Episode 152 Obstetric Medicine

In this episode I am joined by incredible obstetric physicians Professor Catherine Nelson-Piercy & Dr Melanie Nana. We discuss what is an obstetric physician? How can we better work together in pregnancy to care for women with more complex medical issues? Plus learn all about maternal medicine networks.

Want to know more?
https://www.pslhub.org/learn/patient-safety-in-health-and-care/high-risk-areas/maternity/3-ps-in-a-pod-poster-identifying-red-flags-in-pregnant-women-r4568/
https://www.obstetricmedic.org.uk/
https://www.england.nhs.uk/publication/maternal-medicine-networks-service-specification/
https://uktis.org/
https://www.medicinesinpregnancy.org/

You can contact Cathy or Melanie on Twitter @nelson_piercy & @Melanie_Nana1 

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
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Transcript

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Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician, hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and for that matter anyone else that's interested, the obspod is for you. I'm very excited today to welcome two guests to the Obspod. I have with me Professor Katherine Nelson Pearcy, obstetric physician, and also Melanie Nana, obstetric physician. And we're going to start by perhaps hearing a bit about each of them. So maybe Kathy, if you want to start and explain a little bit about who you are.

SPEAKER_01 1:24

Thank you, Florence. So uh I am an obstetric physician, as you've introduced me, and a lot of people don't know what that is. So an obstetric physician, first and foremost, is a physician, not an obstetrician. So I can't deliver babies. I have no training in obstetrics and gynecology. Um, I'm trained as a general physician, and obstetric physicians specialise in looking after women with either acute or chronic medical problems in pregnancy. We that often encompasses pre-pregnancy counselling, some postnatal care, and we work very closely with obstetricians. We work in teams with midwives, obstetricians, other specialist physicians to try and ensure that women with medical problems in pregnancy receive expert care. We are a relatively new breed. There's only 24 of us in the whole of England. However, there are many obstetric physicians in Canada, Australia, New Zealand, so the UK is a bit late to the party, but we're ahead of the rest of Europe. And very excitingly, the Royal College of Physicians has recently created a diploma in obstetric medicine. So trainees now have the facility to train in obstetric medicine. And there is also some funding from Health Education England. I can't remember what they're going to be called when they merge with NHSE, but there is now funding for some more training posts in this specialty.

Florence 3:01

That's amazing. I didn't realise that there are still only 24 of you because I really see you as a pioneer. I've kind of watched through my career and been to your lectures. And I must admit, your your um handbook of obstetric medicine, I bought it and it lives on the shelf in our Labour Ward Consultant Office, so we can handily refer to things. So I can't believe that we're still only at 24.

SPEAKER_01 3:29

Well, for many years there were two, my boss, Michael DeSuite, and Professor Chris Redmond in Oxford. And then Michael created three of us. So there were then five for probably 10, 12 years, and then the last 10 years there's been a gradual expansion because myself and my colleagues at St. Thomas's have trained people. Lucy McKillop has trained people in Oxford, David Williams trained people at UCH, and Queen Charlotte's was also a training centre. So we had four training centres, and those uh training centres have um continued to train people, and most importantly, uh we've now got the backing of NHS England to create consultant posts. There's no point training these people if there aren't consultant posts to put them into. So the the sort of parent obstetric physicians like myself do full-time obstetric medicine, but the new model is for physicians to do some sessions in obstetric medicine with their parent specialty, be it cardiology, diabetes endocrinology, uh, nephrology, clinical pharmacology, because uh to be a full-time obstetric physician, you have to work in a big teaching hospital that has at least 10,000 deliveries to keep you busy. Uh so their obstetric physicians work across hospitals, or more and more people appointed with fewer sessions in obstetric medicine. And the reason why you thought there were more, Florence, is because that work has traditionally been done by obstetricians, either obstetricians who have MRCP or obstetricians who've completed what used to be called the special skills module or the ATSM in maternal medicine. But that's not the same as an obstetric physician.

Florence 5:18

Yeah. So, Melanie, I'm gonna bring you in here. So you presumably started by doing normal acute medicine training, as it were, or or core medical training, and then you've gone into one of these training posts, or what what kind of attracted you and grabbed you into obstetric medicine?

SPEAKER_00 5:42

Yeah, so I um did my medical training in Wales and was training in Cardiff and got to a bit of a um crossing the roads where I couldn't quite decide which medical specialty to do. So I took a little bit of time out after core medical training to do some cardiology, to do some endocrinology. Um, and then just by chance, I went to the European Endocrine Congress and saw Professor Williamson giving a talk on um endocrine problems in pregnancy. Um, and in fact, my friend was sitting beside me and she was like, You've never been interested in anything, like you're interested in this, you need to go and speak to that lady. Um and I did, and that was the first time that I've been introduced to the concept of obstetric medicine.

Florence 6:19

Right.

SPEAKER_00 6:20

I mean, it was such a wonderful group. They invited me across to London. I came to some of the lectures that you've described, um, and I think that's when I caught the bug. Um, and so therefore had to move essentially from Wales across to London in 2020. Wow. And that was just a couple of years after the RCP credential had come out. So I was able to do that while training here. And so, yes, now I'm uh hardcore wanting to be an obstetric position full-time in the future.

Florence 6:53

That's fantastic, and we so need you. I mean, I think kind of maybe for some of the midwives listening or or women listening, it sort of seems a bit weird that we have these silos of different specialties and that it doesn't kind of cross over. But in my mind, one of the values of um having obstetric physicians is that we're all a bit scared of the things that we don't know about. And when I have a woman who's got potentially a medical problem, I know how to deal with her pregnancy. I know how um her body changes in pregnancy, um, but I don't know the cardiac, the heart problem, or whatever it is in the depth that they do. But likewise, they might know everything about cardiac disease in a frail elderly person, but they're more scared of the fact that she's pregnant and they don't understand the physiology and changes of pregnancy. And so that's the kind of bit where it's almost like a Venn diagram, the overlap, where you kind of have both bits of expertise. And that's really, really valuable to me as an obstetrician when someone is a bit more complicated and I need a bit of more additional detailed knowledge that I haven't got in my sort of day-to-day. So it is, although it kind of sounds a bit weird what we're talking about, dividing it up, it's so valuable to have this people that are familiar with medical problems but in pregnancy.

SPEAKER_00 8:38

I think it works both ways as well, because as a group of physicians, I do quite a lot of work with trainees and teaching. And then you get to the point where you become a medical registrar and you're responsible for the on-calls and seeing patients around the hospital. And I think it's often mentioned that the most worrying phone call is when someone says there's a patient in resource with chest pain and they're pregnant, or please can you come to Labour Ward? So I think you know, merging somewhere where there's expertise in the middle and also, you know, then naturally having the relationships with the obstetricians and even obstetric trainees for trainees like myself, it's really, really helpful in providing like the best care for those patients.

Florence 9:14

Yes. Yeah, we've definitely had instances where we've rung up and it's been, where is labor water? You know, not even like, oh my god, I've got to go there. I don't know where it is. Um, I don't know how to get there.

SPEAKER_01 9:26

Sorry, you mentioned the midwives, and I think there's there's two things I want to say about that. Firstly, the people we look after, the pregnant people we look after now are different to the pregnant people we looked after 30 years ago. They're older, they have more comorbidities, and it's now absolutely routine for midwives to book in women with medical problems, and yet the midwifery training does not equip those midwives to know what's important, what's not important, and they need people to ask and people to support them. So, as part of the maternal medicine networks, there's a lead midwife, as you will know, for each maternal medicine network. And one of the really important roles of that lead midwife is to help provide education for all the midwives in the network. It's all very well saying, oh, we've got a specialist midwifery team and they look after all our women with medical problems, but that doesn't help the midwife doing the booking in the community to know whether the woman who has palpitations, whether that is significant or not. It doesn't help the midwife running triage to help assess whether that woman who comes in with atypical chest pain, whether she needs to do something else about that. So I think it's really, really important. And to be fair to NHSE, they did recognize the crucial role of midwives and they funded a full-time maternal medicine midwife when they funded full-time obstetric physician. Interestingly, they only funded half an obstetrician, uh, but that's because there were a lot more obstetricians trained in maternal medicine than midwives trained in maternal medicine. So I think the role of the of the midwives is crucial, and we must never forget that. And I I often, you know, we we say our bit, we do our bit, we give the counseling, and then someone has to provide ongoing care for those women. And I don't, and and it, and in labour. And you know, if we think the the that that that you're scared, Florence, imagine the poor midwife who has to spend, you know, 12 hours with that woman in labor who has heart disease. Uh, and she's not had the training to equip her or him to do that. So I think it's we we do need to, and and the same goes for the obstetricinesis. I think the way training has changed has changed the way we deliver care and made the need for obstetric physicians and and specialist midwives and specialist obstetricians much, much more vital than it was when we had lots and lots of generalists.

Florence 11:56

Yeah, I think that's true. I definitely see a lot more women with more complex, chronic medical conditions. And I mean, particularly where I work at Kingston, we see lots of women in an older age group having their babies. And inevitably, when you're a bit older, you've got more chance of having developed problems in the past. But I think also maybe with fertility treatments and general medical advances, maybe women are more confident about getting pregnant when they've got a chronic medical problem. Um, so I agree, it's definitely on the increase. You mentioned maternal medicine networks, and that's definitely something I've seen a big change in over my career. So we were talking a bit before we started recording about very much, it used to be there was a kind of general clinic, and us as obstetricians, part of our job was to see women with medical conditions, and we would have some basic understanding, but not necessarily everything. And um, you very kindly, when I reached out to you for various weird and wonderful diagnoses or problems that women would come to me with, would point me in the right direction of someone who would know how to look after them. And now that is being much more formalised, isn't it, with the formation of maternal medicine networks. So I don't know if you want to talk about them a bit.

SPEAKER_01 13:28

Yes. So it is try, you know, it's it's there was a sort of postcode lottery uh until three years ago, where you know, if it it would totally depend on the expertise, whether there was an obstetrip physician where you booked or the expertise of the uh of the and experience of the of the maternal medicine obstetrician, if indeed there was an obstetrician with maternal medicine training. So what the networks are doing are importantly not to undo anything that was there already. So in it, you know, in many areas there was a quite a uh an a well-developed informal um setup whereby there would be, you know, that's the cardiologist we use, that's the nephrologist we use. And in if you take the example of diabetes, most obstetric units will have a some sort of joint obstetric diabetes clinic, yes, led by a diabetologist or a diabetes nurse specialist. So the networks are about formalising what existed, but to bring up other units to the right level of making sure that all women with epilepsy have access to a pregnancy epilepsy team in the same way as all women with diabetes, to make sure that not just women who booked at a teaching hospital had access to specialist uh physicians. So, you know, inflammatory bowel disease is another good example. So there will be gastroenterologists in most obstetric hospitals, but that particular gastroenterologist might not have a special expertise in inflammatory bowel disease and certainly not inflammatory bowel disease in pregnancy, even though it's nominally part of their training. So the role of obstetric medicine is to create pathways so that the obstetricians and the midwives know well, what which women with inflammatory bowel disease need to be discussed with the centre. Not all of them, but which, you know, which which women would you bring to the MDT? And that will vary depending on the expertise of the obstetrician and the expertise of the local physicians. So in some district general hospitals, there are fantastic physicians who have joint clinics in, say, rheumatology, but in others there aren't. So it's to make sure that all women have access by creating these agreed pathways. It's not about a lot of people misunderstand the networks as oh, it's all about the teaching hospitals taking all the interesting patients and making all these women travel up miles and miles to deliver in the hub. It's not about that. It's actually about keeping care local as much as possible. It's about educating the local clinicians, empowering them, and allowing women to deliver locally, but with the necessary support from the obstetricians, the midwives and the physicians at the hub if needed. So that I want to make that clear because people thought at the beginning, particularly, oh, this is just people feathering their nests and making the ivory towers bigger. It absolutely is not that. I mean, there are some areas where I think the hub think that's what the role is, but certainly, certainly not in London. In London, people get it because many women are referred into London from, you know, deepest, darkest, Kent, Sussex, Surrey. And we want to keep the women's care local, but we want to make sure that they receive the right care and that the clinicians receive the right advice. And having seen what's what's been happening so far, that is happening. Clinicians are becoming more confident because they know we're on the end of the phone, that we they can email us, they can clarify, but it also makes the hub make clear plans, right? This is your intrapartum plan, this is the postnatal follow-up plan, this is what should happen. So I I'm the eternal optimist, but I do think it is improving care.

Florence 17:13

I think you're right, because I would actually say I am seeing the reverse of everything being sucked into the tertiary centre. I'm feeling it's more we're seeing more women locally with slightly more complex problems. I can't say that isn't making some of us a bit nervous some of the time, but we're seeing women that perhaps previously we would have gone, oh no, because I work in a secondary care um acute hospital. We're not the tertiary centre. And I'm seeing more women who are, oh, actually, she is going to have her baby with us. She does live local to us, but it's okay, she's got this very comprehensive plan, and that is really helpful. But like you said, upskilling the midwives, anesthetists, and sort of day-to-day average obstetricians like myself, it is a it's a bit of a shift.

SPEAKER_01 18:15

Yeah, and the whole team has to be happy. Yeah, experience breeds confidence, experience breeds expertise. And you know, once you realize that every woman with a pacemaker isn't gonna drop down dead when she has a baby, it you you become more confident. But we have a huge amount of work to do. As I said, we we've got the the the whole of the midwifery workforce has to be as confident as as the midwife who works with the specialist uh team. And the other thing to say is if we're gonna reduce maternal deaths, actually we need to concentrate on educating general practitioners, community midwives, because that is where women present and AE doctors, emergency department doctors, that is where women present with acute medical problems. And yes, women die of cardiac disease, that's the commonest cause, but they're not dying of known cardiac disease, they're dying of unknown cardiac disease, presenting with breathlessness. And until we teach all midwives how to recognize pulmonary edema, the significance of orthopnea, we won't prevent deaths from cardiac disease. It's very, it's not difficult, it's just big.

Florence 19:35

Yeah. Yeah, I was going to ask you about GPs because as you've just mentioned, they're a critical part of care, not only in pregnancy and postnatal, but actually preconceptual care. So I know part of what you do is preconception care, and a lot of the embrace reports have referred a lot to the importance of preconception care and counselling and adjusting people's medications and kind of optimizing whatever their medical condition is before pregnancy. So, are you doing teaching and sort of sessions with GPs on that? How are you approaching that?

SPEAKER_01 20:21

Yes, absolutely we are. We we have lots of GP-focused teaching. The GPs want to learn. Um, you have to arrange the teaching at times that suits them, not that times that suits everybody else, and you have to keep engaging. But you know, they have to know so much about so much. I would really struggle to do that job, but they they do want to learn. There is a willingness to learn, but they want it in accessible bite-sized chunks. This is what we do, this is what we do with antihypertensives, this is what we do with diabetes drugs, this is what we do. Like, don't give us a one-hour lecture on anti-heumatic drugs. We're not interested. We want to know what to do. And one of the commonest problems we see actually are problems that involve there are two common problems that involve GPs that I think we could sort out given the right resources. One is inappropriately stopping antidepressant drugs.

Florence 21:20

Oh, yeah, we see that all the time.

SPEAKER_01 21:21

I do the maternal is is appropriate management of hyperemesis. And if we could if we could sort that out, two very common problems, we would improve care overnight.

Florence 21:33

Melanie, I know. Yeah, hyperemesis. I know that's I know that's your baby. So tell us a bit more about that, maybe briefly.

SPEAKER_00 21:43

I guess just touching on the point about hypermises, like we did a study um across Wales of general practitioners, and as Kathy said, they cover every aspect from babies up to elderly patients. So I I completely agree, we can't expect experts in everything. Um, but it was clear. From the work that we did, that more than half of the GPs didn't feel comfortable in prescribing the first line anti-emetics that are kind of recommended in the RCOG guidance. But over 95% wanted to be able to have more education. But they were quite clear it needs to be targeted education about the things that they're going to see. And secondly, you know, being signposted to the appropriate guidance because you can't expect to know everything. But if you know that this is the guideline that I should be reading and it's an evidence-based good resource, that was definitely in demand. So I know that Kathy's in the process of updating the high-premises guideline for the RCOG. And we're trying to include in that flow charts for primary care for emergency medicine for early pregnancy units so that you know succinct information is distributed. I think hopefully that'll be a way forward.

Florence 22:51

Yeah, it's that scary thing again, isn't it? The GPs are scared of prescribing the wrong thing and causing a problem. The problem is in the first trimester, which everyone is worried about because that's when so much development is going on in the embryo. And it makes such a big difference to women because they can get so unwell.

SPEAKER_00 23:12

Yeah. I mean, the the the we did a study of over 5,000 women across the UK who had had high premises, and 5% of them had terminated a wanted pregnancy because of high premises itself, and 7% had suicidal ideation on a regular basis. And we looked at all of the open box feedback. So women had made comments, and it's absolutely traumatizing to even read, never mind for that patient themselves, about how difficult it can be to access care and the appropriate anti-ometic therapy. But we discussed recently, you know, the the lider disaster happened a long time ago. And when we watch things like Call of the Midwife, for example, those are the sort of stories that keep getting brought up, not the stories about how we do drug trials differently now, how we make sure that these are anti-ometics are safe and the wealth of anti-ometic safety data that's available, that that's not the story that keeps getting told despite the fact that we're well aware now that those anti-ometics are safe.

Florence 24:10

Yeah, that's interesting. I know lots of people are doing research on what social media, TV, etc., has impact on in terms of birth and pregnancy care and all sorts of things, but you're absolutely right. That's what's in everyone's head all the time. And then I guess more recently, Balparate, you know, has been such a big thing in terms of headlines and that tighter control around prescribing that. And that sort of kind of brings us on to a bit about medication and and drugs, because I think there is something about women being very scared to take medication in pregnancy. And I use a lot because I have a mental health clinic, Bumps, the best use of medicine in pregnancy. Is that the website you send women to as well?

SPEAKER_01 25:06

Yes, that that is the um UK Teratology Information Service. That that is the patient-facing bit of the web uh of the website, and it's fantastic. And Ken Hodson, who's now the medical director of UKTIS, is very responsive if if you find wrong information on there, uh and they will update it. But for clinicians also, Florence, there is the clinician-facing bit of the UK TIS website where they have much more detailed monographs. So, for example, if you've got a if say you're looking after a midwife who's on searchline and she she wants to actually see the evidence, you you go to the UK TIS clinician-facing bit and you'll get monographs. I mean, actually, for searching, you could go to the nice guideline, which is very good, but that's just an example where you get a more detailed monograph summarising the evidence of different drugs in pregnancy. So I that come, they can't cover everything and they're they're gradually trying to cover everything or it drugs where there's an issue. Uh, for example, when there was a warning about hydroxychloroquine, which there was recently, when there was a warning about onantitron, that UKTIS will respond to that, do a literature review, and write a very detailed monograph. So, and it's a a fantastic resource. It's not comprehensive, but it's it's very, very balanced and much, much more useful than the BNF. So, yes, that is the website that that I would send women to or direct healthcare practitioners to.

Florence 26:37

Excellent. That's really useful. Lovely. So we're coming to the end of the time that you've so kindly given me. And normally at the end of my podcast, I end with what I call a zesty bit. So a kind of really punchy take-home message. What is it we want people to remember from our conversation? And I'm immediately thinking part of it is uh investigating properly whatever symptom, whether that's breathlessness or whether that is um a lump in the breast, doing the investigations you would normally do. But I wonder if either of you have got a kind of zesty bit that you feel like this is what you want people to hold on to.

SPEAKER_01 27:23

Do you want to go first, Melanie? Or do you want me to go first? So if if I were talking to physicians, Florence, I would say that I would say what people have said before me is what would you do if this woman wasn't pregnant? What would you do if this was a man? And then leave it up to the obstetrician to say whether that is appropriate or not. But I realize that probably not many physicians are listening, and we're we're talking to obstetricians and midwives. And I would actually say listen to the woman because she is telling you what's wrong with her, and don't dismiss symptoms that may seem trivial if the woman represents if she's coming in the middle of the night. Women don't do that unless there's something wrong with them. So it's listen to the woman, take a history and and act list active listening. That that I think is what will probably make the most difference to your practice.

Florence 28:32

Yeah, that's that's so true. It's so simple, but it's so true that it needs to be said. Yes. Melanie, what about you?

SPEAKER_00 28:42

So, I mean, I absolutely agree with that, obviously. But I think, you know, we've talked about obstetrial medicine, we've talked about medical problems in pregnancy, and coming from a trainee point of view, there are a lot of resources out there. You know, your podcasts, these reference guides, Kathy's done an enormous amount of work in setting up the maternal medicine network. So I think, you know, don't be afraid as someone who has less confidence, whether you're a midwife, a GP, a junior doctor. Um, if you're concerned about a pregnant woman, there are so many people out there that you can ask and who are very helpful happy to help you. So, you know, reach out and pick up the phone so that we can try and make sure that every woman gets the best care possible.

Florence 29:24

I think that's equally a perfect place to end because that is so true in my experience. If you pick up the phone and actually talk to people, then you immediately get really good advice and help, which sort of brings me back to the beginning of um you having helped me in the past, Kathy. So thank you very much, both of you. It's been such a pleasure to talk to you both. If you've enjoyed this episode, then I'm continuing my conversation with Professor Nelson Pearcy and Dr. Nana next week to discuss breast cancer in pregnancy. So don't forget to subscribe to the podcast so you don't miss that episode. I very much hope you found this episode of the Obspod interesting. If you have, it'd be fantastic if you could subscribe, rate, and review on whatever platform you find your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obsipod on Twitter and Instagram and you can email me theobsipod at gmail.com. Finally, it's very important to me to keep the Obsipod free and accessible to as many people as possible. But it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation. But if you'd like to contribute, you now can. Thank you for listening.