By Caroline Flint

Consultations with doctors in antenatal clinics are often rushed, leaving the women feeling disappointed that they have not had the opportunity to ask questions about their pregnancies. Caroline Flint describes how the system was changed at her clinic to allow more meaningful and better consultations for both the women and the doctors

Women often complain bitterly about the shortness of their consultations with the doctors at the antenatal clinics. In The British Way of Birth one woman says `It feels like a factory in the hospital. You actually spend a total of two minutes with the doctor so it all seems a waste of time.'

The National Childbirth Trust's working party report Change in Antenatal Care states: 'For most the visit culminates with a brief laying on of hands by a member of the obstetric team who may have no more idea of whom the person is he is examining than she does of him. It is not surprising that women feel disappointed when they are in and out of the examination room in a matter of minutes and have no opportunity for discussion or for voicing anxieties'.

We have already looked at ways of utilizing midwifery skills so that more women see midwives, thus freeing the doctors for a longer and more meaningful consultation with fewer women. But let us look at how the clinic is arranged so that the woman can spend the maximum amount of time with her medical attendant.

One of the most dehumanizing of experiences is waiting in a queue to be weighed publicly or queuing to have one's blood pressure taken. Even though these procedures may appear to streamline the clinic I suggest that it actually hampers the consultation with the doctor.

If the women queue have measurements of weight, blood pressure and urine the questions that crop up at that time remain unanswered because it seems useless to ask someone who is weighing 120 women. Women usually wait to ask the person who palpates them. If the person who usually weighs them is a midwife, perhaps her skills could be better used seeing women for a complete antenatal consultation.

Reproduced with kind permission from Nursing Mirror, December 15 1982

At St George's Hospital; we made a radical difference to the quality of consultations when we bought scales for each consulting room so that women are always weighed in a room with a doctor present. This initiates conversation about how the woman is eating, she also has her blood pressure taken at the doctor's desk so that she is sitting down at the same level as the doctor which encourages her to talk to him or her. Only after she has had the opportunity to chat to the medical attendant does she lie down on the couch to be palpated. We are trying to imitate the GP's surgery where everything is done in one room and women have the opportunity to talk all the way through the consultation.

This description explains why I suggested, last week, that the quality of the consultation is decreased when a doctor uses two rooms because he or she misses so much when a patient is only seen while she is lying down.

Horizontal women find it more difficult to talk, to negotiate, to remember what questions they wanted to ask. Women lying down are very disadvantaged if they only see their medical attendants in this position. I believe that we shall never achieve excellent and satisfactory antenatal care as far as our patients are concerned until we start by seeing all women sitting up, in their normal clothes and at the same physical level as the doctor.

Midwives seem to do this quite automatically, and it is interesting to see that when women are used to having a choice between a consultation with a midwife or with a doctor they often opt for the midwife because they know there will be more opportunity to talk and ask questions.

The quality of the consultation is improved when it is accepted by all medical attendants that an integral part of obstetric care is how a woman feels about what is happening to her. This is most easily introduced by use of the nursing process in midwifery, when women are given an opportunity to discuss how they feel about their pregnancy and labour and their forthcoming role as a mother.

When a woman knows her medical attendant the quality of the consultation is much better. And the medical attendant also finds enormous pleasure seeing women and already knowing their names. Continuity of care is difficult to achieve in most antenatal clinics in the way that we run them at the moment. But we achieve a quite a high level of continuity in our midwives' clinic by allocating women to the same midwife each time they come. Midwife Omari has red stickers on her patients' notes, Midwife Thomas has green. Each midwife has 15 minute appointments and so each women is given a realistic appointment always with the same midwife.

This seems to be more difficult to achieve at the consultants' clinics when we are dealing with far more women. But we achieve some degree of continuity by the sister/hostess greeting each woman as she arrives - going through her notes with her, and asking her whom she would like to see this week. Women then have the opportunity to say `Can I see Doctor X, I always see him' or `Can I see Midwife Y, she wanted to know about my daughter's rash'.

Some clinics must have conquered this problem by now, have you? Please write and let us know - all ideas gratefully received.