Patient communication and obstetric scanning: Contemporary issues

Introduction
Obstetric ultrasound is an integral component of antenatal care in the developed parts of the world. Practically all pregnant women in the United Kingdom will have at least two or more ultrasound scans in the antenatal period within the National Health Service (NHS) or even more, privately. Dedicated training and staffing has ensured that this service is provided reasonably, effectively and safely

A key component of obstetric scanning is effective communication. Breaking bad news is an integral part of training in obstetric scanning; however no amount of training can adequately prepare the sonographer/sonologist for the varied scenarios requiring effective communication with the patient that they would encounter during their professional life of obstetric scanning. This requires continue professional development.

Obstetric scanning as opposed to other areas of clinical sonography has some unique characteristics when it comes to effective communication:

  • Majority of obstetric patients are expecting good news irrespective of the circumstances surrounding their pregnancies.
  • The sonographer/sonologist and the patient in most cases are meeting for the first time and hence are total strangers to each other.
  • The patient in most cases is accompanied by family members (partners, husbands, children, friends, mothers etc) who may hinder or enhance effective communication.
  • Both the patient and the professional are embarking on a voyage of discovery espe- cially if the scan is the first in the pregnancy and hence unprepared for what they are going to see on the screen.
  • Image optimisation may be limited by factors such as maternal obesity, fetal position and movement, oligohydramnios, shadowing from other structures as well as other arte facts.

The key aspect of communication in obstetric scanning can be broken down into the following challenging tasks:

  1. Clear explanation of the primary objective of the examination and managing patient’s expectations
  2. Explaining the examination findings which in some cases may be unexpected
  3. Breaking bad news
  4. Offering impromptu counselling
  5. Avoiding unnecessary information
  6. Discussion of further care/follow-up
  7. Report writing at the end of the examination

Communicating in general is both verbal and non-verbal with the non-verbal component playing a more prominent role in its effectiveness. This is particularly very poignant with obstetric sonography (Simpson and Fernando, 2008). Factors that potentially could affect effective communication in obstetrics include patent expectations, education, language barrier especially with increasing immigration as well as the environment within the examination room among others. The context, content and manner in which any information is given to patients may have a significant bearing on how it is interpreted, and whether clearer explanation is sought thereafter (Marteau T,1989).

Explaining the primary objective of the examination and managing expectations
Communication starts from the point of contact with the patient right from the time the patient walks through the door of the examination room. This is the point where the building of the relationship between the practitioner and the patient begins. A cheerful welcome and nice exchange of pleasantries with the patient by the sonographer/sonologist would go a long way in establishing a positive rapport throughout the rest of the examination and help with any needed communication during and after the examination. A sonographer/sonologist perceived as cold, impersonal, clinical, stroppy or economical in interaction right at the point of contact may not evoke confidence in the patient and may make an otherwise positive examination a negative experience for the patient.

The objective of the examination for the sonographer/sinologist may occasionally be totally different from the patient’s expectations. Pre-appointment counselling at booking before dating scan is very useful in terms of ensuring that the patient knows the reason why she is having the examination. It is not uncommon to find the occasional patient whose expectation of the dating or the 20 weeks scan is an opportunity to just obtain pictures of the baby or primarily to know the sex.

The primary objective of the first trimester scan is to confirm the presence of a pregnancy, viability, numbers of embryos, dating, measurement of the NT and any other markers necessary for Aneuploidy screening and finally to give the patient an Aneuploidy risk assessment. In the presence of a multiple pregnancy, chorionicity becomes mandatory. The objective of the 18-20 week scan is a head-toe fetal structural survey within the confines of the National Health Service Fetal Anomaly Screening Programme (NHS FASP, 2010) minimum standards with the aim of picking up anomalies that are amenable to intrauterine or postnatal treatment rather that looking for markers for Down’s syndrome which ideally should have been picked up with the first trimester screening. Growth scans on the other hand are mainly to pick out the small and sick babies that need obstetric intervention.

Wellbeing and reassurance scans may be necessary in those that have had poor obstetric histories; however unnecessary obstetric scans should be avoided in all cases. We all need to remember that the “as low as reasonably achievable” (ALARA) principle still stands irrespective of previous obstetric history. It is not uncommon to find patients who have had recurrent miscarriages coming with the expectations of two weekly scans throughout the pregnancy as “promised by their General Practitioner”. In such patients it is important to be fair and firm when communicating their scan needs right at the beginning of the pregnancy with a view to balancing needs and benefits.

Fetal sexing expectation is a growing demand and a few NHS Trust are already using this request as a means of generating extra funds in cash strapped service. This should not however divert from the primary objective of the examination which should be clearly stated at the beginning of the examination. The patient should also be politely warned at the outset of the limited time allocated for the primary examination and potential for a “camera shy baby” in terms of fetal positioning. It is also only wise to advise the patient of the lack of 100% accuracy of sexing by ultrasound and the importance of delaying any change in nursery colours based on ultrasound sexing as well as the need for payment if it is the units’ policy.

Explaining the unexpected and breaking bad news
Explaining the unexpected finding and breaking bad news are closely linked with each other and the best advice is to be prepared at all times as you never know what you are going to find.

Fetal Hydrops at 20 weeks.
Talipes at 20 weeks.

Frank Chervenak et al write that: “Given the intensity and power of fetal pictures, it is not unreasonable for laypersons to assume that the well-trained physician can see everything and therefore control human biology and assure perfection.” Nature does not ensure that all conceptions result in term or healthy babies. Ironically, most clients coming for a scan do not think this way at all.

An obstetric ultrasound examination is taken as a positive event and in most cases family members come along for the occasion always expecting good news. However when the contrary happens, the effect could be devastating for all present. The sonographer/sinologist is only human and nothing is more shocking than finding the unexpected.

There are unexpected findings which initially may seem positive to the practitioner but may be bad news for the patient i.e. unexpected finding of multiple pregnancy may be an economic disaster for a family. There are also negative unexpected findings which may initially be perceived as bad news by the sonographer but taken as good news by the patient. A classic example is that of the disappearing twin in a previous sonogaphically confirmed early twin gestation in a patient who had all along planned for a singleton pregnancy. Therefore care and professionalism are extremely important with any of these scenarios.

Breaking bad news is one of the few unpleasant tasks of any obstetric sonographer/sonologist. It is not easy but it is best to grasp the nettle and be direct, and unequivocal when giving the information that needs to be given (Fallowfield and Jenkins, 2004). Sympathy and empathy are also important. There should be no ambiguity with the choice of words as it is important that the patient understands what is being said.

Honesty is also paramount especially in the presence of unexpected intra-uterine fetal death. Prolonged starring at the screen should be avoided once a diagnosis is made. It is a waste of time and only helps in further exacerbating patient’s anxiety. Remember the patient can see what you are looking at on the slave monitor unless she has declined the offer at the beginning of the examination.

“The baby’s heart beat is not present any more” is simple enough. To begin, with a warning shot like: ‘I am afraid, you will not like this, but I cannot find your baby’s heartbeat.’ may be taken initially as an indication of lack of skill. Most sensitive clients will identify a change in the body language of the sonographer/sonologist, even before any words are said. A few will actually ask: ‘Is everything alright?’

In one Canadian study (Alkazaleh et al, 2004) a significant number of women indicated a preference for the term ‘baby’ rather than ‘fetus’, although this was in the context of giving bad news. The study further revealed that highly educated women appeared to have variable preferences concerning the use of these terms.

It is always advisable to have two sonographers/sinologists confirm the absence of foetal heart pulsation before intra-uterine foetal death is confirmed to the mother for medico-legal reasons. The role of the bereavement counsellors in terms of communication and further counselling cannot be overemphasised and appropriate referral should be offered.

Offering impromptu counselling
The finding of the unexpected such as a structural anomaly during a routine ultrasound examination is a huge shock to both the patient and the examiner. It may also immediately bring up anxieties about “what do I tell the patient and would I be able to answer the question she is going to ask me” in the practitioner who is not obstetrically trained.

Among the burning questions the patient would need answers to are: “what is wrong with my baby”; “what are the clinical implications”; “Are there any treatments”; “Is my baby going to be alright”;

The best advice for the obstetrically untrained practitioner is to describe the anomaly in simple English without the use of any medical jargon and be honest if there is any limitation of knowledge about clinical implications, need for further examinations including any invasive test rather than giving wrong information. Immediate on-the-day referral to the local fetal medicine clinic or advice from the local senior midwife in charge of screening is usually the best option (Breeze et al, 2011).

Many fetal medicine units in the NHS have patient information leaflets on common fetal anomalies such as pyelectasis, Polyhydramnios, cleft lip/palate, echogenic bowel, talipes etc which can easily be handed out to the patient along with any verbal information given pending further local help. It is best to avoid the “Friday afternoon scenario” with proper scheduling of scan clinics preferably not on Friday afternoons when local or outside referral is practically impossible leaving the patient to face a dreadful weekend before getting help on the Monday morning.

Avoiding unnecessary information
The tendency to give unnecessary information should be avoided at all cost by sonographers. Unnecessary information which is not likely to influence further care only leads to anxiety in mother. The classic example is the patient that is informed her foetus is breech presenting or lying transversely in late second or early third trimester. This is unnecessary information as the foetus at this stage is virtually in a “private pool” and free to swim in any direction with a high chance of spontaneous version closer to term. Such mothers are likely to remain anxious until subsequent scans confirm cephalic presentation.

Discussion of further care/follow-up scans
Patients recall relevant and irrelevant details of any professional dialogue. Sometimes, the contents of the dialogue are deliberately distorted. There is a BMJ Commentary (Lind, 1986) whose portions are still relevant to today’s practice of Obstetric ultrasound:’ If the scan is undertaken by the obstetrician responsible for the patient then full discussion and explanation can take place. One question usually leads to another and inevitably away from merely discussing the fetal image to details of clinical management; the answers should therefore come from the person who will make the final clinical decisions. The next best alternative would be to have an obstetrician immediately available to a non-obstetric scanning team; queries from both the team members and the patient could then be dealt with promptly.

The sonographer who is not obstetrically trained should avoid making comments about further care/follow-up (Ragavendra et al, 1998). Comments about mode of delivery, especially the need for caesarean sections based on the presence of fibroids or estimated fetal weight on ultrasound examination can only make subsequent discussions with the obstetric team difficult. This is particularly poignant with the present drive to reduce the rate of non-medically indicated request for caesarean section in the NHS.

The need for any further follow-up scans should also be left to the managing obstetric team in order to prevent conflicts between the patient and her obstetric team with the exceptions of those where serial scan have been requested in advance.

Reporting at the end of the examination
At the end of an ultrasound scan, the woman is normally given a written report, which is a medico-legal document. Hand written ultrasound reports should be a thing of the past in modern obstetric ultrasound communication. They are not structured, not detailed in most cases, non-standard and variable in terms of information they contain depending on who is writing them. Hand written reports are also not easy to archive.

There are many affordable obstetric ultrasound softwares available in the market presently and all obstetric units should endeavours to purchase one. The long term advantages outweigh the initial cost of purchase. Electronic printable obstetric ultrasound reports standardises reporting for all examination and makes communication easier between all the professionals involved in the patient care easier. They are easy to use and read with structured fields for required information. They also make archiving easy. Many of them come with image management as well. They also integrate easily into the already existing Patient Information Management System in most NHS hospital. Most electronic ultrasound reports contain a disclaimer/warning that ultrasound cannot and will not see all abnormality in pregnancy for medico-legal reasons. The relevance of such a statement is yet to be tested in a court of law, since the patient has not signed anywhere to signify that she understands this statement.

Conclusion
Obstetric ultrasound communication is a relatively simple skill which is influenced by many complex factors affecting its desired effectiveness. Like with all acquired skills, there is a learning curve and improvement occurs with experience as most scenarios in obstetric ultrasound tend to repeat themselves. The unique nature of obstetric ultrasound makes it even more important that the practitioner gets this important aspect of our job right at all times irrespective of the varied human complexity of unpredictable responses to unexpected findings, perceptions of inadequacy of information, and the known hazards of working at a frontier service.

References

  1. Marteau T. Framing of information: its influence upon decisions of doctors and patients. British Journal Of Sociology and Psychology (1989) 28: 89-94.
  2. Chervenak FA, McCullough LB, Brent RL. The perils of the imperfect expectation of the perfect baby. Clinical Opinion, Obstetrics. American Journal of Obstetrics and Gynecology (2010) 203: 101.e1-5.
  3. Breeze ACG, Ziauddin A, McEwan. Suspected fetal anomalies. Obstetrics, Gynaecology and Reproductive Medicine (2011) 21:8 236-241.
  4. Alkazaleh F, Thomas M, Grebenyuk J et al. What women want: women’s preferences of caregiver behaviour when prenatal sonography findings are abnormal. Ultrasound Obstetrics Gynecology (2004) 23: 56-62.
  5. Lind T. Obstetric ultrasound: getting good vibrations. British Medical Journal (1986) 293:576.
  6. Simpson R, Fernando R. Preparing for challenging communication in obstetric scanning. CETL project 2007/08 [www.ihse.qmul.ac.uk/docs/11229.pdf] Accessed on 19.09.2011.
  7. Ragavendra N, Laifer-Narin SL, Melany ML et al. Disclosure of results of sonographic examinations to patients by sonologists. American Journal of Radiology (1998) 170(6) 1423-1425.
  8. NHS Fetal Anomaly Screening Programme -18+0 to 20+6 Weeks Fetal Anomaly Scan National Standards and Guidance for England- 2010.
  9. ter Haar G, Duck FA (eds). 2000. The Safe Use of Ultrasound in Medical Diagnosis, BMUS/BIR, London.
  10. Fallowfield L, Jenkins V. Communicating sad, bad and difficult news. Lancet (2004) 363: 312-319.
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