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Pregnancy and reproductive health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

General practitioners (GPs) are uniquely placed to provide comprehensive, patient-centred primary care for both women and men for their reproductive health and experience of pregnancy. Pregnancy care encompasses the full spectrum of reproductive health from contraception, unplanned pregnancies, preconception, antenatal, intrapartum, postnatal care periods and termination options, with a focus on patient wellbeing, patient safety and joint decision-making.

In 2019, there were 303,054 babies born to 298,567 mothers in Australia.1 Statistics show that the national birth rate is falling, while the average age of women who gave birth has increased,1 with the highest proportion of mothers aged 30–34 years.1 In addition, the number of teenage mothers decreased dramatically over the past decade.2 Adding to the complexity of pregnancy care is that approximately 15% of couples will experience infertility.3 Failure to achieve pregnancy within 12 months of regular unprotected intercourse is likely to indicate infertility and further management is needed, although this may be commenced earlier in certain circumstances, including in women aged over 35 years or those who have a health condition that may impact their fertility.3,4

Access to culturally safe, appropriate and timely family planning and pregnancy services is vital to ensuring positive health outcomes for women and babies.5 Regular antenatal care in the first trimester is associated with better maternal and child health in pregnancy, fewer interventions in late pregnancy and positive child health outcomes.1,5-7 Access to services in Australia is impacted by location, socioeconomic status1 and other factors including culture, religion, language and health literacy. Appropriate access to maternal and infant health services remains a challenge within rural, remote and Aboriginal and Torres Strait Islander communities, which can lead to corresponding long-term consequences.7 This highlights the valuable role of the rural GP with procedural skills to provide quality obstetric care and continuity of care. The ability of the GP to identify and access relevant health assessments, government initiatives and health promotion programs appropriate is also important to this area of practice.

It is imperative that GPs can identify, manage or refer key red flags that may present in all stages of a woman’s reproductive and pregnancy experience. This includes screening, identification and management of short- and long-term health conditions that impact reproductive health, fertility and pre-conception care, as well as identification and management of complications that arise during and after pregnancy, including threatened miscarriage, mental health conditions, intimate partner violence and the management of terminations.

This area of medicine requires sensitive communication and consultation skills to assist women and their partners with contraception choices, pregnancy planning, unplanned pregnancy discussions, antenatal, intrapartum and postnatal care, high-risk pregnancies, access to assisted reproductive technologies, and access to termination services, with a focus on patient safety, wellbeing and joint decision-making. Skills in trauma-informed care and in delivering bad news are also essential. GPs will provide pregnancy and reproductive care within their scope of practice, regardless of whether they have obstetric training and will work collaboratively with other health professionals and cultural mentors within the private and public sector to provide shared care and continuity of care.

References
  1. Australian Institute of Health and Welfare. Australia's mothers and babies. Canberra, ACT: AIHW, 2021 [Accessed 2 September 2021].
  2. Australian Institute of Health and Welfare. Australia’s children. Canberra, ACT: AIHW, 2020 [Accessed 23 September 2021].
  3. Hunt S, Vollenhoven B. Assessment of female fertility in general practice setting. Aust J Gen Pract 2020;49(6)304–08.
  4. Katz DJ, Teloken P, Shoshany O. Male infertility – The other side of the equation. Aust Fam Physician 2017;46(9):641–46.
  5. Munns A. Community midwifery: A primary health care approach to care during pregnancy for Aboriginal and Torres Strait Islander women. Aust J Prim Health 2021;27(1):57–61. doi: 10.1071/PY20105.
  6. Rolfe MI, Donoghue DA, Longman JM, et al. The distribution of maternity services across rural and remote Australia: Does it reflect population need? BMC Health Serv Res 2017;17. doi:
  7. Jones E, Lattof SR, Coast E. Interventions to provide culturally appropriate maternity care services: Factors affecting implementation. BMC Pregnancy Childbirth 2017;17(1):26. doi: 10.1186/s12884-017-1449-7.
  8. Thackrah RD, Wood J, Thompson SC. Cultural respect in midwifery service provision for Aboriginal women: Longitudinal follow-up reveals the enduring legacy of targeted program initiatives. Int J Equity Health 2020;19. doi:

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • discuss sensitive topics related to pregnancy and reproductive care with women and their partners
 1.1.1, 1.1.2, 1.1.5, 1.1.6, AH1.3.1, 1.2.1
  • conduct a consultation in relation to reproductive health that engages the patient and uses a shared decision-making approach
 1.1.1, 1.1.5, 1.1.6, AH1.3.1, 1.3.1, 1.4.1, 1.4.3, AH1.4.1
  • consider cultural safety, emotional wellbeing and the socioeconomic context for each patient who presents for fertility, pre-conception or pregnancy care
 1.3.1, 1.3.2, AH1.4.1
  • identify and provide preventive health advice for women and their partners planning pregnancy, including appropriate vaccinations and pre-conception screening
 1.2.2, 1.2.3
  • adopt a trauma-informed care approach as appropriate to the consultation
 1.4.1., AH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • conduct a focused physical examination, targeted investigations and screening in women in relation to pregnancy and reproductive health
 2.1.1, 2.1.2, 2.1.3, 2.1.4, AH2.1.1, RH2.1.1
  • determine an appropriate clinical management pathway for patients with reproductive health challenges, standard and complex pregnancies and unplanned pregnancies
 2.1.8, 2.1.9, 2.1.10, AH2.1.2, RH2.1.1
  • communicate and collaborate with other health professionals involved in the care of patients with pregnancy and reproductive healthcare concerns
 2.2.2, 2.3.1, 2.3.2, AH2.3.1, AH2.3.2, RH2.1.1, RH2.3.4
  • explain the concept of continuity of care in relation to reproductive and pregnancy care
 2.3.2, 2.3.4, AH2.3.1, RH2.1.1, RH2.3.1
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify current and relevant resources to support the pregnancy and reproductive health needs of patients
 3.1.1, 3.1.2, 3.1.4, 3.2.2, 3.2.4, AH3.2.1, AH3.2.2, RH3.2.1
  • identify barriers to reproductive healthcare that exist for the practice population and assist patients to access appropriate care
 RH3.2.1, 3.2.1, 3.2.2, 3.2.3, 3.2.4, AH3.2.1, AH3.2.2
  • identify the available, current and relevant genetic screening tests
 3.1.1, 3.1.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate self-awareness of personal cultural or religious values or beliefs that may impact ability to deliver patient-centred reproductive or pregnancy care
 4.2.2, 4.2.4, AH4.2.1, AH4.2.2
  • reflect on their personal skill set and recognise when it is in the patient’s best interest to be referred for reproductive healthcare
 4.2.1, 4.2.2, 4.2.4, 4.2.5, RH4.2.1
  • respect women’s autonomy in their reproductive healthcare decision-making
 4.2.4, AH4.2.1
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • provide safe and timely access to reproductive healthcare
 5.2.1, 5.2.2, 5.2.3, 5.2.4, 5.2.5, 5.2.6, AH5.2.1
  • manage time efficiently to provide comprehensive initial antenatal and postnatal visits
 5.1.3, AH5.1.2, AH5.1.3, 5.2.3, AH5.2.1
  • discuss the medico-legal aspects of reproductive healthcare, especially as they relate to each state and territory
 5.2.2, 5.2.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. A pre-pregnancy check should include a detailed history, review of medications, examination, arrangement of investigations and consideration of referral to a non-GP specialist, if appropriate. Genetic carrier screening and testing for other inherited diseases, such as haemoglobinopathies, should be offered to all couples, if not at a pre-conception consultation, then at the first antenatal consultation.
  2. Challenges in both attempting to conceive (ie infertility) and pregnancy (ie miscarriage) can produce significant emotional distress, which may include parents blaming themselves and feeling shock, anger, grief, depression and anxiety. Be mindful of the language you use in these consultations as you can unintentionally say something that the patient takes to heart or misinterprets. Communicate with empathy, remind them it is not their fault and be clear with your advice and explanations.
  3. When a patient presents with a positive pregnancy test, what is your follow-on comment? Be mindful that not all pregnancies are planned. It is best to explore your patient’s feelings about the pregnancy before assuming they will be happy about it. Simply asking ‘How do you feel about the pregnancy?’ can be a powerful question and help you navigate the consultation and build patient rapport.
  4. Be aware of your local services for pregnancy counselling, and medical and surgical termination of pregnancy. There may be other GPs in your area who have done additional training. Understand your state or territory laws and regulations for termination of pregnancy.
  5. In the first routine antenatal consultation there is a lot to discuss and it can be overwhelming in a standard consultation. Think about how you will structure your consultation. What are the most important things that need to be covered? Then arrange investigations and have the patient return to discuss them. The return consultation should be longer to allow time to cover everything. It can be helpful to direct your patient to websites, reading material and other information to access in between these consultations, so they can return with their questions. However, consider your patient’s health literacy and the best ways you can help to educate them.
  6. It is important to know what your local services offer for those times when you need to refer patients to hospital for emergency care. Think about the following: Should you call ahead? Should you write a letter for the patient to take with them? Is there a pregnancy assessment centre that offers a quick assessment of the patient so they don’t have to attend the emergency department?
  7. Pregnancy is a time of increased risk for reoccurrence or exacerbation of mental health issues and domestic violence. Have this in the back of your mind for all antenatal consultations and start conversations early with the patient. Think about how you might bring these topics up for discussion in a sensitive, non-judgemental way. Remember to give the patient ‘permission’ to discuss these issues. Try normalising statements such as: ‘Pregnancy can be an emotional and tough time, and lots of people feel anxious or depressed. Is that something you would like to talk about?’ Allow the patient to be part of the decision-making process about risk minimisation by continuing or recommencing treatment, arranging psychological support, discussing support networks, and so on, as appropriate.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Pregnancy and reproductive health

Julie, a 35-year-old female, presents with vaginal spotting for two days. She has no past medical history. Julie believes she is pregnant as her period is late and she had a faint positive pregnancy test at home four days ago. This would be her first pregnancy.

Questions for you to consider Clinical exam assessment area Domains

How would you ensure Julie feels safe to discuss intimate sexual history in the consultation? 

Was the pregnancy planned? How does your patient feel about the pregnancy?

What if this were Julie’s third pregnancy – and the previous two were miscarriages. Would that change your approach?

What if you were a male GP? Would that change your approach?

What if Julie were an Aboriginal or Torres Strait Islander? Would that change your approach?

How would you determine if the patient has emotional support through this uncertain time?
  1. Communication and consultation skills
 1,2,5

What further information do you need to make a diagnosis?

What are the ‘must not miss’ parts of the patient’s history?
  1. Clinical information gathering and interpretation
 2   

How do you approach vaginal bleeding in women of reproductive age?

How would you manage this situation if you couldn’t easily access investigations? What if it was a weekend?

What are your differential diagnoses for vaginal bleeding in women?
  1. Making a diagnosis, decision making and reasoning
 2

What is your management plan for women with vaginal bleeding in suspected pregnancy?

How would this management plan change if Julie were experiencing bleeding and in her third trimester?
  1. Clinical management and therapeutic reasoning
 2   

What if Julie were an Aboriginal or Torres Strait Islander, or a patient from a remote area – would that change your management?

Would your management change if Julie had a history of recurrent miscarriage or subfertility?
  1. Preventive and population health 
 1,2,3

How might your own personal beliefs and values influence the pregnancy care you provide?
  1. Professionalism
 4   

What follow-up is needed for Julie?

How will you ensure Julie, and any investigation results, are followed up?

What legal aspects should be considered if Julie were 15 years old? Or a female with an intellectual disability?
  1. General practice systems and regulatory requirement
 5   

When would you consider performing a speculum examination in this case? Would this change your management?
  1. Procedural skills
 2   

How do you communicate the uncertainty of this situation to Julie?
  1. Managing uncertainty
 2   

What would be the emergency features or red flags in the history and examination that you would be concerned about?

How would Julie be triaged in your practice to ensure she is seen today?
  1. Identifying and managing the significantly ill patient
 2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Use your practice software to identify patients who are pregnant or planning pregnancy. Review their medication history. Identify guidelines and resources that help you identify drug safety in pregnancy (and breastfeeding).

Use practice software to find a patient who presented with infertility and review the case notes and the course of events. Identify Australian guidelines for managing infertility and compare the investigations that were arranged and the way the patient was managed with the guidelines you have identified. (See journal articles listed in the learning resources section.)

  • Is there anything you would have done differently? Why/why not?
  • Ensure you are familiar with your local referral pathways.
  • Were you able to find many patients in this search? Reflect on the importance of correct visit and past medical history coding in the clinical software.

Make a list of differential diagnoses of vaginal bleeding in pregnancy (first, second and third trimesters) and the post-partum period.

  • What are the important points in the history, examination and investigation that will help you identify the probable diagnosis?
  • What are the key points or red flags that will be most important to identify?

Identify a pregnant patient in your practice. Make a list of the preventive health measures that should have been offered to this pregnant patient. Now change the demographic of this patient and write a list of preventive health measures for each of these demographics: 1. younger (under 30 years); 2. older (over 40 years); 3. Aboriginal or Torres Strait Islander; 4. different ethnic background.

  • Were the preventive measures offered? When should they be offered?
  • Compare the lists. What is similar? What are the differences and why are these differences important?
With a supervisor

Undertake a speculum examination (in a non-pregnant patient) with your supervisor present and ensure you are comfortable with how to perform the procedure, how to discuss the procedure with your patient and gain consent, and what you see whilst performing the examination.

  • What feedback did you receive from your supervisor about how you went?

Plan how you would manage a routine first antenatal consultation. Include details of what should be discussed and how time should be managed. Discuss this with your supervisor.

  • What changes or other ideas did your supervisor suggest?

Discuss the subtle clues that may help identify postnatal depression, how to broach the subjects that may reveal this, how to perform and interpret an Edinburgh Postnatal Depression Scale/Score, and key management strategies.

  • How would you sensitively ask a patient about postnatal depression?
  • What tips did your supervisor give you?
In a small group

Role-play the following pregnancy consultations. Have group members rotate through the roles of patient, doctor and observer.

  1. Interpretation of an early pregnancy ultrasound where the pregnancy is yet to be sighted (first trimester).  
  2. Nausea and vomiting in pregnancy (first and second trimester). Discuss what is considered ‘normal’ versus nausea and vomiting of concern (ie hyperemesis gravidarum).
  3. Positive oral glucose tolerance test (OGTT) in pregnancy.
  4. Pubic symphysis pain (usually in the third trimester).
  • How did your questions and explanations compare to the rest of the group?
  • As a group, agree on the ‘must not miss’ history and examination points for each situation.
  • Consider writing your own cases and use them to provide feedback to each other.

Discuss how to arrange a termination of pregnancy and what services are available in each of your local areas.

  • Do these services differ? How do you refer to them?
  • What are possible barriers to a woman accessing these services? What is the cost?
  • What are the legal issues to consider?

Organise a teaching session with your group. Allocate each member a topic or case to research and present to the group. When teaching your peers, remember to include the important resources you used. Here are some topics/cases that you might like to consider:

  • What is a biopsychosocial assessment? How does this relate to the pregnant patient?
  • What is intergenerational trauma? How might this relate to how Aboriginal and Torres Strait Islander patients access healthcare when pregnant?
  • A 35-year-old female presents with an inability to fall pregnant after 12 months. What are the key history, examination, investigation and management areas for this patient? What if the patient was 25 years old? What if she was 45 years old? What are your considerations for her partner?
  • What fertility treatment is available in Australia? In urban areas? In rural or remote areas? What are the costs involved?
  • How does your pregnancy history and assessment change for different ethnic and cultural groups?
  • Outline the different mental health screening questionnaires and discuss which are better suited for the antenatal and postnatal patient and why. Practise using them with your group.
With a friend or family member

With the permission of a friend or family member, role-play a consultation of breaking the bad news of a high-risk first trimester screening result. Video this consultation and review it with your supervisor or another doctor.

  • Think about more than the clinical aspects of the case. What was your body language like? Did you say ‘Um’? Did you use jargon? Did the patient fully understand what had happened? How do you know this?
  • Ask the ‘patient’ how you went.

If appropriate, ask a friend or family member what they thought of the Australian healthcare system during their pregnancy or fertility journey.

  • Identify what was done well and what could be improved.
  • Reflect on how general practice can help facilitate pregnancy and fertility care. Consider how people’s experiences may be affected by culture, ethnicity, being Aboriginal or Torres Strait Islander, living in rural or remote communities, and so on.  

Review a local hospital patient information sheet with your friend or family member and practise explaining a condition or procedure to them. For example, explain pre-conception genetic carrier screening, first trimester screening (including what happens if identified as high risk), gestational diabetes (positive OGTT), public versus private antenatal care, etc.

  • What was challenging about these conversations?
  • What questions did the ‘patient’ ask? Reflect on why these questions were asked. What could you change about the way you delivered the information to reduce these questions?
  • Was the handout useful? Would you use a different one in the future?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Through history, examination, appropriate investigations and referrals, formulate a management plan (with the patient) for the following presentations:
    • unplanned pregnancy: discuss non-directive counselling, the available termination of pregnancy options (medical and surgical) and the legal aspects of termination
    • subfertility/infertility: discuss support services, ways to optimise fertility for males and females, when to refer and in vitro fertilisation (IVF) considerations (psychological support, legal aspects, etc).
  • After completing a history and examination, conduct a pre-conception consultation, including a discussion of:
    • genetic diseases and the available pre-conception tests
    • screening and any ethical considerations
    • managing chronic diseases prior to and during pregnancy
    • preventive health, including advice about diet, supplements, medication, lifestyle, smoking, alcohol and substance avoidance, weight management and immunisations.
  • After completing a history and examination, identify what needs to be covered in an antenatal consultation and include the following:
    • confirming pregnancy
    • identifying women who may need additional medical, social or cultural support
    • managing routine pregnancy, including arranging investigations, screening tests and education about diet, lifestyle, supplements, immunisations, and delivery and care options
    • managing normal symptoms of pregnancy, including physiological changes, nausea, vomiting, back pain and pubic symphysis pain
    • managing (and referring if appropriate) minor intercurrent problems of pregnancy, including breast disorders, screening for gestational diabetes and infections during pregnancy (eg urinary tract infections, pelvic inflammatory disease, vaginal thrush)
    • types of antenatal care (eg shared care, midwifery-led care, private versus public hospital care, rural models)
    • types of delivery (vaginal birth – unassisted, vacuum and forceps; caesarean section).
  • After completing a history and examination and arranging investigations (if appropriate), identify, and know when and where to refer, the following complications of pregnancy:
    • bleeding in early pregnancy
    • foetus small for gestational age
    • ultrasound abnormalities
    • premature labour
    • deep vein thrombosis
    • undocumented breech presentation.
  • After completing a history and examination, identify, and know when and where to refer, the following emergencies in pregnancy, including:
    • bleeding in early pregnancy (threatened miscarriage, miscarriage, ectopic pregnancy)
    • bleeding after 20 weeks
    • puerperal infection
    • injury affecting pregnancy
    • hypertension
    • pre-eclampsia
    • eclampsia
    • premature labour
    • mental health.
  • After completing a history and examination, identify what needs to be covered in a 6-week postnatal consultation. Include the following:
    • breastfeeding concerns: mastitis, breast pain, nipple trauma, thrush
    • sleep issues
    • mental health, including postnatal depression and psychosis
    • screening for intimate partner violence
    • deep vein thrombosis
    • postpartum bleeding
    • complications or perineal and abdominal (caesarean) wounds
    • postnatal contraception
    • cervical screening, if required
    • advice on the need for babies to be checked.
  • Be able to undertake the following procedures according to recognised best practice:
    • female pelvic examination
    • pelvic speculum examination, including cervical screening
    • urine pregnancy testing
    • collection of pathology specimens (vaginal swabs).

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
These two articles provide a systematic and clear framework to approach female and male infertility presentations.
Textbooks
Advice on managing nausea and vomiting during pregnancy. Advice on prescribing different medications during pregnancy and breastfeeding.
Online resources
National guideline for what is expected during antenatal care. Guidelines on preventive health activities for the pregnant patient.
Learning activities
eLearning activities on the topic of pregnancy care.
  • The Royal Australian College of General Practitioners. gplearning:
    • Antenatal and postnatal shared care
    • Alcohol in pregnancy
    • Pregnancy advice and support
    • AJGP Clinical Challenge – June 2020: Reproductive health
    • check, unit 568, January – February 2020: Mothers and babies
    • check, unit 580, March 2021: Women’s Health
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/pregnancy-and-reproductive-health 9/10/2024