Fetal Medicine

1. Introduction

2. Set agenda / Purpose of consultation

3. History (relevant)
- Check gestation
- First pregnancy or had pregnancy before –previous pregnancy
- How has this pregnancy been so far ?
- Screening? Amnio?
- Medical problems
- Drugs
- Baby’s sex

4. Explanation of findings (scan) – as much as appropriate or wanted!

• Further investigations recommended
• Scan in fetal medicine department – details and confirmation and look for other associated
anomalies
• Fetal echo
• Karyotyping – amnio/cordocentesis (explain fetal risks)

5. Management
• Option of TOP (KCI >22/40) (Preferably discuss this last)
• Confirming pregnancy: -Further scans/karyotyping
-Referral to fetal medicine /tertiary care
-MDT approach – neonatal/paediatric/surgeon/genetics
-Antenatal steroids
-Regular scans
-Delivery plan – MOD, timing, place, c/s for obst. Indications
-Neonatal team for delivery
-NICU beds
-Progressive abnormalities/stable ones

6. Address patient’s concerns/questions

• Baby’s kidneys/lungs/gut –function is carried out almost always by placenta and any of
these abnormalities may not affect the wellbeing of baby in-utero, but significant once
delivered.
• Is there anything that we didn’t talk about in discussion?

7. Closure
• Further appointments
• Discuss again with partner/family
• Leaflet about counselling
• Names/contact
 Breaking Bad News
1. Introduction

2. Agenda / Purpose
I know you have come to discuss the results of tests that were arranged from your last clinic
appointment but before we do that is it alright if I get some background information about you because
I haven’t met you before.
History:
What was the initial complaint that led to this/these investigations (open question?)
Then ask relevant history
3. Check Understanding
Why do you think you had these tests and what is your understanding

4. First warning / sign post

There is something important that I have to discuss. Would you like someone else to be with you?
Would you like to call somebody?

5. Second sign post

I am afraid I don’t have good news.

6. Give results straight after 2nd sign post and pause

7. Show empathy
I am so sorry – I wish I had better news. I know it comes as a shock.

(Allow grief reaction)

Do you want me to call your husband or friend?

8. Take control of consultation (This is important- you have to complete consultation and follow your
agenda. Don’t get distracted by spending too much time consoling her)

I can see you are upset which is understandable. We now have to have a plan as to how we move
forward from here.
We have to now know how we can help
9. Agree a plan
What further investigations
What support
Information leaflet
CNS contact – for cancer ask cancer nurse specialist (CNS) to see her, who will discuss all the support
system
MDT
Further appointment with family and friend
10. Closure
Summarise what we agree
Thank you for speaking with me
Double handshake
 Maternal Medicine

1. Introduction

2. Agenda of consultation

3. History
- Could I ask you how old you are? What do you do for a living?
- Current pregnancy
- Previous pregnancies - delivery, events, complications
- Medical and psychiatric
- Medications
- Allergies
- Surgery
- Family history - BMI, VTE
- Social history - smoking, alcohol, drug abuse
In this station - medical problem is central theme e.g. cardiac disease, sickle etc.

4. Explore the medical condition

- How long
- What treatment - whether teratogenic
- What effects on her life
- Who looks after this condition - hospital doctor or GP?
- What pregnancy does to condition?
- What condition does to pregnancy?

5. Management of pregnancy
Antenatal - Booking additional tests
- MDT (other teams, anaesthetic review)
- Tertiary care (high risk)
- TOP if appropriate
- Serial assessment of condition
- Fetal surveillance
Intra-partum - MOD
- Timing
- Place
- Epidural
- Continuous monitoring (Don’t forget the baby!!)
- C/S for obstetric indications
Postpartum - Treatment of condition
- Breastfeeding
- Follow up
- Contraception
- Pre-pregnancy counselling
- Future pregnancy
6. Address patient concerns
- My apologies - I have given you a lot of information. Is there anything I wasn’t clear about?
- Any further questions?

7. Closure/summary
- We have now agreed this is how we will look after your pregnancy.
- Thank you for speaking with me.
 Domestic Abuse

1. Introduction
Know where you are

2. Agenda
Thank you for coming to the clinic today.

I understand you had a scan today/I understand you had a booking with the midwife today etc.

I will discuss the results of scan in a minute/discuss the care of your pregnancy in a minute, but before I
do that – do you mind if I ask you about some background information of this pregnancy, which helps
us to put things in the context of care that we may offer.

3. History
Would you mind if I asked you how old you are? What do you do for a living?

Tell me about the pregnancy – is it a planned pregnancy? If not is it a welcomed pregnancy?

Any medical problems?

Previous pregnancies

S/H

D/H – allergies

Mental Health
Have you had any mental health issues before?

Have you had any treatment for depression?

Is anybody in your family suffering from mental health problems?

Social History
You told me you work as a ‘teacher’ – how are things at work?

How are things at home?

The sonographer has informed me that your scan is normal. He has however also informed me that he
has noticed bruises/ scars on your body and we are concerned about it.

How have you got these bruises?

Linda – can I tell you that violence against women is common in our society and with what we have
seen/what I have been informed – I am quite concerned.

I must assure you that whatever information you give me will remain strictly confidential.

Does or has your partner ever abused/been violent towards you?

Has anyone else abused/been violent towards you?

4. Quantify the violence

How long?

What abuse – physical, emotional, sexual

Rape – unintended pregnancy TOP, interference with contraception

Are there children in the house?

Has your partner been abusive to children?

Are you safe?

Do you fear safety of children?

Has your partner even threatened to kill you?

5. Address other issue that she presented with like USS report

6. Management strategy for domestic abuse – safety assessment

Does your abuser have a weapon?

Has he threatened to kill?

Do you feel safe going home?

If safety in doubt – ADMIT

‘Domestic abuse is completely unacceptable and none of us should have to go through this.’

7. Referrals – with consent

Domestic violence telephone helpline – Women’s Aid

Local support groups / social worker / DA midwife

8. Safety Planning
If she does decide to go home- plan the escape situation.

Lip balms with numbers on it etc.

9. Documentation
In hospital notes but not handheld notes. Also document if you strongly suspect DA but woman
declines.

10. Arrange follow up

11. Break confidentiality if

Children safety an issue / abusive to children- involve police

Rape – can involve police but charges can be made by patient only

12. Closure
 Pre-pregnancy Counselling
1. Introduction

2. Agenda: Your agenda and patient’s agenda

3. History
• Would you mind if I asked you how old you are?
• What do you do for a living
• Tell me about yourself – how is your health in general
• Medical problems (diabetes, stroke etc)
- How long
- What treatment
- How does it affect her
- Who looks after her
- How well is it controlled
• Previous pregnancy and delivery and any complications
• Other medical problems and mental health
• Surgery
• Allergies / medications
• Social – smoking, alcohol, support at home, living with
• Ask about father – healthy, any medical conditions
• Ask about smear test
• Ask current contraception

4. Medical Disorder – discuss

• How medical disorder affects her pregnancy
• Affect of disease on pregnancy etc
• Chances of abnormality in fetus discuss, any chance of genetic predisposition/counselling
• How pregnancy will be managed (MDT etc) – antenatal care – details
• (Your medical condition may alter the way we look after your pregnancy)
• Intra-partum – MOD, timing, place
• Postnatal – breast-feeding, contraception, etc.

5. Advice before contemplating pregnancy

• 3 months folic acid
• Changes in medication
• Discuss with specialist looking after her condition
• Any baseline investigations necessary
• General advice – smoking, alcohol, rubella immunity, smears, healthy diet
• Maintain contraception until input awaited from specialist looking after condition

6. Address patient concerns/questions

7. Closure
So we agreed that you may continue to use contraception until a review by your doctor looking after
your condition. You may as well start using folic acid.

Once you get pregnant you should let your GP know so that we can make arrangements to book your
pregnancy early and start looking after your pregnancy from the very beginning.

Thank you for speaking with me.

 Demanding/Difficult Patient
1. Introduction
Patient may want to see consultant

2. Agenda
My midwife colleague has informed me about the purpose of your clinic appointment/consultation
today. I am going to see you on behalf of my consultant and will try to be as helpful as possible.

3. History
• Before we discuss how I may be able to help – is it alright if I get some background information
about your/your relative’s pregnancy and ask you a few questions

• Would you mind if I asked you how old you are? What do you do for a living?

• Tell me about this pregnancy – MOD, when, any problems

• Medical problems

• Medications

• Allergies

• Surgery

• F/H

• Social history – how are things at home, do you smoke or drink

4. Explore the demands, give BALANCED argument – e.g. wants c/s

• What is your reason for having this baby by c/s

• Pros and cons

• Although you are well within your rights to ask for c/s given the guidance from NICE and let me tell
you that we will respect your wishes.

• But unfortunately I am not in a position to book your c/s straightaway and will have to bring you
back to see my consultant.

• In the event of patient demanding to see consultant – think ask arranging to see on call consultant

• My apologies for inconvenience.

5. I know we discussed a lot but is there anything I wasn’t clear about.

Any further questions

6. Closure - summarise
I will arrange follow up appointment with consultant.

Thank you for talking to me

 Booking Questions
1. Introduction

2. Agenda
Congratulate her on pregnancy

3. History
• Is this your first pregnancy?
• Tell me about your previous pregnancies
• How is this pregnancy going so far?
• Ethnic background
• Medical problems – explore
• Allergies
• Surgery
• F/H – clots in family
• VTE
• BMI
• FOQ
• Mental health
• Social – smoking, alcohol, how are things at home

4. Medical/current problem
• How it affects pregnancy and how pregnancy affects this condition
• Any condition like DM, cardiac, renal etc
• What is the current situation/control
• How does it affect her health outside pregnancy (QOL)
• Recent test results – echo, renal test, HbA1c, etc
• Who is looking after – GP vs hospital doctor?
• Any more treatments
• Medications that may be unsuitable during pregnancy

5. Management
Antepartum

Intra-partum

Postpartum

6. Address patient concerns

7. Closure
Arrange follow up
 Abnormality question

1. Introduction

2. Agenda of consultation

3. Background information (history)

• I have the results of the scan and will discuss that in a minute. Because I haven't met you
before - can I just ask you a few questions to get some background medical information?
• Would you mind if I asked you how old you are?
• How many weeks are you today/how far are you into your pregnancy?
• Have you had any concerns in this pregnancy until so far
• Screening
• How is your health in general - any medical problems, any conditions/diseases running in your
family, any medications in this pregnancy?
• Previous pregnancy - if any problems in previous pregnancy or any problems with the child

4. Discuss the results

• Would you like anyone else present for the results?

• Check background understanding
• What does it show
• Do you want me to tell you the results

5. Management – give both options

If wishes to continue pregnancy - Further scans/amniocentesis

- Referrals to FMU
- Support/appointments
- MDT approach
- Support groups
TOP – ASK her if she wants you to give her more information – If yes THEN explain this option

6. Address patient's concerns

I know I have given you an immense amount of information today.

Is there anything I wasn't clear about - I am happy to explain it again.
Would you like me to see you again with the presence of your partner/relative?
Are there any further questions?

7. Closure

Summarize - what you've agreed

Follow up
Leaflets
 Angry Patient (ASSIST)
1. Introduction
• Full name
• Position
• I am going to see you on behalf of my consultant who unfortunately is not in clinic today due to
some important engagement/leave/conference
• I know you had expected to see the consultant but I can reassure you that I will try to be as helpful
as possible.
• Expect patient outburst

2. Acknowledge (A)
Accept the mistake/event

3. Say Sorry (S)

I am sorry that you had to go through this and I can clearly see you are very upset with what has
happened which is understandable. My apologies once again.

4. Story (S)
• Listen/empathise about her story.
• Show empathy while listening to the story – that must have been difficult, echo back what she is
saying
• Check how she is now/coping and ask how her partner is coping.

5. Investigate (I)
• Tell her that our hospital takes these events seriously.
• If your experience was not good in hospital – it is unacceptable for us as well
• If your experience in hospital has not been pleasant it also defeats our purpose of providing best
care possible – it is unacceptable for us as well.
• We do have a system in place to investigate these events or any complaints and I can reassure you
that we will investigate it
• I am keen to help you.
• I am on your side.

6. Solution (S)
• Agree to a plan – way forward
• Reassure her that you will investigate
• Raise the issue with management and write back to her
• Formal complaint – PALS
• Follow up appointment with consultant
• Offer – consultant (on call) to see and review

7. Travel together (T)

Conclude the consultation with what the plan is – whether she wants to come back in clinic to see the
consultant.

Thank you for speaking with me and I apologise once again.

If a relative has come to speak to you – acknowledge this.

Ask – do you have any information about the events that led to this (subsequent operation?)

Tell the patient – how we are going to provide immediate and further care.
 Stillbirth / IUD follow up
1. Introduction
Name
I am obstetric doctor in clinic today and I am going to see you on behalf of my consultant

2. Agenda
Mrs Jones – I have gone through your notes and am aware of the recent unfortunate events. I am really
sorry about the loss of your baby / recent pregnancy. We are going to discuss the results today but
would it be okay if I ask you a few questions first?

3. History
• Check how she is doing and coping.
• How is your partner coping?
• How are the other members of family?
• Did you name the baby? Address the baby in the rest of the consultation with the name (Jack)
• This must have been a really difficult time for you- I am so sorry for your loss.
• How was the pregnancy otherwise?
• Problems?
• Medical problems?
• Medications
• Screening/scans were normal
• No congenital or disorders running in family
• Can you tell me about the events leading to the unfortunate loss of the baby? - Explore

4. Discuss and explanation of the results

Explain that there is nothing she has done to cause this and she should not blame herself.
Reveal the results e.g. post mortem etc.

5. What results mean for her future pregnancies

She has an excellent chance of achieving successful pregnancy in future.
She is very unlikely to have another SB.

6. What we can do to support

Would you like me to arrange an appointment for you and your partner with our counsellor
midwife/bereavement midwife/psychologist?
They can be quite helpful in these situations and perhaps help you to cope better.

Offer further appointment with us/consultant.

7. Plan for future pregnancy

Book your pregnancy early with GP
We will look after in consultant led clinic
We will organise additional monitoring
Early IOL

8. Closure
I know I have given you a lot of information today – is there anything I was not clear about? Would you
like me to repeat anything?

Any further questions

Thank you for speaking with me. Double handshake.

In case patient in clinic where notes are not available and you have no information:

1. Introduction
2. Agenda – you don’t know purpose of appointment?
Mrs Jones – I am sorry I haven’t met you before. Normally when we make arrangements for
patients to come in our clinic we organise notes to be present in clinic so that we get the
background medical information and understand the purpose of the appointment.

Unfortunately I don’t have your notes or any background information and I am very sorry for that.

Do you mind if I ask you why you are in clinic today. I will use this information to try and help you.