The role of the GP in maternity and reproductive health
As a GP, your role is to:
- provide pre-conception and health promotion advice (including vaccination) to optimise the health and wellbeing of women who are pregnant or planning a pregnancy
- work with midwives to provide antenatal care, and share care with secondary care for more complicated pregnancies
- provide postnatal care, including postnatal monitoring and medication management, detection and management of postnatal physical and mental health problems, support for breastfeeding, postnatal contraception
- provide care for medical problems that are present in pregnancy – this may include physical or mental long-term health conditions that may predate the pregnancy or develop during pregnancy
- provide care and support for women, and their partners, affected by pregnancy or baby loss and infertility.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including self-care, initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
- Normal pregnancy symptoms and signs
- Abnormal pregnancy symptoms and signs, including abnormal abdominal palpation (fetal size and lie), bleeding, hyperemesis, pain (abdominal or pelvic), pre-eclampsia symptoms and signs, preterm labour, reduced fetal movements, symptoms of venous thromboembolic disease, symptoms suggestive of exacerbation of coexistent medical conditions
- Perinatal mental health symptoms
- Postnatal symptoms including abnormal bleeding and symptoms of breastfeeding problems
Common and important conditions
- Perinatal mental health, including adjustment disorders, antenatal depression, ‘baby blues’, chronic mental illness in the perinatal period, obsessive compulsive disorder (OCD), paternal perinatal mental illness, postnatal depression, post-partum psychosis, post-traumatic stress disorder (PTSD) and tokophobia
- Pre-conception care and advice, including health promotion advice (for example, smoking cessation and weight loss), medication adjustments, optimisation of pre-existing medical conditions, immunisation, supplementation, family history-taking to identify couples at increased risk of a child affected with an inherited condition
- Pregnancy with social complications, such as domestic violence, drug and alcohol misuse, homelessness, safeguarding concerns, teenage pregnancy
- Prescribing prenatally and perinatally, including teratogenesis
Antenatal care
- Principles and guidelines for routine antenatal care, including recommended supplements, dietary and lifestyle advice, immunisation in pregnancy
- Antenatal screening for fetal and maternal conditions
- Pregnancies complicated by pre-existing medical conditions, including asthma, cancer, cardiac disease, diabetes mellitus, epilepsy, hypertension, human immunodeficiency virus (HIV) infection, mental health conditions, obesity, thyroid disease and venous thromboembolism
- Indications for aspirin prophylaxis
- Antenatal complications, such as:
- bleeding and pelvic or abdominal pain in pregnancy
- congenital abnormalities
- early pregnancy loss: miscarriage, ectopic and molar pregnancy
- growth problems: abnormal symphysial fundal height
- haematological problems such as haemoglobinopathies (including sickle cell disease and thalassaemia), haemolytic disease (including rhesus incompatibility and prophylaxis) and thromboembolism
- infections, for example urinary tract infection, asymptomatic bacteriuria, group B streptococcus, chickenpox, chorioamnionitis, Covid-19, cytomegalovirus, hepatitis, herpes simplex, HIV, listeria, parvovirus and rubella
- intrauterine death and stillbirth
- malpresentation including breech and transverse lie
- metabolic problems arising in pregnancy, for example hyperemesis, gestational diabetes, jaundice, obstetric cholestasis
- multiple pregnancy
- pregnancy-induced hypertension, pre-eclampsia and eclampsia
- reduced fetal movements
Delivery
As a GP you should understand this aspect of maternity care and women’s experiences of the common types of delivery, but in general a GP is not expected to be able to provide intrapartum care.
- Normal labour and common problems of labour including premature labour, prolonged pregnancy, induction of pregnancy
- Caesarean sections: indications and associated complications, options for subsequent deliveries, including vaginal birth
Postnatal care
- Normal postnatal care, including routine ‘neonatal examination’ and ‘maternal six-week to eight-week check’
- Infant feeding, including breastfeeding (see also the Children and young people topic guide)
- Postnatal problems, including breastfeeding problems, bladder and bowel problems, mental health problems, retained products, uterine infection, wound problems
- Providing contraception advice postnatally and after pregnancy loss
- After baby loss, including sudden unexpected death in infancy (SUDI); consider a parent-led bereavement care plan providing continuity between settings (including GPs)
Unwanted/unintended/unplanned pregnancy and termination of pregnancy are covered in the Sexual health topic guide.
Examinations and procedures
- Antenatal examination, including abdominal palpation, assessment of symphysial fundal height and fetal heart rate, blood pressure and urinalysis
Investigations
- Pregnancy investigations, including:
- laboratory tests to evaluate gestational diabetes, obstetric cholestasis and pre- eclampsia
- screening and prenatal diagnosis for congenital abnormalities, including amniocentesis and chorionic villus sampling
- antenatal screening, including triple test, quad test, nuchal test, haemoglobinopathy screening and anomaly ultrasound scan
- tests for infection including asymptomatic bacteriuria, HIV, syphilis
- ultrasound for dating, growth and fetal wellbeing
- urinary and serum β-HCG
- Primary care investigation of female subfertility, including blood tests and ultrasound
- Semen analysis
Service issues
- Local arrangements for fertility treatments, antenatal care and delivery, including shared care with midwifery services and with secondary care
- Local services to support women who are breastfeeding
- Local support and services for women with perinatal mental health problems, including strategies to identify these women
- Maternity rights, benefits, schemes and associated administration, for example., Healthy Start, maternity certificate Mat B1 form, maternity exemption from prescription charges
- Safeguarding of unborn children and neonates
- Screening for domestic and intimate partner violence in the context of antenatal care
- Strategies to reduce teenage and unplanned pregnancies
- Working to reduce inequalities and ethnic disparity in pregnancy outcomes, including maternal death
- Cultural variation in approaches to pregnancy and childbirth
Case discussion
Sophia Khan is a 40-year-old mother of five girls who comes to see you to tell you that she has found out she is newly pregnant with her sixth child. She has type 2 diabetes and has a body mass index (BMI) of 42. She speaks poor English, and her husband translates for her. He tells you she is ‘fine’ except for some achy joints and asks how soon they can find out the sex of the baby. Sophia looks downcast and close to tears. Her medical records show that she had an emergency caesarean at her last delivery due to fetal distress. The health visitor had suspected that she suffered from postnatal depression after this child was born and arranged for Sophia to see you when the baby was two months old, but despite your best efforts to explore this she was very reluctant to talk to you about how she was feeling.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | If I or my partner are personally struggling with fertility or recurrent miscarriage, how would I react when consulting with women for whom getting pregnant seems easy, or who have an unwanted pregnancy? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | How do I explore the couple’s reasons for wanting to know the sex of the fetus? How do I react to families from cultural settings where female babies are less valued than males? How do I respect a patient’s choice not to discuss personal matters such as their emotions with me? How do I know when to press them harder on this and when to step back? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What are the issues around the use of interpreters, particularly if they are a family member or intimate partner? What alternative interpreting services are available in my locality? How can I develop my non-verbal communication skills? How do I explore the couple’s reasons for wanting to know the sex of the fetus? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How do I assess Sonia’s diabetes control? How do I try to assess whether or not she is depressed? What tools can I use for screening for postnatal depression? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How do I assess the gestation of a pregnancy? Am I proficient at carrying out a routine antenatal check? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What would make me decide I needed to arrange to see Sophia without her husband present? How would I communicate this to them? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What do I know about the management of diabetes in pregnancy? How can I advise her on this at the initial consultation? What pre-conception advice should be given to women with diabetes planning a pregnancy? What are the local arrangement for care of pregnant women with diabetes? What are the local guidelines on delivery for women who have had a previous caesarean section? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How do I manage Sonia’s multiple risk factors for pregnancy complications? How do I address my concerns that this fetus might be at risk of sex-based abortion? How do I evaluate whether her ‘achy joints’ may have an underlying physical cause or whether they might be somatisation? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How do I ensure Sophia has coordinated care with community teams, including GPs, midwives, health visitors and secondary care antenatal services? How do I raise any safeguarding concerns that might relate to this pregnancy? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | How do I keep up to date with the latest guidelines and recommendations for conditions that I might see infrequently (such as diabetes in pregnancy)? How do I maintain my skills in providing antenatal care for uncomplicated pregnancies when it is increasingly common for women to be cared for almost exclusively by midwives? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How does my organisation ensure that all women who are of child-bearing age and have diabetes receive appropriate pre-conception advice? What are the different systems of record-keeping used in antenatal care and how are they coordinated? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How can we promote mental and physical wellbeing in the perinatal period? How can we tackle the stigma around perinatal mental illness? How much do I understand about different cultural attitudes to childbearing? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What services are available locally to support women struggling with perinatal mental health problems? In what ways can we develop services to help patients for whom English is not their first language? |
How to learn this area of practice
Work-based learning
Primary care placements are the ideal opportunity for a GP registrar to learn how to manage maternity and reproductive health because it is where the vast majority of patients with these concerns are cared for.
Some GP specialty training programmes contain placements of varying length in obstetric and gynaecology units. These will give you exposure to patients with obstetric concerns, including possibly experience in day assessment units or outpatient clinics for women with complicated pregnancies. It is also a good opportunity to observe deliveries, including normal deliveries, assisted deliveries and caesarean sections.
Self-directed learning
Reproductive health is part of normal life experience for many GP registrars and reflecting on your own experiences or those of or family and friends in this area of healthcare can provide valuable insights.
The RCGP Women’s Health Library provides educational resources and guidelines on women’s health, including maternal health resources and a women’s health toolkit. You can find eLearning module(s) relevant to this topic guide at elearning for healthcare and at RCGP eLearning.
Learning with other healthcare professionals
As a GP registrar, it is essential that you understand the variety of services provided in the community. Working with community midwives will give an insight into community antenatal care. Health visitors have a key role to play in supporting women in the postnatal period and time spent shadowing them can give valuable insight into how they provide this support. Learning how to work with these professionals is an essential aspect of being able to provide holistic care.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Diagnosis and management of common symptoms in pregnancy
- Primary care investigations for failure to conceive
- Routine antenatal screening tests
Simulated Consultation Assessment (SCA)
- A woman in early pregnancy requests an abortion.
- A woman in a stable same-sex relationship requests referral to the assisted conception clinic
- A woman who is 10 days postnatal attends with flu-like symptoms and a painful breast
Workplace-based Assessment (WPBA)
- Case-based Discussion (CbD) about a woman who is hepatitis B positive on routine antenatal testing and her husband is her only sexual partner
- Learning log on a couple who have had a recent stillbirth
- Clinical examination and procedural skills (CEPS) – examination of a pregnant woman in the third trimester of pregnancy