, so I would agree to see her for the rest of her antenatal care and try to maintain a good and effective doctor-patient relationship. Clearly swollen ankles and raised blood pressure may be the harbinger of pre-eclampsia, necessitating vigilant observation of her urine (for proteinuria), and serial BP measurements. She should be advised to rest as much as is feasible and attend at least weekly or more often if things deteriorate. She needs to be warned to report headaches, visual disturbances or reduced fetal movement, indicating a progression of her illness and necessitating the intervention of an obstetrician or the labour ward.During the regular antenatal appointments it may become apparent the reason for her difficult relationship with the midwife. Is it just a clash of personalities, was something not done to her liking in the previous pregnancy or has there been a poor standard of midwifery? In a large practice or an urban area it may be possible to find another midwife, but not in a small or rural setting so thought will have to be given to the postnatal period where the midwife has a statutory responsibility to visit. Depending on relationships, an unofficial word with the midwife may be appropriate. However a discussion with the midwifery manager or local obstetrician may help broker a solution. If not it may be necessary for the GPs to provide this care. If this conflict is an isolated case nothing further needs to be done, however, if in discussion with GP or hospital colleagues a pattern of behaviour is revealed this may need to be addressed, with some form of performance management or risk assessment, which may lead to a disciplinary procedure. Accurate contemporaneous notes of all consultations should be kept and managers should follow any disciplinary procedure to the letter. It may be wise to have a discussion with your defence body if you have any concerns about any of this.

Dr Keli Thorsteinsson

'My duty of care overrides any get-out clauses in the GMS contract'

Antenatal care is an additional service under the GMS contract and we have presumably opted out of it, for reasons unknown.

Lisa is now 35 weeks pregnant and displaying possible early pre-eclamptic signs. It is clearly imperative that she receives close medical supervision from now on, until she and her child are no longer at risk. She must understand the importance of this, whatever happens. I perceive that my duty of care to this woman and her unborn child overrides any get-out clauses in the GMS contract at this stage. However irksome, an awareness of the obstetric medicolegal minefield will serve as further motivation in this situation. If there really has been a complete breakdown of trust here and she persists in refusing further follow-up, I will ring her at home to try to explain what risks she is taking. I will even consider contacting the father and getting him on board. I can't see that there are any issues of confidentiality of importance, as my duty to the child overrides those, in my mind (I would most likely contact my defence organisation first, just in case I am badly wrong). If all else fails, I will write to her with my concerns (if nothing else, to document them) and offer to look after her from now on. I could try to ring the community midwives or a consultant obstetrician to see if they have any helpful ideas on how to proceed. Certainly it is not uncommon for patients to lose trust in me or one of my colleagues, and care is often passed between doctors in that situation. This scenario does raise the issue of patients requesting GP services that we don't get paid for. I've not really been a GP long enough to know how new this is, but it does feel like we are having to play hardball with PCTs more often since the latest GMS contract. Who does that most affect? Patients and their care. Who do patients most often blame? GPs, that's who – Department of Health spin sees to that. I will add that I think we are relatively lucky in Shropshire, from what I read in the press.

what does this teach us?

Learning checklist

Professional obligations

• Providing antenatal care is an additional service under the new GMS contract.• This means practices can choose to opt out of providing it, although most don't. There is also a financial penalty for doing this.• Where a practice does opt out of providing an additional service, the PCT must ensure its provision outside the practice on the patient's behalf, often with a neighbouring practice. • In providing maternity care, participation of the doctors is extremely variable. Some doctors see antenatal patients regularly, while in other practices this work is almost entirely performed by midwives. The practice is, however, obliged to comply with local guidelines, which usually follow NICE guidelines closely.

Urgent care

• Care of a pregnant lady presenting with possible complications such as the case described falls within normal GMS services and is unaffected by decisions to opt in or out of the additional service. However, her routine care is also likely to be your responsibility as part of the additional service, even though it may usually be devolved to midwives.

Awkward patients

• When a patient doesn't fit into the practice system, such as refusing to see the most appropriate member of the team or demanding visits at inconvenient times, it is important to try to understand why this might seem rational to them.

• Find out what their previous experiences have been, what they might be afraid of and how strongly they hold their views. Then you might be able to start negotiating a series of options. In this case these may be a change of midwife, hospital-based care or GP-led antenatal care.Patients who don't access antenatal care

• Autonomy of a pregnant patient has to be balanced against the best interests of the unborn child, who is unable to express his or her autonomy. Lack of antenatal care does carry a significant increase in risk of obstetric complications and perinatal mortality. The mother needs to be understood and services can usually be made sufficiently flexible to meet her needs.

Richard Stokell is a GP and trainer in Birkenhead, Merseyside

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