Many healthy, low-risk women choose antenatal shared care (ANSC) because they prefer to be cared for by a doctor they have an existing relationship with and feel more comfortable under their care.

The Medical Council has identified some recurring themes in ANSC complaints that have resulted in poor outcomes for women and their babies. The main issues are:

• fragmented communication
• lack of recognition that an issue is outside the GP’s area of expertise, and
• failure to realise the seriousness of clinical observations or results.

If you are a GP involved in ANSC arrangements, you can strengthen your practice by:

1. maintaining continuity of care and strong lines of communication with the maternity service you are sharing the care with,
2. working within your scope and relying on the support of trained specialists, and
3. recognising when and how to escalate concerning clinical observations or results.

Maintaining continuity of care

While it’s true that ANSC can provide a holistic model of care, there is also a risk of communication and continuity of care breakdowns when there are two carers.

Confirmed by research published in MJA Insight this year, a lack of communication between the hospital and the GP increases the risks of:

• delayed or missed diagnosis,
• inappropriate prescribing, and
• lack of preventative care.

A complaint recently received by Council sadly reflects the impact of missed diagnoses, especially when there are two lives on the line.

A pregnant mother had regular antenatal checks, per the ANSC model. The patient’s blood pressure at her initial booking appointment was 120/70 but her blood pressure started to increase after her 20-week appointment.

At her 38-week appointment, her blood pressure was 155/95 and the GP confirmed protein in her urine. She was told that her blood pressure was high, to undergo a blood test and ultrasound and to present to hospital if she felt at all unwell. However, no further information was given to the patient about the risks she or her baby faced in association with her high blood pressure. The sonographer provided their report to the doctor the day of the ultrasound, highlighting concerns about dangerously low levels of amniotic fluid, but the doctor did not contact the patient or the hospital.

While awaiting her follow up appointment, the patient felt the baby’s movements stop. She presented to hospital where doctors confirmed there was no heartbeat, and she delivered the baby stillborn.

In seeking a response to the complaint, it was apparent the doctor had not followed the ANSC guidelines for escalation, nor were they credentialled to be undertaking ANSC.

To maintain continuity of care in ANSC arrangements, obstetrician Michael Nicholl (Clinical Professor in Obstetrics & Gynaecology at the University of Sydney) advises GPs to:

• first and foremost, establish a connection between yourself, the local Primary Health Network (PHN), and the local maternity service,
• get to know how the local service works, how it connects with primary care, and who to contact within the maternity service if you have concerns (e.g., the ANSC midwife coordinator),
• understand what the requirements are to provide shared care and what the local pathways and protocols are to support shared care arrangements, and
• keep up to date with the education opportunities provided by the Primary Health Network or the maternity service and don’t be afraid to ask for assistance.

Work within your scope

GPs must be formally credentialled for ANSC before undertaking work in this space. Each PHN has their own ANSC guidelines, which outline registration requirements. At a basic level, GPs wanting to participate in shared care must register with their local PHN and meet ongoing requirements such as having direct obstetric experience. It is also important to ensure that your medical indemnity covers this additional responsibility. Local PHNs may offer clinical placement to upskill doctors with minimal obstetric experience.

Professor Nicholl warns, “Maternity care can be tricky because of the physiological changes of pregnancy. Keeping up to date is the best way of staying abreast of what’s new but there will always be situations where you need support from a trained colleague or specialist.”

Recognise when and how to escalate concerning clinical results

It is crucial for GPs involved in ANSC to protect the safety of the pregnant woman and the fetus by recognising when clinical results and observations are serious and escalating accordingly.

In another complaint before the Medical Council, it became evident that the GP involved had repeatedly dismissed concerns the patient raised about numerous symptoms, including headaches, high blood pressure and pitting oedema. The doctor allegedly advised the patient that 147/90 was only “slightly high” blood pressure and did not recognise that this high blood pressure and the other symptoms raised were red flags for pre-eclampsia and should have triggered a call to the antenatal clinic. The doctor’s failure to follow the ANSC guidelines contributed to the premature birth of the infant who passed away from pre-eclampsia related complications.

Professor Nicholl says, ‘Most poor outcomes in maternity care come from not recognising the woman or fetus at risk. Follow the recommended guidance, be scrupulous about your documentation and the trends in your pregnancy observations and listen to the woman. If a woman has concerns, then listen and address those concerns with the appropriate escalation.’

GPs are encouraged to build strong relationships with their local maternity service and become familiar with local protocols for escalating concerns. Birth units are open 24/7 and are always available to help with acute problems. For less acute problems, many services will have pregnancy assessment units linked to the birth unit or ambulatory care services.

In any instance, Professor Nicholl reiterates that ‘hospitals don’t expect that you need to do everything in isolation. Shared care is exactly that – the sharing of the woman’s pregnancy care needs.’

Takeaway messages

• Ensure you have the appropriate accreditation and medical indemnity cover to undertake ANSC.
• Seek support from colleagues and additional training if you feel you are working outside your area of expertise. Keep up to date with opportunities for upskilling.
• Connect with the local maternity service and become familiar with local protocols and pathways to support ANSC arrangements. Know who the contact points are for your local ANSC service and use them if you have questions or concerns.
• Review the guidelines of the PHN you are accredited for to ensure you are familiar with the clinical indications that require you to contact the patient’s hospital for support and specify when to refer patients back to their hospital. When referring the patient back, ensure that a thorough clinical handover is completed.
• When providing pathology or ultrasound referrals, send a copy to the patient’s hospital to ensure they receive results and the patient’s hospital records can also be updated. It is also a good idea to give copies of reports to the patient to double check that documents are available.
• Ensure you document all key information on the patient’s antenatal card using standard and widely accepted abbreviations.

Resources

• Antenatal shared care guidelines: Central & Eastern Sydney PHN (May 2021)
• Is poor peer communication putting your patient at risk?