Dr Sam Manger 0:00   

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the Traditional Custodians on the lands on which this podcast was recorded, and the Traditional Custodians on the lands and waters on which you are listening. We pay our respects to the Aboriginal and Torres Strait Islander Elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s First Nations people. 

 

Preview: Dr Kirstin Millard 0:18 

Often especially in the public system, you’ll be meeting that person for the first time when you’re in labour. So, I think always giving the perception that you have time and patience and are willing to listen is really important. 

 

Dr Sam Manger 0:33   

Hi, I’m Dr Sam Manger, a GP, and your host of this series, The Clinician’s Guide to the First 2000 Days, brought to you by the Queensland Government through Health and Wellbeing Queensland.  

Prevention across the First 2000 Days offers an opportunity for healthcare professionals to support generational health improvements, but preventative health will only be successful if it is done with confidence and empathy and an evidence base.  

Over the course of this series, I will be talking to some of Queensland’s leading experts to explore how they discuss preventative health and how to create meaningful change for the next generation. Let’s get started! 

Our second podcast of this series is going to deep dive into the medical side of antenatal care, and to do so, I have Dr Kirstin Millard and Kieran Froese joining me today.  

Kirstin is an obstetrician and gynecologist with a Masters of reproductive medicine. Kieran is an endorsed clinical midwife and has been a midwife for almost 20 years.  

Both Kirstin and Kieran work at Mater Mothers in South Brisbane and at Hatch. Thank you so much for joining me, Kirstin and Kieran.  

Kieran Froese 1:37   

Thank you.  

Dr Kirstin Millard 1:38   

Thanks for having us. 

Dr Sam Manger 1:38   

 Kirstin. Let’s start with a sort of broad overview question, how has pregnancy care changed over the last 10 to 20 years, since you first started working in this field? 

Dr Kirstin Millard 1:39   

There’s been lots of really exciting changes, I think, in the pregnancy care space, a lot around new technologies, in medical things, and also in what we know about diseases. So, a lot in the maternal fetal medicine space, we’ve got new testing for chromosomal abnormalities with the NRPT tests, which allows more accurate screening. We’ve got better ultrasound machines, so our ability to diagnose abnormalities earlier. We know a lot more about preterm birth and risk factors for that, and now have treatments for it. We know more about pre-eclampsia, and we’ve got better risk factor screening for that, and treat and potential preventions available too. So that’s…for me…it’s really exciting. We’re much better at looking after really small babies, and so now some babies will survive if they’re born from 23 weeks onwards. So that’s big changes.  

Dr Sam Manger 2:47   

Yeah, that’s fantastic, so definitely some improvements in both screening, diagnosis and management, sort of across the board, by the sounds of it. Kieran, have you seen a lot of changes over your 10-20 years?  

Kieran Froese 2:56   

Yeah, I think there’s been a real improvement in accessibility to different models of care, and particularly midwifery led models of care. So, we’ve seen since…since probably 2011, the M@NGO trial, we’ve seen midwifery led continuity models really open up, and seen really improved outcomes across all risk groups. 

Dr Sam Manger 3:18   

And has the role of a doctor and midwife change in that time? 

Kieran Froese 3:21   

Midwifery has changed somewhat in that we’ve seen the development of endorsed midwives, so we’ve got midwives who are able to operate more autonomously and provide independent care to people.  

Dr Kirstin Millard 3:34   

I’d say it’s definitely become more collaborative, definitely more collaborative…and the playing field is much more level.   

Kieran Froese 3:40   

Yeah, and that’s really where we’re going to see the best outcomes, isn’t it? When we’re working together, and we’ve got different roles that complement each other. 

Dr Sam Manger 3:48   

Yeah, absolutely, the blended approach is the best approach. And so, Kieran, is there a certain number of appointments or checks a woman would expect as part of routine antenatal care? 

Kieran Froese 3:58   

Yeah, in the public system across Queensland, our schedule of visits is informed by UK guidelines, the NICE guidelines, and so that sort of lays out a schedule of expected visits. In some high-risk groups, you might see more regular appointments, and often, then in private care, you might have more appointments as well, and more individualised care to what people need.  

Dr Sam Manger 4:24   

And would you say there’s a sort of average, because you can be guided somewhat by the various sort of books out there and guidelines, but it seems to be that the closer you get to due date, the more frequency you get reviewed? 

Kieran Froese 4:36   

Absolutely. So, most people in… in a public system, which is a more standardised system, would expect to have visits at 24, 28 to32, 34, 36, 38, 40 weeks. And like I said, in a private system, you can probably expect a few more visits earlier in pregnancy and also later in pregnancy, when it might go down to weekly visits So you’re just having much more contact with your care providers. 

Dr Sam Manger 5:03   

Which makes sense. Does that differ across Queensland or in other services? So, do we see the recommendations are still the same regardless of geographic region? 

Kieran Froese    5:11   

Regardless of geographic region, it’s all the same. But like I said, there’s higher risk models of care, or people with more risks in their pregnancy and they can expect to be having more contact with their healthcare providers through their pregnancy.  

Dr Sam Manger 5:24   

And so, Kirstin, let’s jump into starting at the beginning! So, the first trimester, and this is obviously a very important part of antenatal care, if a woman sometimes may miss this because she may not be aware that she’s pregnant. And so, can we start with what’s included in first trimester tests, and then what to do if someone misses these early screening tests. 

Dr Kirstin Millard 5:43   

So, the first…the first test every woman needs, is a set of blood tests, which includes full blood count Group and Hold, HIV, syphilis, rubella, hepatitis B, C. Some women will need thyroid function tested, and some women with the risk factors for gestational diabetes should have an HBa1c tested as well. 

 

Women should have a viability scan and then a dating scan between seven to 11 weeks, and then many women also choose to have an early anatomy scan around 13 weeks. If women choose to have aneuploidy screening, this can be done either at an 11-to-13-week scan with the hCG PAPP-A blood test, or they can choose to have the NIPT blood test from 10 weeks’ gestation. 

 

Dr Sam Manger 6:31   

Let’s break that down a little bit more detail. So, you mentioned that viability scan, a dating scan and an anatomical scan as options, so to speak, for that period. So that’s quite a number of scans. Does the government pay for that, or does the patient pay for that?  

That can often be a deciding feature. If ultrasounds are expensive. What’s the pros and cons of each of those? So, the dating scan is obvious. That’s to see if it’s intrauterine, and what your sort of estimated date of conception is, and delivery. And the anatomical scan, what does that sort of look at? 

Dr Kirstin Millard 6:59   

So, the early anatomy scan is growing in popularity because people are now having noninvasive prenatal testing, which is a blood test It doesn’t…that doesn’t allow for a view of the baby earlier on. So, with the improvement in ultrasound technology, we can now actually see the structures of the baby reasonably well at 13 weeks…13 weeks, it doesn’t replace the later scan.  But if a baby has a significant heart defect or has severe Spina Bifida, this can be detected on this early scan, and this gives women a chance for earlier counseling and potentially earlier action, rather than waiting to find out about this at 19 weeks. 

 

Dr Sam Manger 7:43   

And so, you mentioned the NIPT there, which is a maternal blood test picking up a little bit of baby DNA and looking at that and it…and it seems within that there are multiple levels of intensity that you can do within that. Could you give us a little brief overview as to that?  

Dr Kirstin Millard 7:58   

So, the NIPT test is most accurate for three major trisomy’s, so 21,13 and 18, and is reasonably accurate for sex chromosome abnormalities. Its accuracy does decline when you test for more things, so that has to be conveyed to patients before you use this test. In all the results you get, though, it is quite accurate for Down syndrome and the other trisomy’s. It’s still a screening test, and you would recommend a diagnostic test, such as amniocentesis if you’re going to change your plan for the future of the pregnancy. Another technology that’s coming soon is checking the blood group of the baby with NIPT. And that is very accurate, though, 

Dr Sam Manger 8:46   

With the NIPT it sounds like so there’s… there’s a number of tests, and since, if there’s the basic screen sort of components, you see the three trisomy’s, plus or minus six chromosomes. And then you’ve got other layers that a woman can decide based on, as you say, cost, based on what they’re actually going to find out. And then, as you say, informed consent around, okay, well, if we get a positive screening test, then these are the options from here, like an amniocentesis for a diagnostic. So, there’s a whole conversation that goes in around that, are there any good resources that you will often use, or can weigh these things up in a helpful way?  

Dr Kirstin Millard 8:59   

Most of the labs that perform these tests have quite good resources attached to them. We commonly use VCGS, and on the back of their pathology form is an A4 sheet which gives information for the patient. 

Dr Sam Manger 9:35   

And VCGS stands for? 

Dr Kirstin Millard 9:38   

Victorian Clinical Genetic Services.  

Dr Sam Manger 9:40   

Okay. Very good, thank you very much. And then as we progress through the pregnancy, so we’re going up to sort of 18, 20-week mark now, what are the routine tests that are recommended throughout the rest of the pregnancy?  

Dr Kirstin Millard 9:52   

So, the next test that people need is their morphology scan, and that can be done between 19 and 23 weeks. It’s generally done a little later if you’ve had an early anatomy scan, or a little earlier, if you haven’t. 

Dr Sam Manger 10:09   

Again, that’s looking for anatomy and various other things. And then throughout the rest of pregnancy, we’ve got the 28-week check and so on. So, what are those sort of screening tests that we do from a medical point of view? 

Dr Kirstin Millard 10:19   

Between 24- and 28-weeks women should have a full blood count Group and Hold and a glucose tolerance test and syphilis screening. The final prescribed set of blood tests is between 34 and 36 weeks, which is a full blood count.  

Kieran Froese 10:35   

Full blood count and another syphilis screen. 

Dr Kirstin Millard 10:38   

Thank you. So, Syphilis is now recommended to be screened three times in all pregnancies. 

Dr Sam Manger 10:42   

Wow, that is that’s quite a change. So, is that because we’re seeing an increase in rate of syphilis? 

Kieran Froese   10:47   

A rapid increase in syphilis in all populations, so it’s now universally recommended that everybody has three syphilis screens during pregnancy, and anybody that hasn’t had a 36-week syphilis screen should theoretically have that screening done when they’re giving birth.  

 

Dr Sam Manger 10:48   

So, we’re seeing an increased rate, that’s worrying. And is there any role for swabs or, you know, group B strep and all those things? 

Dr Kirstin Millard 10:59   

Women will be swabbed at 36 weeks for Group B streptococcus. In Queensland, we take a risk factor-based approach. So, if you’ve had a baby that previously that’s been affected by GBS, or you have prolonged rupture of membranes, or you develop a fever in labour, then you would be treated with antibiotics, because your risk of GBS is higher. If you have a swab and GBS is detected for some other reason, so either on a swab or you had a urine test during the pregnancy, which showed GBS, then you would be treated during labour.  

Dr Sam Manger 11:53   

Again, that highlights the importance of the urine MCS being done as part of that sort of early first trimester screen.  

Kieran Froese 11:58   

That’s right.  

Dr Sam Manger 11:58   

And some of the common symptoms that will happen in that first trimester. So, you’ll often see a variety of symptoms, but hyperemesis being pretty common. Kieran, this must be something that you deal with a fair bit, and Kirstin as well. So, what are the common approaches to assessing and treating these sorts of common symptoms? 

Kieran Froese 12:17   

So, I’d say nausea and vomiting in pregnancy is very common for a lot of people in particularly in that first trimester. For most people, that eases off after the first trimester. Some people have a more severe form of nausea and vomiting called hyperemesis and that may continue all the way through the pregnancy. For the majority of people, it can be managed with simple medication. So anti-emetic medication. There are different combinations of medication that people can find effective, as well as, to some extent, lifestyle type factors…like people often find it helpful to have something in their tummy, so not feel empty. And usually things like dry crackers, dry toast, low flavor foods can be helpful for that, as well as getting enough rest.  

Dr Sam Manger 13:08   

Kirstin, do you want to add anything to that? What are the medications that we’re referring to? The anti-emetics? 

Dr Kirstin Millard 13:12   

There’s a variety of medications, and there is a good SOMANZ guideline, Society of Obstetric Medicine for Australia and New Zealand, they have a really good guideline on hyperemesis. So, it’s a graded step up. One of the common one’s people use is Doxylamine or Restavit as a first line. Pyridoxine…ginger can be helpful. Maxalon, Stemetil can be useful too. Ondansetron is…should be used sparingly because it can cause constipation, which can then make your nausea worse. But it is what…sometimes the only thing that people find effective. Sometimes people need to come into hospital, sometimes just for some rehydration, but sometimes need a several day stay, sometimes people need steroids as well. But that would certainly be in the context of having seen an obstetrician and in hospital.  

 

Dr Sam Manger 14:02   

And very severe illness. So here’s the opportunity for you both to sort of add in any sort of pearls of wisdom that I’m sure you have when it comes to common challenges that a woman may experience as they progress in their pregnancy, from a sort of inverted commas, normal pregnancy point of view, and how we can if there are any tips or tricks that can help women in that regard? 

 

Kieran Froese 14:20   

I think just general discomfort is common as pregnancy progresses. In early pregnancy, you tend to see more of the nausea and vomiting of pregnancy, and then you often get a bit of an easier period through the second trimester, when symptoms are easing off, but the discomfort hasn’t become quite so prominent. And then as you get into third trimester and your belly is growing really big, and the effects of the hormones of pregnancy are making your joints more relaxed, you can start to get more discomfort in your hips and back, more trouble with sleeping, finding comfortable positions. We recommend women sleep on their side in pregnancy, especially from 28 weeks onwards, and so people can sometimes feel quite limited in the number of sleeping positions that they have, as well as being interrupted to go to the bathroom many times through the night and have some trouble getting back to sleep sometimes when they’re feeling very alert. 

Dr Kirstin Millard 15:15   

Fatigue can be a big problem for women, and both from sleeping and iron deficiency is pretty common as well.  

Dr Sam Manger 15:22   

So, it’s an interesting point, because we don’t test for iron routinely. The iron deficiency you’re picking up through, obviously hemoglobin, if they’ve actually become anemic, but otherwise, we’re not actually screening for it, you know. So, we just picking up if a woman becomes more fatigued, to a point where we actually will investigate it then and all the hemoglobin drops and or we actually think there’s a high risk, say, for nutritional deficiencies. From whatever reason, these are the reasons we might actually look into iron.  

Dr Kirstin Millard 15:45   

That’s correct. I’ve got a pretty low threshold for checking for iron. So, anyone who’s had a history of iron deficiency, anyone who has hyperemesis, I would routinely check them. If they’re tired, I would check it. 

Dr Sam Manger 15:57   

Fair enough, because that seems to me the case as well,,. for some GPs, fairly low threshold for checking that iron, as you say, based on past medical history, symptoms and obviously contextual factors like hyperemesis, less intake would make sense, and that baby is obviously utilising a lot of those nutrients to grow, so Mum’s taken second best there.  

And so, we’ve talked about a number of things here, very useful in sense of screening tests through our pregnancies. And we’ve mentioned a number of really good guidelines and resources around that, for advice for health professionals to look at, sort of across the pregnancy. What is the main go to resources that might be available, say, from Queensland Health or other national resources that you would just commonly recommend or use. 

Kieran Froese 16:36   

The Queensland clinical guidelines should probably be the first go to for most things. I also find the Australia, New Zealand food safety standards really helpful in terms of advising people about dietary recommendations and cautions to take during pregnancy.  There’s a few dietary… not restrictions… but areas where people need to be more cautious during pregnancy. 

 

Dr Sam Manger 16:59   

So, let’s talk now about the actual model of care, and we know the importance of continuity of care during pregnancy. And so, Kieran, what are the benefits and challenges of different models of maternity care?  

As we said, we’ve seen that change a little bit over the last 10 to 20 years. Midwife led care, GP shared care, private obstetric care. So, there’s a raft of options that a woman can go into. What are the benefits and challenges of that? And how do we advise around that? 

Kieran Froese 17:23   

We’ve really learnt a lot more in recent years about the benefits of continuity of care in pregnancy, and that’s really changed the landscape for maternity care in across all models, trying to look at improving continuity, whether that’s continuity of specific care, or continuity of philosophy of care as well. In terms of midwifery, there’s been a lot of evidence in the last 10 to 20 years supporting midwifery continuity, including lower rates of preterm birth, lower rates of intervention during birth, improved breastfeeding rates for breastfeeding initiation and continuation. So, there’s a lot of evidence to support midwifery continuity, to an extent, some of those benefits extend to other forms of continuity.  

 

And what we see often with GPs is that…that it is a family doctor who is able to provide continuity over a much broader spectrum of the family’s life, and this is a time when a lot of people are starting to access health care far more regularly than they may have previously. So, it’s a good time to get in touch with the community, understand who your local doctor is and who you’re going to be seeing through your pregnancy. And it’s also really important for GPs, often as the primary contact and the referring point, to know what’s available in terms of models of care, so that they can refer women appropriately into a model that they want to have. 

 

Dr Sam Manger 18:53   

Yeah, that’s a key point around becoming aware of what is available to us, whether it’s, as you say, midwife led services that may be local, private or, you know, connected to the hospital in some respect, and or obviously private obstetricians, I think most GPs be aware of that pathway, but probably less aware of their sort of midwifery options locally. I’m curious about the rural and remote context of this, and how…how models of care have changed for people who have traditionally that much more difficult geographical access to care, absolutely. And has telehealth changed that? Or how are we managing… how we supporting people in those regions?  

Kieran Froese 19:25   

Yeah, telehealth has really changed the landscape of…of healthcare and how accessible different models of healthcare can be to people all over the state, but particularly in those regional and remote areas. So, whether that’s being able to have specialist appointments via telehealth without traveling or even just having consultation during…during pregnancy, can add more accessibility to more models. I’m also conscious that across the regions of the state, we’ve seen closures of private services, and that limits accessibility for some people to models of care that they can have for their birth as well, so requiring people to either travel long distances or to limit their options. 

Dr Sam Manger 20:10   

Kirstin, have you seen this too, being an obstetrician in the hospital sector, where you see more people, you know, being they’re… being referred in, but that you’re doing more tele health, or you’re doing more sort of remote care. Is this becoming more common and more reliable, or is it? Is it still very much in person is gold?  

Dr Kirstin Millard 20:28   

Most people, if they live locally, would be seen in person, certainly in the private system. Publicly, Mater Hospital uses a lot of telehealth to link in sort of with their satellite hub. So, women will come to Inala or Coorparoo or out at Springfield and be seen by midwife there and link in via telehealth to the obstetrician at South Brisbane. So, it’s been utilising every day, really, yeah. 

Kieran Froese 20:55   

Yeah. I think in in some of the bigger Metro centres, the use of telehealth has seen reduction in waiting times for women, because those appointments can be more seamlessly back-to-back, without having to wait in a waiting room, find parking at a hospital and travel. So, it’s increased efficiency. 

Dr Sam Manger 21:17   

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Dr Sam Manger 21:56   

And now back to the conversation! 

And so now let’s get into the conversation around birth plans, around, you know, how do we open up that conversation? When should we start having that conversation? And what are the nuances of that conversation? So, Kieran, I’ll throw to you on this one.  

Kieran Froese 22:11   

First, I think birth plans have become a bit of a hot topic, and at times they’re viewed quite controversially, depending on who you speak to. One of the outcomes of the New South Wales inquiry into birth trauma found that we really need to be paying more attention to birth plan and centering women’s wishes in the care that we provide. I’m really fond of birth plans. I think it’s a great opportunity for us to keep a woman or her family’s values at the centre of the care we provide, and it’s really difficult for us to keep her values at the centre of our care if we don’t know what those values are. So, I believe that everybody has a birth plan, whether that is just going home with a healthy baby, or whether that’s more detailed about how you want certain procedures to be offered to you during your care. So, I think softening our views and making people feel really welcome to voice what’s important to them forms the basis for having a healthy culture around birth plans.  

Dr Sam Manger 23:13   

And do you recommend starting that conversation, you know, in the first trimester, or you think as things progress around the sort of 20-week mark when let’s start talking about this in a bit more formal way? And are there guidelines or resources or checklists in a way that can help guide this conversation? 

 

Kieran Froese 23:29   

I don’t usually get too deeply into birth plans right from the outset, although I might be feeling around to see if people are coming into the pregnancy with really set ideas. Most people have a really flexible view of their birth plan, and we know that most people come to this with flexibility. It’s a little bit like if you’re planning an international holiday, you will make plans. You don’t just arrive in the airport in LA and see what happens; you make plans around what you want to do and how you want to have the best of your trip, but you accept that things may change, flights might be canceled, weather may interrupt things. So, it’s really similar with birth plans.  

Most people accept that there’s a lot of elements that might be out of our control, but it’s really important if we can identify early the people that have less flexibility in their birth plan, so that we can put some specialist work into understanding what care they’re willing to accept, what interventions they may be willing to accept, and how we might navigate complications if they come up. I find, for most people, really starting to get into the workings of a birth plan probably happens over about 30 weeks where the birth is becoming a little bit more imminent and prominent in the thoughts, and it gives us a good opportunity, by that stage, to really understand what factors, what external factors, might be influencing plans around birth as well, and then giving us enough time to look at putting education and planning in to help people achieve the birth of their dreams.  

Dr Kirstin Millard 25:04   

The birth planning, or mapping, is probably the word that I think I like to use better, it’s an evolving conversation that you have throughout the course of the pregnancy, and it’s definitely an easy conversation to have when you have a continuity of care model, but can still to some extent, be done in other antenatal settings as well. 

Kieran Froese 25:28   

There are plenty of resources. So, if you look online, there’ll be templates and checklists that you can fill out. What we often see when people come in with these sort of templated birth plans is often, they come from an American perspective, not from an Australian perspective. And 90% or more of those birth plans are routine care for us. So sometimes you may have several pages of wishes, which is just routine, which is why it’s really good to have a conversation about this stuff before sort of landing in birth suite, because you can sometimes streamline those wishes and desires and bring it back to sort of the core values. 

Dr Sam Manger 26:12   

Yeah, in GP training, and I’m not familiar with the other specialties, but we often talk about the ICE acronym, which is ideas, concerns and expectations. And that seems like a good place to start with this sort of birth mapping, or birth plans. What are the ideas around this? What are your concerns and what are your expectations? And that can then lead into and then what happens if you know, yes, that plan A but what happens if X happens, then what? What are your ideas, concerns, expectations around that? Because, as you say, some women won’t want certain types of interventions at that stage. They may change their mind, obviously, but it’s really important to open that up, at very least.  

Now, one thing we are seeing, and I live in this, I work in the Sunshine Coast hinterland, so we’re seeing it around the place, is the increasing rise of home birth requests and other professionals to their birth, such as Doulas. So, is this a trend that we’re truly seeing increasing sense of an increase in home births, and what’s the best way to approach this?  

 

Kieran Froese 27:10   

I think there does seem to be a trend towards people opting for care, potentially outside of recommended guidelines, of which I want to say home birth, when done safely, is not outside of recommended guidelines. It’s considered very safe in the right setting. Once you’re getting into Doulas and free birth, it may be moving away from that clinical safety, and maintaining safety in these cases is really about keeping the dialogue open, so having really smooth referral pathways and transfer pathways, so that if things aren’t feeling safe or aren’t going to plan in a home situation, that there’s very easy transition into hospital, it doesn’t feel like a failure of the birth for the woman or for the care providers. And that the care providers in the hospital can also welcome that woman in with open minds to help still provide her with a birth that feels safe and satisfying for her. And when I speak about safety, there’s obviously clinical safety, but I think emotional safety needs to be considered in that as well. 

Dr Sam Manger 28:22   

Definitely. Is this, this is something you must be presented with Kirstin? 

Dr Kirstin Millard 28:26   

Yes, look, it’s a very can be very challenging situations when these women come to hospital. And I think the important-ness is openness, understanding of what their specific needs are, being nonjudgmental, and remembering that we’re there for the best outcomes for mums and babies. 

Dr Sam Manger 28:45   

Having that conversation throughout pregnancy about what the birth plans are, what the intentions, and, as we say, ideas, concerns, expectations are, if a home birth is a part of that, then make sure that conversation is fully had, and you can, as you say, have a safety plan/are minimised as best as possible, and make it transparent to the rest of the team, so the hospital ideally knows that this woman’s doing a home birth and this is going to be around this time. And just in case something goes not to plan, then, you know, just be aware. And so, it’s not at the last moment sort of raised. 

Kieran Froese 29:17   

It’s really exciting that Sunshine Coast University Hospital is now commencing a publicly funded home birth program, and I think this is the best step forward to providing safe care to people that want to give birth in their homes, to have it open and yeah, have those pathways really clearly mapped out.  

Dr Sam Manger 29:38   

Yeah, I think so. I think if we, as a healthcare system, just recognise that there’s obviously some desires and trends here, and what protocols can we develop that ensure that we can meet women’s and families desires as well as provide safe, complete care, then we’re going to create the best outcome here. So new pathways, new models of care, seems a reasonable choice, is making sure we’re ticking those boxes in regard to effectiveness and safety and other aspects.  

Now this sort of brings into the question around choosing between private health if they’ve got the funds to do so. Obviously, there are benefits to that, as you said before, around more frequent contact, potentially, but this can be more expensive. There’s the cost-of-living crisis that’s going on. So how do you sort of encourage GPs to navigate that decision making progress around which way to go, private or public or, you know, midwife, or whichever sort of GP shared care and so on. 

Kieran Froese    30:31   

Again, I think it’s really important for GPs at that point of referral to fully understand what’s on offer in their local area, and then be able to speak to women early in their pregnancy, or even in preconception about what is important to them and which model of care might be best placed to provide the right care for them, so that referrals can be made public versus private. It’s really important that GPs or any care providers don’t make assumptions about what is best for a woman, but actually speak to her and her family about what’s best for her. So, while you may think that private care is out of financial reach for some people, I find it interesting that often people are very keen to rub pennies together to make things happen, basically. And vice versa, there may be people that have the financial means but are choosing public care because some of those values may be more important to them as well. And so, it’s always just very important to be listening to people and what values they hold close to them. 

Dr Sam Manger 31:42   

There is clearly the emerging role of different technology in whether it’s models of care, in supporting women throughout the antenatal period, making it ideally more accessible and engaging. How can we leverage technology? What are the trends that you may be seeing? How are we going on that front? 

Kieran Froese    31:58   

It’s really exciting what some of the new technology is offering in healthcare and maternity care. The use of apps in maternity care is still quite new, but it’s interesting, the greater accessibility that some apps are able to provide for people. So, in particular, at the Mater, we have use of the MoTHer app, which has been developed in collaboration with CSIRO, and that allows women with gestational diabetes to be able to have their blood sugar levels viewed in real time by clinicians in the hospital remotely. So, this reduces the number of visits that women need to make to a hospital, and it can allow suggestions and recommendations for intervention to happen sooner than waiting for a two-weekly appointment. For example, there’s other apps that are being used in technology that’s being used to improve access to education, so women have more options for antenatal education in their pregnancy, and also remote communities, or, yeah, virtual communities, so parents groups or pregnancy groups that can happen over Facebook, for example, or other apps where people can connect with other people in similar situations to them.  

 

Dr Sam Manger 33:24   

Yeah, that’s an exciting potential, isn’t it, just the as we’ve talked about before, around rural and remote care and providing best care from a medical and midwifery point of view, but providing best community care as well, we can utilise technology. Obviously, there are local community mothers’ groups and pregnancy groups, but that may not be available at that time, given population density and so on. So, creating virtual settings like that is a really great use of technology, because that peer support component can be a real bit of magic when it happens well and supports really well.  

So, Kirstin now moving back to the medical a little bit, if we consider potential complications during pregnancy, such as pre-eclampsia, gestational diabetes, which we’ve mentioned a few times now, fetal growth restriction. What are the some of the early warning signs as the pregnancy progresses that we… that healthcare professionals should be aware of, and what steps do we take?  

Dr Kirstin Millard 34:15   

I think I’d just like to point out that all these conditions can be quite insidious, and so emphasise again, the importance of all the routine tests and investigations that we discussed earlier in the importance of early detection of these conditions. Every time a woman comes to an antenatal appointment, she should have her blood pressure checked, and she should have her symphysis fundal height checked to look for the size of the baby.  

I would usually inquire about headaches or blurred vision and swelling, though these are all very nonspecific symptoms. If a sign of gestational diabetes might be a large baby, but that’s really the only sign there is. So again, the importance of that glucose tolerance test for that. And similarly, there’s probably no symptoms of Rhesus incompatibility. I would always tell women, if they don’t feel right, that they should come for an assessment, whether that be with their GP or to their local hospital. And that’s very non-specific, but sometimes that is all it is. They just feel weird or wrong and that can detect things. Often nothing is wrong, and that’s fantastic, but always to get checked out if they have any concerns  

Kieran Froese 35:30   

Fetal movements are something else we always inquire about, and can be a sign, again, that there is something unusual going on with the pregnancy. Again, it’s very nonspecific, so most times, everything we find with that.  

Dr Sam Manger 35:45   

And so, can we just summarise that a little bit? Because we talked about some of the important, just sort of baseline examination features and processes during sort of second and third trimester. And you mentioned a number of points there, and I just want to open it up to just add anything else. So, blood pressure, obviously, palpation, the abdomen, symphysis fundal height, which some can review. Are there any other important parts of examination? Their fetal movements, you mentioned. Any other aspects that would be routine parts? 

Dr Kirstin Millard 36:16   

At 36 weeks, ensuring that the baby is cephalic is important. 

Dr Sam Manger 36:20   

And so, that’s the medical side, but when we deep dive into those modifiable health behaviors, which we’ve done with our, as I say, our other health professionals in other episodes, is fantastic, but what are your approach from a midwife or an obstetrician point of view around discussing preventative health practically, and it may be around their activity or their diet or sleep. Is there anything, common FAQs that you would see come up and ways to approach this? 

Kieran Froese    36:46   

I think, like I said, before pregnancy, for a lot of people, might be the first time that they’ve really had regular interactions with healthcare professionals, especially if they’ve otherwise had a reasonably healthy lifestyle. So, it’s a really opportune time for us to be able to ask questions, and often that’s broached just in terms of general inquiries about their comfort, their sleep, how they feel, like how their appetite is, can allow small moments to put preventative health care in the focus of their pregnancy and their care. And for a lot of women, pregnancy becomes an incentive to improve aspects of their health. So, you will often see women that may smoke, reduce or be able to quit smoking during pregnancy because their priority is put on the baby. This is the time where women will often stop drinking alcohol and start looking at their diet and exercise a little bit more closely. And so, it can be quite an opportune time to start looking at that on a bigger picture as well. Why would you go back to smoking if you gave up smoking during your pregnancy, when actually this could provide a really lovely lifestyle for your child not to be exposed to this or for your partner to quit smoking as well. So, there’s lots of opportunities to just take that narrow lens of the pregnancy and extend it out further into their wider lifestyle.  

Dr Sam Manger 38:16   

Yeah, it is an opportunity to look at, obviously, we’re predominantly managing the baby and the Mum in this context, but to zoom out, as you say, and look at the whole person, then the whole context, and I said, the sort of familial situation as well. Now on that, what about the mental health and wellbeing? Because clearly that’s a something of significant importance in this period of life. Do you have any screening tools or strategies that are used in antenatal care to address either mental health concerns, common ones, anxiety, depression and so on?  

Kieran Froese    38:41   

It is really a prominent time for it, whether it’s hormonal influence or lifestyle influences and changes that are happening in pregnancy. But also, mental illness can be quite irrational and just come without anything logically underpinning it. We use standardised screening tools in pregnancy. We use standardised screening tools in pregnancy, so we use the Edinburgh Postnatal Depression Scale, and ideally, we would be using that two- or three-times during pregnancy and then again postnatally. And what that does is just allows us to standardise responses, so have a response that is comparable, and it also makes for ease in terms of referral and communication with other healthcare professionals So, when we’re referring people on, and we can put a number to the responses from the Edinburgh Postnatal Depression Scale, it’s…it’s very clear what we’re talking about. Because sometimes when you’re talking about mental health and mental illness, it can become vaguer in terms of the terms.  

Dr Sam Manger 39:46   

So even though the Edinburgh postnatal is for postnatal depression, it’s still, and it makes sense to use the same tool, so you can track and see the trend over time, but that’s still, it seems, an acceptable tool to use in the antenatal period. 

Kieran Froese    40:00   

It is fairly routinely used in the antenatal period, sometimes in the context of assessing the risk of postnatal depression, but it really is a good mood screening tool. It is quite a snapshot in time. So, it refers to how you’ve been feeling in the last seven days, and again, to sort of have the same tool used multiple times through the pregnancy and the postnatal period allows us to compare results and really see the progression. At the end of the day it’s just a screening tool, and it has limitations, as all screening tools do, so I would say it’s of more importance to be really listening to women and people, so you know, whether that’s partners or other people, about how they’re feeling and how they feel that they’re coping, because sometimes that isn’t clearly reflected in a screening tool, but responding to how they feel that they’re coping. 

Dr Kirstin Millard 40:59   

That’s right checking in at every appointment and how they’re going. I would just like to add that mental health assessment is part of the MBS funding for the pregnancy management fee and at the postnatal point as well.  

Dr Sam Manger 41:12   

Stay with us, we’ll be right back to continue our conversation. 

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Dr Sam Manger 41:47   

And now back to the conversation! 

Now, then just again, widening out and zooming out a little bit more when we think about how to actually encourage partners to participate in antenatal care, especially when there’s typical life and social stresses that are around and becoming potentially more of a concern going forwards. So how do you approach this aspect about engaging partners into the care?  

Kieran Froese    42:11   

That’s a really good question. Some partners are very engaged right from the outset, and they’ll be attending visits. Others less so, whether they’ve just got other priorities. I find in delivering antenatal care, it’s really good to have a combination of visits where the partner is present, but also when they’re not, because that allows us to do further psychosocial screening on risks of DV and control in the home as well.  

But it is great when partners come in too… I like to look at their role in supporting their…their pregnant partner through the pregnancy or the birth.  

We’ve sort of evolved as in our society and our culture, that there’s an expectation that the partner is the primary support person during birth, but sometimes we…we lack in giving them real, useful tools that they can use during that time to support. So, there’s always the opportunity to…to talk to them about what their actual role is, and that extends through the whole continuum of pregnancy, birth and early parenting. As partners have become more involved in particularly early parenting, there’s a…there’s an instinct to remove some of those roles away from the birthing parent, but sometimes in relation to breastfeeding, we really want to preserve that relationship that the mother and baby have and allow the non-birthing parent to take on a more supportive role, still bond with their baby without feeling that they have to feed the baby in order to bond.  

 

Kirstin was telling me just yesterday about an online gaming group for non-birthing parents, which is a really nice way to view support for the non-birthing parent. There are also some dad specific antenatal classes; I know there’s some in Brisbane and there’s some in regional centres. One of the things I’ve noticed with these is that they often put them in the context of a pub, so beers and babies, or, you know, antenatal classes at the pub. And you know that is seen to improve engagement, but I think that can also be somewhat problematic and stereotypical in itself; that men, particularly, won’t engage unless there’s beer involved, which simply isn’t true. 

 

Dr Sam Manger 44:24   

What are some of these programs that you’ve come across, Kirstin?  

Dr Kirstin Millard 44:27   

Oh, I heard it on the ABC Radio. I think it wasn’t online. I think they were meeting in person, having dad’s gaming sessions, which sounded really fun and really, really great, because it’s going to allow men to get together who may not enjoy other forms of activities.  

Kieran Froese    44:48   

I think it’s really important, just on this note, that we extend the non-birthing parent out to people that may not identify as men as well. We’re seeing growing numbers of families that are made up in all sorts of different ways, and sometimes the non-birthing parent, if they don’t identify as a man, may feel excluded from some of these dad specific groups. And so, we need to find space where everybody is included. 

Dr Sam Manger 45:16   

It’s interesting phenomena when we talk about the change in the role of the non-birthing parent over the last, say, 60-70years, where it was very much traditionally, a women’s only and, or doctor/midwife only situation with the mother, the birthing mother. And then slowly, men have sort of been invited more into this circle. And I’ve got three kids, and it still feels like this; .we’re still a little bit lost as to what role that is outside a very stressful, anxiety producing area where you don’t have a lot of control, but certainly providing…opening up this conversation, developing more community based or peer support, or just other resources to sort of normalise and just have this conversation is going to be a healthy thing going forward.  

Kieran Froese    46:01   

Yeah, I want to point out that being a support person in birth, it’s really hard! Like, no shade on the women who are actually giving birth, but that role as a support person, like you say, it can feel like you really don’t have a lot of control, and often in relationships, your role has been to protect and save your partner from challenging situations. And so, birth may be one of the few times that your role is simply to support without protection. I usually use the analogy of it’s like running a marathon… or doing any sort of endurance sport where if your partner’s on the sideline, you don’t want them to pull you out of the race because you’re red and sweaty and in discomfort, you want them to cheer you on and see the strength that they see in you that you may have forgotten, that you’ve still had. And so, as a support person, you often have to change your mind set a little bit to support, rather than protect. 

 

Dr Sam Manger 46:58   

Yeah, that’s a very important point, thank you! And two other aspects here around one being trauma informed care, and how we approach people who may have experienced trauma in their lives, and how that may impact their engagement with the healthcare service. So, what’s the approach to…what’s the emerging approaches to this? 

Kieran Froese    47:18   

It’s a really topical point at the moment, and we are learning a lot more about traumatic outcomes from birth versus positive outcomes and trying to implement preventative strategies. So, part of that is doing education with all of our staff around trauma informed care and what we refer to as universal precautions.  

So, we should be treating everybody as though they have trauma in their history, whether that’s birth trauma, sexual assault, physical assault, anything that they find traumatic. But we should be treating everybody as though they have that history, and that might mean just as simply as taking things quite slowly, speaking to them about what the recommendations are for procedures, and then being very specific about the consent that we gain from them to do in in maternity care, particularly, we’re doing a lot of intimate procedures. And they might be procedures that we’re very comfortable with, because we do all the time, but for a lot of the people that we’re delivering care to, they don’t take their pants off in front of people every day. And so really kind of keeping that at the core of those procedures, that we’re taking very slowly, explaining what the expectations will be, what they can expect to experience from that procedure and that their consent is important to us and can be withdrawn at any time as well.  

Dr Sam Manger 48:48   

Kirstin is this something you’ve come across a bit and in particular, what I’m wondering is… it’s a really big area, and we can’t provide training on trauma informed care over the podcast. So, a good starting point is at least a sort of screening question, or at least opening up the conversation. So how would you broach this within an early… in a consult? Would you ask directly, has there any experiences of trauma that you think may be relevant to your care going forwards? Or how do we actually broach this as a topic to bring up.  

Dr Kirstin Millard 49:23   

I start with… sort of a broad question, how do you feel about your last birth, or was there anything that was particularly concerning, anything you wanted to discuss? Sometimes I’ll ask, did you have any traumatic experiences? And let it open up from there. It’s also then about asking again about what their wishes are for this. Do they have any particular concerns that they want me to know about? Sometimes you’ll meet people during their antenatal care and have plenty of time to go through this and discuss things. Often, especially in the public system, you’ll be meeting that person for the first time when they’re in labour. So, I think always giving the perception that you have time and patience and are willing to listen is really important. 

Kieran Froese    50:09   

Yeah, asking open questions. So, when you’re reviewing a previous birth, we often have access to records, but a woman’s experience of that birth may be very different to the objective details that we can get in a report. And so, you may have those facts about the previous birth in the back of your mind but asking her how she experienced it may shed greater light onto it. 

Dr Sam Manger 50:35   

And this has raised the importance of GPs in particular, because we’re typically the first point of call for a lot of these, obviously pregnancies, and then, as we said, it’ll refer off accordingly. But we have a very important role in that those early paths of care in particular, and of course, across pregnancy, but bringing it up as we would almost any consult, where past medical history, past mental health history, past birthing history, and then being curious around that experience, and just having those open ended questions, and then to the sort of ideas, concerns and expectations around pregnancy, just opening up that question.  

It’s likely with those open-ended questions that the truth will come out as it were anyway, and as the pregnancy and relationship develops, then we can get a little bit deeper, if we need to, if we suspect that there’s something else going on here. And often there can be clues, can’t there, around the way people have their, they want their pregnancy to go a certain way, and that may be informed by past experiences.  

And then that will give us the clues to delve a little bit further. And then that, again, brings us to different cultural backgrounds, and people of different cultural backgrounds, and First Nations Peoples and how they may have different beliefs and practices and approaches during antenatal care. It’s obviously a potentially very sacred time of a person’s life. And so, what’s your advice around how we perhaps, ensure our advice is sensitive and tailored individual needs? 

Kieran Froese    51:57   

I think once again, it’s really important that we ask women, ask people what values are important to them, and particularly not to draw assumptions about the influences of a person’s culture on the values that that are important to them. During this time, I’ve worked in the past with cohorts of refugee women in Brisbane, and a good example of this is Muslim women wearing a hijab. It’s quite a visual cue that they have a set of beliefs, but when you actually start to ask women more specifically about what’s important to them, surprise, surprise, you find women have very open and different views. And so, an example was I started asking women who wore a hijab what they wanted to do during birth if their hijab came off. And some women, it was very important to them that I could help them replace their head covering. Other women were like, you’re giving birth, what does it matter? And other people, it was more dependent on who was in the room at the time, whether their heads were covered, and so holding that space quite sacred and close for them, making sure people knocked at the door before coming in, to allow people to make adjustments if they needed to. And I think this is particularly prominent when it comes to First Nations People that we don’t prescribe what’s important to them, but we ask them what they need and what’s important to them.  

Dr Sam Manger    51:57   

So, as you say, recognising the cultural norms, practices and influences that may be present, but also not assuming that they are present, and always being curious into personalising those still. 

Kieran Froese    53:41   

Absolutely I mean, we work in a Catholic-based hospital, but you could not assume that because somebody marks themselves as Christian on their paperwork, that they come with a preordained set of beliefs that follow that package. They’re made up of a whole lot of different influences and the only way we’re going to find out about them is asking.  

Dr Kirstin Millard 54:05   

Absolutely right. There are so many cultures in the melting pot that is Australia that I don’t think you can expect to know every single culture, so that all you can do is ask. 

Dr Sam Manger 54:15   

Be humble and curious.  

Dr Kirstin Millard 54:16   

Yeah, that’s right. Let them define  

Dr Sam Manger 54:18   

Yeah. Excellent. Are there any good resources on this front, especially for First Nations Australians. So are there, you know, the Queensland Clinical Guidelines, I imagine, support from a medical point of view, that side of things. But are there any go-to’s that you would recommend for health professionals?  

Kieran Froese    54:32   

I’ve read some good books in the past, but actually going to the people is really the best resource I can think of. So, whether that’s the client or patient themselves, keeping in mind, when we’re talking about First Nations People, we’ve got generational trauma as well that can be related to healthcare and institutions. So sometimes the individual may not even identify what the triggers and the sources of trauma are. Sometimes it’s really important to be going to the elders in the community and understanding also with First Nations People. We’ve got so many different cultures in Australia, it’s not… it’s not one homogenised culture, and so understanding the values of the people that are local to you, but then understanding each individual within that culture as well.  

Dr Sam Manger 55:26   

And finally, what are the top three things you wish every woman knew as they entered pregnancy? Kirstin let’s start with you.  

Dr Kirstin Millard 55:31   

They need to take folate before they get pregnant, and for the at least the first trimester.  

Kieran Froese    55:37   

So, I guess that ties in with preconception care, doesn’t it? So being your best healthy self before getting pregnant, if you’ve got the option.  

Dr Kirstin Millard 55:45   

Go and see your doctor early, I think is really important, so they can start you being informed on what care you need from there, and potentially refer you on to the hospital sooner rather than later. And my last point is about as a patient, they have choice, and they have a voice, and they need to tell they need to stand up for themselves and tell the health professionals what it is that they want throughout their pregnancy and not just be passive.  

Dr Sam Manger 56:15   

And we as health professionals can remind them of that, that you have rights. Please do tell me if there are things absolutely in the direction, you’d like them to go and or you’re not comfortable with something. And of course, there’s always a genuine compromise of agendas there, but you can’t fix that unless you know what those intentions are.  

Dr Kirstin Millard 56:30   

Absolutely we can’t hold people’s values at the centre of our care if we don’t know what those values are.  

Kieran Froese 56:36   

So, to piggyback off that point, I think people need to be really informed of healthcare options and maternity care options so that they can choose a model of care that really fits their needs as best they can. And the other big point that I would want to make sure people are aware of, is that this is a really big deal! Having a baby, every single time, is a huge transition that happens in your life. And to some extent, you have to be completely broken down as a person to be rebuilt as a parent. And so this idea of matrescence and becoming a mother needs to be respected, and people often go into pregnancy being very aware of that they’re going to be tired and they’re going to lose some of the autonomy in their normal lives, and it’s going to be hard work, but sometimes they don’t realise how much love they’re going to feel and how their heart will just explode with love for this child, and Kirstin and I both have older children, and so I think we can say from a point of experience that there’s a lot of fun ahead.  

Dr Sam Manger 57:47   

There’s that initial investment, it does pay off. 

Kieran Froese 57:50   

Yeah. 

Dr Sam Manger 57:50   

All right, well, thank you both for your time and expertise and insights and experiences today. It’s been wonderful to have you both on. Thank you. 

Kieran Froese 57:56   

Thank you.  

Dr Sam Manger 57:57   

You’re welcome.  

Dr Kirstin Millard 57:57   

Thank you.  

Dr Sam Manger 58:01   

Today, we’ve been talking to Dr Kirstin Millard and Kieran Froese about antenatal healthcare. For more information on today’s topic, visit the Health and Wellbeing Queensland website @www.hw.qld.gov.au. If you’ve liked today’s conversation, be sure to subscribe for future episode updates.  

We’ll see you next time on the Clinicians Guide to the First 2000 days.