CCE-CBD-160.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you structure the antenatal care for Sarah in the next 12 weeks?

Answer:

For Sarah Thompson, a 32-year-old woman at 28 weeks gestation with gestational diabetes mellitus (GDM) and a history of postnatal depression, an evidence-based, patient-centred antenatal care plan is essential.

Frequency and Content of Visits:

• 28-36 weeks: Fortnightly visits
• 36 weeks onwards: Weekly visits until delivery
• Visits can be face-to-face or a combination of telehealth (if suitable) due to rural location but must include essential in-person assessments (e.g., blood pressure, fundal height).

Key Assessments Each Visit:

• Maternal observations: BP, weight, fundal height, fetal movements
• Fetal well-being: CTG if indicated from 36 weeks, growth scans at 32 and 36 weeks to monitor for macrosomia related to GDM
• GDM management: Review BGL diary, dietary adherence, metformin effect, and consider insulin if glycaemic targets are not met
• Mental health screening: Regular use of EPDS (Edinburgh Postnatal Depression Scale) and observation for signs of anxiety or depression

Rural Practice Considerations:

• Ensure Sarah has a clear birth and emergency transfer plan due to limited access to specialist care
• Discuss the option of early relocation to a tertiary centre from 38 weeks or earlier if complications arise
• Multidisciplinary team involvement, including diabetic educators, mental health services, and social support

Documentation:

• Maintain up-to-date shared care documentation in line with RACGP Antenatal Care Guidelines

Q2: How would you address Sarah’s concerns regarding postnatal depression?

Answer:

Sarah’s previous history of postnatal depression places her at higher risk of recurrence. A proactive approach is warranted.

Risk Factors and Screening:

• Acknowledge Sarah’s valid concerns and normalise her experience
• Screen at every visit using EPDS from now until the postnatal period (first screen now at 28 weeks)
• Discuss warning signs she and her support network should monitor

Mental Health Plan:

• Develop a GP Mental Health Care Plan (MBS 2715/2717)
• Provide psychological support referrals, ideally a perinatal psychologist with telehealth options if local services are limited
• Consider prophylactic pharmacotherapy postpartum if recurrence risk is high, involving shared decision-making (fluoxetine is breastfeeding safe)

Education and Support:

• Provide resources such as PANDA and Beyond Blue
• Encourage attendance in antenatal classes that include mental health education
• Engage Sarah’s partner/family for support planning

Q3: What are the key considerations for planning Sarah’s delivery?

Answer:

Timing and Mode of Delivery:

• Aim for delivery between 38-40 weeks, considering GDM and fetal growth
• Assess for macrosomia; offer induction of labour at 38-39 weeks if macrosomia or other risks are present
• Discuss risks/benefits of vaginal vs caesarean delivery

GDM and Rural Location:

• Develop an emergency transfer plan
• Consider early relocation to the nearest hospital from 37-38 weeks
• Pre-book specialist care in the event of complications like shoulder dystocia due to GDM macrosomia

Multidisciplinary Coordination:

• Ongoing communication with obstetric services
• Include Sarah in shared decision-making for her birth plan

Q4: What advice and management will you provide regarding Sarah’s GDM?

Answer:

Lifestyle Advice:

• Continue dietary control with a dietitian review
• Encourage moderate physical activity (e.g., walking 30 mins daily if appropriate)

Monitoring:

• BGL targets: fasting <5.3 mmol/L, 1-hour postprandial <7.8 mmol/L
• Review glucose diary at each visit

Medication Management:

• Increase metformin dose if needed (within safe range)
• Escalate to insulin if BGLs remain above target despite metformin and lifestyle interventions

Postnatal Follow-up:

• Discuss oral glucose tolerance test (OGTT) at 6-12 weeks postpartum
• Advise on long-term T2DM risk and lifestyle modification
• Encourage breastfeeding, which can reduce diabetes risk

Q5: What preventive health measures should be included in Sarah’s care?

Answer:

Immunisations:

• Pertussis vaccine now (recommended 28-32 weeks)
• Confirm influenza vaccine was given earlier (20 weeks)
• COVID-19 booster if not already given (as per ATAGI guidelines)

Breastfeeding Support:

• Provide information and referrals to lactation consultants
• Discuss potential challenges due to GDM infant macrosomia

Contraceptive Planning:

• Discuss postnatal contraception before discharge (e.g., long-acting reversible contraception)
• Educate on timing and safety of different methods in lactation

Postnatal Checks:

• Schedule early postnatal follow-up (1-2 weeks postpartum) and 6-week check to assess physical and emotional wellbeing

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive antenatal care plan tailored to GDM and rural settings
• Mental health risk identification and management using validated screening tools
• Clear delivery planning incorporating rural practice logistics and shared decision-making
• Evidence-based GDM management with escalation plans and postnatal diabetes prevention
• Emphasis on preventive health measures including immunisations and breastfeeding support

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PITFALLS

• Failure to address mental health history and proactive screening for PND
• Neglecting emergency planning for rural transfer and delivery logistics
• Delaying escalation of GDM treatment when BGL targets are not met
• Inadequate postnatal follow-up, missing opportunities for T2DM prevention
• Overlooking preventive care, including immunisations and contraception counselling

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REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (“Red Book”)
• RACGP Antenatal Care Guidelines
• Diabetes Australia on Gestational Diabetes
• ATAGI Immunisation Recommendations

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers clinical information through history, examination and investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Makes diagnoses based on sound clinical reasoning.
3.2 Prioritises issues to be addressed in patient care.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans.
4.2 Prescribes and monitors appropriate therapeutic interventions.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection.

6. Professionalism

6.1 Adopts a respectful, reflective, and responsible manner.

7. General Practice Systems and Regulatory Requirements

7.1 Provides care in accordance with relevant policies and regulations.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient safety.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potentially serious conditions and provides appropriate care.

12. Rural Health Context (RH)

RH1.1 Provides antenatal care within a rural general practice context.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD