Dr. Karen Buhler (biography, no disclosures)
What care gaps or frequently asked questions I have noticed
In BC women are receiving maternity care from fewer providers. The numbers of family physicians who offer maternity care continues to decline: 769 GPs billed intra-partum fee codes in 2010-11 compared to 665 in 2014. This has led to a concentration of expertise for primary maternity care to a small percentage of family physicians, midwives, and a few obstetricians resulting in long wait times for many women for their first prenatal (PN) appointment. At the same time new knowledge about prenatal care and advances in ultrasound and screening tests have made early pregnancy care more important and more complex than ever before. This care must often take place at the very first encounter when a woman confirms her pregnancy. Thus every primary care provider must be up to date on recent guidelines. With practice change occurring rapidly this can seem like a daunting task. Yet, if we miss important early deadlines for advice and screening tests our care is compromised with potentially devastating consequences for a woman or her infant.
Data that answers these questions or gaps
To assist practitioners Perinatal Services BC created the Primary Maternity Pathway and is regularly updated. http://www.perinatalservicesbc.ca/health-professionals/professional-resources/pathways-toolkits/prenatal-care-pathway. But who can refer to a 24-page guideline during a short encounter? The Vancouver Division of Family Practice in 2014 developed a 2-page Early Prenatal Care Summary Checklist for Primary Care, http://www.perinatalservicesbc.ca/health-professionals/professional-resources/checklists, which has been updated once since then. (See App 1) This document outlines essential care for the first trimester. In addition the Division has proposed some practice tips and tools that can simplify care and improve efficiency.
What I recommend (practice tip)
A sample outline of the first few encounters with a pregnant woman is offered below:
- First visit: Confirm pregnancy and establish due date
- Review patient-completed pregnancy history. Pay special attention to alcohol, tobacco and other substance use.
- Address any urgent concerns: folic acid, alcohol, violence… and provide advice.
- Establish provisional due date and check timing for genetic screening.
- Order lab tests (routine PN tests + patient specific tests).
- Order early dating US (aiming for >7w).
- Give woman resources for decision re genetic screening (PSBC website “Patient Decision Aid” or pamphlet).
- Begin referral process for a maternity provider if needed (suggested websites, local providers, referral sheets, patient driven, Pathways).
- Second visit: Genetic screening
- Review options for genetic screening, including private pay options.
- Ensure woman understands the benefits and harms of testing including the possibility of false positive and negative results, knowing or not knowing, and how this fits with their family values.
- Confirm woman’s decision for PN genetic screening and if so, which test(s).
- Fill in Prenatal Genetic Screening Lab requisition form and establish how she will be notified.
- Third visit: complete the antenatal history and physical exam or postpone if more counseling re genetic screening is needed or referral to maternity provider is within a few weeks.
- Consider referral to Public Health antenatal program.
What is new?
Following are highlights of newest recommendations for early PN care:
- Offer all women early dating ultrasound.
- Screen most women for Thalassemia.
- Screen for TSH and reference for pregnancy normals.
- NIPT is now covered by MSP in BC for women with a positive serum screen or with risk >1/300.
- Refer vulnerable women early to Public Health for support with significant improvement in outcomes.
What are some practice tips and tools?
Timing is important. Visit 1 and 2 can be days apart or a week or more depending on when the woman presents for care. If the woman presents near 13 weeks genetic screening decisions need to be made within days so the first visit may have to include this information.
Provider resources:
A history form can be filled in by the woman in the waiting room, leaving time to focus in on important areas during the visit. The form attached also includes a validated question screening for poverty and the TACE alcohol screen. See App 2. Routine PN lab tests can be ordered on a single pre-printed or auto-filled EMR form. See App 3. Ultrasounds can be booked by the patient herself at some facilities, if you indicate the best timing. A reference table of genetic screening options available to women based on their age and when they present for care can be found in App 4 or at: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/screening/prenatal-genetic/resources-and-faqs.
Prenatal Genetic Screening Laboratory Requisition can be filled in online, printed, or added to your EMR as an e-form: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/screening/prenatal-genetic/lab-requisition-form-and-reports
Patient resources:
The PSBC website has excellent information for PN genetic screening in multiple languages and formats for patients and has an excellent patient decision aid. http://www.perinatalservicesbc.ca/Documents/Screening/Prenatal-Families/ScreeningDecisionAid.pdf
A calculator for providers and women gives the best dates for the SIPS and IPS tests: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/edd-calculator
How do I get paid for this work?
Billing for the time that is needed for early PN care is a challenge. Counseling visits only apply when mental health symptoms are present. For full service FPs and maternity-network associated FPs patient telephone and patient conferencing fees can apply (14076, 14077). Prevention fee codes can apply in pregnancy (14066). See App 5 for a summary. Finally the GP for Me Attachment Incentive for mother and baby, if it applies and they remain in your practice, can be billed at any time in the pregnancy (14074).
With a checklist for providers’ reference, efficient systems, and good quality patient information all primary care providers will be able to offer the right care at the right time for newly pregnant women.
Appendix/Resources
- EARLY PRENATAL CARE SUMMARY CHECKLIST FOR PRIMARY CARE http://www.perinatalservicesbc.ca/Documents/Resources/Checklists/PSBC_Prenatal_Checklist.pdf
- YOUR PREGNANCY AND HEALTH HISTORY (View)
- PN TEST PRE-PRINTED LAB REQUISITION (View)
- PSBC PRENATAL GENETIC SCREENING REFERENCE CARD (View)
- BILLING CODES FOR PREGNANCY, POSTPARTUM, AND NEWBORN CARE (View)
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What is the rationale of screening most women for thalasemia? if a woman’s CBC is normal, is more screening needed and if so,what test is recommended?
I had the same question as Cindy. Is this because of the variety of ethnicities Dr Buhler would see with her practice in Vancouver which are at higher risk of thalassemias (Asian, Mediterranean, Middle Eastern populations)? I don’t think it would be indicated to ‘screen most women’ in the majority of practices in BC with large proportions of Caucasian prenatal patients. Important to consider, though, in non-Caucasian patients.