Fetal Medicine 1. 2. Set Agenda / Purpose of Consultation 3. History (Relevant) - Check Gestation
Fetal Medicine 1. 2. Set Agenda / Purpose of Consultation 3. History (Relevant) - Check Gestation
1. Introduction
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
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
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
7. Show empathy
I am so sorry – I wish I had better news. I know it comes as a shock.
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.
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?
Previous pregnancies
S/H
D/H – allergies
Mental Health
Have you had any mental health issues before?
Social History
You told me you work as a ‘teacher’ – how are things at work?
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.
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.
5. Address other issue that she presented with like USS report
‘Domestic abuse is completely unacceptable and none of us should have to go through this.’
8. Safety Planning
If she does decide to go home- plan the escape situation.
9. Documentation
In hospital notes but not handheld notes. Also document if you strongly suspect DA but woman
declines.
Rape – can involve police but charges can be made by patient only
12. Closure
Pre-pregnancy Counselling
1. Introduction
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
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.
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?
• Medical problems
• Medications
• Allergies
• Surgery
• F/H
• 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
6. Closure - summarise
I will arrange follow up appointment with consultant.
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
7. Closure
Arrange follow up
Abnormality question
1. Introduction
2. Agenda of consultation
• 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
7. Closure
2. Acknowledge (A)
Accept the mistake/event
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
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
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?
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.