Historically we have been guilty of overmedicalising the physiological events of pregnancy and childbirth.
This is quite understandable when you consider the origins of our present routines of maternity care. They were established during the years of rationing that followed the Second World War, when maternal and perinatal mortality and morbidity rates were much higher than they are now. This approach has long been outdated. Hence, the new guideline on antenatal care from NICE is most welcome.
I agree with many of Dr Saul’s opinions (‘NICE guideline aims to streamline antenatal care’ Guidelines in Practice, November 2003).
The timetable recommended by the guideline for normal antenatal care appointments is clear, and the acknowledgement that the primigravid state is of greater clinical significance than that of subsequent pregnancies is realistic.
The setting of standards for gestational age assessment by ultrasound scanning and the precise requirements relating to testing for Down’s syndrome will help to remove some of the variation in provision across the NHS.
Although antenatal appointments are usually relaxed encounters, useful in building the doctor-patient relationship, they are really just a form of screening. The art of midwifery or general practice in the antenatal period lies in spotting deviations from the norm and acting upon them.
I would perhaps be less inclined than Dr Saul to offer extra antenatal appointments for reassurance purposes; surely this contradicts one of the guideline’s major evidence-based conclusions? However, my situation may be very different from his with respect to patient population and the availability of supportive midwifery colleagues.
I was delighted to read the guideline’s advice not to offer iron supplementation routinely to all pregnant women. I have campaigned for years unsuccessfully against our local policy of treating the physiological haemodilution of pregnancy. It is not only unhelpful but also a potential hazard to toddlers. Iron is commonly associated with accidental overdose in young children, with serious and sometimes fatal outcome.1,2
The only point on which I disagree with the guideline relates to toxoplasmosis. The risk associated with disposing of cat litter is, I believe, overstated. As long as it is done daily it is safe, unlike exposure to soil that cats may have fouled. The new guideline with its clear and precise advice provides any interested GP with a useful source of clinical audit topics. It would be easy to collect data on compliance with the set programme. Reasons for deviating from the programme could be useful as a practice-based equivalent of the confidential enquiries produced by the RCOG. Auditing iron prescription would be a topic close to my heart. Once again, NICE is to be commended for its useful publication. We have put it at the top of the agenda for the next practice liaison meeting with our midwife.
Dr Chris Barclay, GP, Sheffield
- Juulink DN, Tenenbein M, Koren G, Redelmeir DA. Iron poisoning in young children: association with the birth of a sibling. CMAJ 2003; 168: 1539-47.
- DoH 2002/0493.