March 1997
SAN FRANCISCO – A study conducted by Philip Rosenthal, MD, director of pediatric hepatology at the University of California at San Francisco, shows documented proof of something that the pediatric community has known for a long time: mainly the lack of communication between obstetricians and pediatricians.
In the normal course of their jobs this might not matter, but when an obstetrician has a patient with some type of condition or disease that could affect her child it's paramount that the pediatrician be made aware of it. And, often this does not happen.
Rosenthal's study focused on how obstetricians in California conveyed the results of their patients' hepatitis B serologies to the pediatricians who would be taking care of their patients' children. Questionnaires were mailed to a random sampling of 801 obstetricians and 1,030 pediatricians. There was a response rate of 65.7% from obstetricians and 71% from pediatricians.
![[bar]](/art/gradred.gif){kind=small}
"There was a great difference of opinion between obstetricians and pediatricians regarding how to communicate hepatitis B virus serology results on the mother," the study reported. Of the obstetricians who responded, 49% said they always asked the nurse to inform the pediatrician; 51.2% said they always verbally informed the pediatrician; 39.1% said they always placed an order in the mother's chart and 5.7% said they always sent a letter to the pediatrician.
Pediatricians, however, had different answers for how they received serology results. Of the pediatricians who responded, only 12.9% said that they always received the results from the obstetrician's nurse; only 2.6% reported that they always received a verbal communication from the obstetrician; 14.1% said they always retrieved the information from a written report in the mother's chart and 4.2% reported that they always received a letter from the obstetrician.
"Based on the results of our study, it is possible that other maternal results, e.g. syphilis or human immunodeficiency virus serology, may not be efficiently communicated to the newborn's physician," the study reported. Any disease or condition that the mother has that could affect her unborn child should be communicated clearly to the pediatrician, Rosenthal said.
David Wood, MD, MPH, director of clinical outcomes management at Shriners Hospitals, Tampa, Fla., and one of Rosenthal's co-authors, said that syphilis is one maternal condition that may be troublesome. The problem occurs when the mother is seropositive but documentation of her treatment isn't available. "You really have to go out of your way to find the information," he said, adding that asking the mother isn't always the answer because she may not know what type of treatment she received.
Beyond actual maternal diseases, pediatricians also need to be apprised of other factors that might affect the baby, such as substance abuse, maternal depression, maternal exposure to harmful environments and much more."Part of the communication problem may be just the lack of detection on the part of the prenatal care," Wood said. If the obstetrician hasn't detected a problem he or she can't communicate it to the pediatrician.
Another concern Wood mentioned was the mother's intrapartum care and factors introduced during that period, such as various drugs, that might affect the child. "Generally the intrapartum care is documented at some level, but there isn't a good summary of that care that's been made available to pediatricians," he said. "You end up having to search through their records and document that. That's time consuming and important information may get lost."
Along with inadequate documentation or maternal care that isn't thorough enough, there are other factors that lead to this communication gap. "It's probably just the previous practices," Rosenthal said. Obstetricians take care of the mother, and pediatricians take care of the baby, and often the two sides just don't come together.
"For the majority of kids who have normal deliveries, the pediatrician never sees the obstetrician," Wood said. There's a hand-off of the newborn from the obstetrician to the pediatrician, Wood added, but it's a hand-off with no actual contact, so important information can and does fall through the cracks.
Obstetricians make many assumptions that inhibit communication, Rosenthal said. "They're thinking that telling the nurse or writing something on the mom's chart will automatically, effectively get that information to the pediatrician."
So, how can maternal serology results and other important information best be communicated from the obstetrician to the pediatrician? Rosenthal thinks that the best method would be to make each state responsible for tracking results, maintaining a repository of information and passing that information on, along the same lines as what is done with newborn screening.
Another way that this information could be communicated is to have the mother actually carry what Rosenthal referred to as a "maternal passport." This little booklet of information would include the mother's test results, as well as other details about her health and her prenatal and intrapartum care. It would then go with her to the hospital and be given to the pediatrician.
An even simpler system for communication would be a checklist that the obstetrician fills out. "I think we should probably have a task force to take a new look at the communication between the obstetrician and the pediatrician, with the goal of setting new standards of what information should be passed on and how it can be transmitted accurately," Wood said.
When Wood worked at Cedars-Sinai Medical Center in Los Angeles, a charting system followed the mother through pregnancy and delivery and then provided forms to the pediatrician. "Better information systems, whether it's manual or automatic, would really help," he said. "The more you automate the communication, either through policy or through medical record automation, the more that you're going to make sure that the information gets transmitted."
But, before policies and procedures can be established and systems can be designed to track this information, the two parties need to reach an agreement. First they need to recognize that there is a problem, Rosenthal said. The next step is to get together and talk. "If it's a certain hospital that you use the same group of individuals then, obviously, you could go one-on-one with those individuals and try to work out a better mechanism for getting information," he said. Once the two sides start meeting in small groups they could move on to larger groups to design and implement systems that would become standards in their fields.
For more information:
- Rosenthal P. Hepatitis b virus serology in pregnant women: transmittal of results from obstetrician to pediatricians in California. Pediatr Infec Dis J 1995;14:927-31.
You can express your
views on this article, or other relevant themes, in the
Infectious Diseases in Children
Specialty Forums.