Privileging and consultation in
maternity and newborn care
Steven Goluboff, MD, CCFP, FCFP Larry Reynolds, MD, MSC, CCFP, FCFP Michael Klein, MD, CCFP, FCFP, FAAP
Richard Handﬁeld-Jones, MD, CCFP, FCFP Maternity and Newborn Care Committee
C anada appears to be headed for a crisis in the
number of providers of maternity and new-
born care. Family physicians are turning away
To foster positive roles for family physicians
in maternity and newborn care, the College of
Family Physicians of Canada’s (CFPC) Maternity
from maternity care for practical reasons, such as and Newborn Care Committee (MNCC) propos-
effects on lifestyle, poor and unfair remuneration, es the following recommendations.
and rising malpractice fees. But another impor-
tant factor is that they are losing their sense of Recommendations
autonomy as maternity care providers. Department organization and responsibilities.
Family physicians’ perception that modern These recommendations apply to hospitals (usually
maternity care is complex and technical and larger ones) with separate departments for obstet-
“best left to the exper ts” leads to feelings of rics and gynecology, pediatrics, anesthesiology, fam-
powerlessness and being under valued. These ily medicine, and midwifery.
feelings discourage family physicians from pro- • Responsibility for care provided by department
viding maternity and newborn care. This paper members should rest with each depar tment
addresses this growing problem by suggesting head. This should include assessing credentials
ways to deﬁne the roles and responsibilities of and granting privileges, quality assurance, disci-
family physicians (and other providers) accord- plining members, and ensuring that policies are
ing to clear privileging policies and consultation carried out by members.
relationships. • No department professional group should be
We believe structures that foster responsibility, responsible for any other.
self-regulation, collegiality, and mutual support • Departments should cooperate with each other.
among providers will promote a higher standard • Where program management is in effect (ie, a
of care than those that encourage dependence of maternity and newborn care program), quality
one group of providers on another. For example, assurance will also be carried out on a program
consultations, whether between family physicians basis and address the functioning of the full
and specialists or between two family physicians, maternity and newborn care team.
are likely to be most useful and appropriate when • In departments of family practice where few mem-
both par ties are knowledgeable in their own bers provide maternity and newborn care, consid-
domains and are mutually respectful. er establishing a division of maternity and
The settings in which medical students and newborn care for those who do. This division
family medicine residents learn the skills and atti- would be responsible for developing maternity and
tudes required for effective maternity care present newborn policies for the department as a whole.
a special challenge. Because of the crucial inﬂu- Often smaller hospitals (particularly those in
ence of role models, these trainees should experi- rural and remote settings) do not have depart-
ence family practice obstetrics where positive and mental structures; physicians and midwives are
collegial structures exist. The unintended educa- members of a single staff organization. The head
tional message to trainees who see family physi- or chief of the medical staff is often a family physi-
cians functioning in dependent roles is that cian but could be from another discipline.
obstetric practice is beyond their abilities. Normally in such a setting, assessing credentials
Choosing not to incorporate maternity and new- and granting privileges is a responsibility of the
born care into future practice is an unacceptable hospital-wide staff or, occasionally, of the provin-
consequence. cial licensing authority.1,2
1716 Canadian Family Physician • Le Médecin de famille canadien ❖ VOL 46: SEPTEMBER • SEPTEMBRE 2000
Policy development. Regardless of the hospital experience. This could assist providers in gaining
organizational structure (departmental, program conﬁdence or incorporating new or advanced skills
management, or a combination), coherent and into their practice. Providers should have input into
consistent policy development for all maternity the choice of probation supervisor, who could be
and newborn care is needed. anyone qualiﬁed for that task.
• Policies should be developed by a multidiscipli-
nary committee consisting of obstetricians, pedi- Scope of privileges. A distinction is made here
atricians, anesthesiologists, family physicians, between basic skills for which any family physi-
nurses, midwives, and administrative represen- cian providing mater nity and newbor n care
tatives. Each department should be represented. should be granted privileges and more advanced
This would be consistent with the national skills that should be treated on an individual
guidelines for Family-Centred Maternity and basis. The following are the basic skills:
Newborn Care.3 • spontaneous term singleton vertex labour and
• Policies should apply equally to all disciplines. birth;
• The chair of the committee could be a member • induction of labour for postdates pregnancy or
of any of the constituent disciplines. ruptured membranes at term with no evidence
of fetal compromise6,7;
Granting privileges. Decisions on privileges • basic fetal surveillance;
should be based on evidence and best practice • assessment of placental function by ordering
standards. The CFPC’s MNCC supports the CMA and interpreting appropriate clinical and labora-
policy summary “The Physician Appointment and tory investigations;
Reappointment Process.”4 Key principles in this • management of dystocia in the ﬁrst and second
policy are as follows. stages of labour by nonpharmacologic and phar-
• All processes should be fair, equitable, docu- macologic means, including oxytocin8;
mented, transparent, and just. • management of shoulder dystocia;
• Regular evaluation of appointed physicians should • outlet and low vacuum extractor or forceps-
be conducted by the appropriate department head. assisted births;
• The quality of a physician’s care is the most • repair of laceration or episiotomy;
important criterion to consider at time of appoint- • management of postpartum hemorrhage;
ment, reappointment, and granting of privileges. • vaginal birth after cesarean section (VBAC);
• A physician’s credentials, skills, expertise, and • examination and care of newborns; and
quality of care, as judged by peer assessment, • basic neonatal resuscitation, including intuba-
should be considered during the process. tion and management of meconium.
Where any of these skills, par ticularly the
In particular, the following guidelines should more complex ones, are underdeveloped or where
be considered for maternity and newborn care. experience is limited, family physicians are
• Maternity and newborn care privileges should encouraged to seek mentoring from other family
be granted according to skill and expertise. No physicians or consultants or take ALSO or
evidence shows that any particular training or ALARM courses. Further speciﬁc privileges for
clinical experience produces ideal maternity more advanced skills can be granted to individual
care providers. family physicians following appropriate review of
• No evidence supports having stated lower or previous training and experience.
upper limits of births attended or procedures
performed to maintain privileges.5 Consultations. Consultation plays an integral
• Privileging should always take place in the role in all health care settings. Principles of con-
context of departmental and institutional qual- sultation have been well described, both generally
ity assurance and risk management programs. and in obstetrics.9,10 Key principles for maternity
• Risk management courses, such as Advanced and newborn care include the following.
Life Suppor t in Obstetrics (ALSO) and • Mandatory consultation should not be part of
Advances in Labour and Risk Management departmental policy because family physicians
(ALARM) are encouraged and desirable but vary greatly in skill and expertise and because a
should not be mandatory. policy of mandator y consultation has never
• A probationary period could be used when providers been shown to improve care. It should be
are unable to document adequate previous assumed that responsible physicians will seek
VOL 46: SEPTEMBER • SEPTEMBRE 2000 ❖ Canadian Family Physician • Le Médecin de famille canadien 1717
consultation when required, according to indi- Director of Continuing Medical Education of the College of
vidual clinical situations. Family Physicians of Canada.
• There are circumstances when consultation
might be seriously considered, either from a Correspondence to: Dr Richard Handﬁeld-Jones,
specialist or a family practice colleague. The College of Family Physicians of Canada, 2630
Consultation should be obtained when physi- Skymark Ave, Mississauga, ON L4W 5A4
cians lack the requisite skill or experience, when
diagnosis is in doubt, or when the problem is References
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with clariﬁcation of who is to assume the team paper on training for rural family practitioners in
leadership for ongoing care. Informal and often advanced maternity skills and caesarean section. SOGC
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particular patients should be discouraged for 3. Health Canada. Family-centred maternity and newborn
the medical and legal protection of all those care; national guidelines. Ottawa, Ont: Minister of Public
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and general management issues but rather to The physician appointment and reappointment process.
ensure consultants have the beneﬁt of a com- Le processus de nomination des médecins et de renou-
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No. 58; 1996 Nov. Available from: Society of Obstetricians and
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Dr Goluboff practises family medicine and is an Associate from: Society of Obstetricians and Gynaecologists of
Clinical Professor in the Department of Family Medicine at Canada via http://www.sogc.org/SOGCnet/sogc_docs/com-
the University of Saskatchewan in Saskatoon. Dr Reynolds mon/guide/index_e.shtml. Accessed 2000 Jun 2.
is a Professor in the Department of Family Medicine at the 9. Ross LG, College of Family Physicians of Canada, Task
University of Western Ontario and is Chief of the Force on the Relationship between Family Physicians and
Department of Family Medicine at St Joseph’s Health Care Consultants, Royal College of Physicians and Surgeons of
in London, Ont. Dr Klein is a Professor of Family Practice Canada. The relationship between family physicians and
and Pediatrics at the Department of Family Practice at the specialist/consultants in the provision of patient care.
University of British Columbia, is Head of the Division of Mississauga, Ont: The College of Family Physicians of
Maternity and Newborn Care at the Children’s and Women’s Canada; 1993.
Hospital of British Columbia in Vancouver, and is Chair of 10. Reid AJ, Carroll JC, Ruderman J, Murray M.
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1718 Canadian Family Physician • Le Médecin de famille canadien ❖ VOL 46: SEPTEMBER • SEPTEMBRE 2000