General Practice: Specific recommendations

Communications

• GPs should ensure they undertake a careful risk assessment during telephone consultations with, or concerning, women who are or who may be pregnant. If they are in any doubt they should see the woman or arrange an appropriate referral for her.
• Whenever possible, the GP should give the woman’s named midwife confidential access to her full written and electronic records.
• GPs should ensure that any significant letters are copied into the woman’s hand-held maternity record.
• Midwives should ensure that all investigations that they initiate are copied to the GP.

Making urgent referrals

• There needs to be a routine system in every maternity service by which GPs, midwives and obstetricians can communicate rapidly with one another, and seek advice, if a woman’s condition gives rise to concern. This might be phone, fax or email.  For this purpose conventional referral letters are inadequate and take too long. Referral management systems must not impede access to urgent appointments.
• A GP should make “fast track” referrals directly to appropriate physicians if women have serious medical conditions such as congenital cardiac disease or epilepsy at the onset of pregnancy. They should not rely only on conventional referral pathways to an obstetrician or midwive as this introduces delays that may compromise the woman’s health.

Migrant women and women who do not speak English

• A medical assessment of general health before or at booking of migrant women may prevent complications or even death in later pregnancy. This should include a cardiovascular examination, performed by an appropriately trained doctor, who could be their usual GP.
• Relatives should not act as interpreters. Funding must be made available for interpreters in the community, especially in emergency or acute situations.

Obesity

• GPs should record the Body Mass Index of pregnant women and those contemplating pregnancy, and should counsel obese women before and during pregnancy regarding weight loss or healthy eating.
• Women with obesity are not suitable for GP midwifery-led care because their pregnancies are higher risk. These women should be referred for specialist care because of possible co-morbidity. 

Mental health and substance misuse

• GPs should take detailed histories from pregnant women about any previous psychiatric illness and its severity, enquire directly about substance misuse or addiction and check their previous records if there is any doubt.
• GPs should communicate details of their patient’s previous psychiatric history, including that of alcohol and drug misuse, not only with obstetricians but also with midwives, preferably with the woman’s consent.
• GP should refer a pregnant woman with a significant mental health history to a psychiatric service, preferably a specialist perinatal service, during pregnancy, so a management plan can be developed.
• GPs should not work beyond their level of expertise in managing drug using women. They should refer or seek advice from specialists in drug misuse.
• Women who misuse drugs and alcohol should be managed by multidisciplinary teams involving GPs, specialists in substance misuse (who may be GPs), specialist obstetricians and midwives, health visitors and social workers. Each woman must have a lead professional, and agency, to take responsibility for the overall management and coordination of her care. This would not usually be the GP.

Social services and child protection

• Close multidisciplinary and multi-agency support must continue to be provided for women who have had their baby removed into care by social services.