The Antenatal Clinic - Facilitating Safe Paediatric Surgical Care
15 September 2021
A look at Mrs Claire Clark, RCSEd Fellow and Consultant Paediatric Surgeon, and the role of the antenatal clinic in facilitating safe paediatric surgical care.
Antenatal screening, and the planning of the immediate post-birth period for babies with surgical pathology, is important to effective delivery of paediatric surgical care. Antenatal surgical clinics form part of RCSEd Fellow and Consultant Paediatric Surgeon Claire Clark’s clinical practice. She believes such clinics, which are held in partnership with the neonatal and fetal medicine team, provide a key opportunity to not only plan the best location and timing of delivery of such children, but also to explore any parental anxieties surrounding the birth and care of their child.
Mrs Claire Clark is one of eight consultant paediatric surgeons based at the Royal Hospital for Children and Young People in Edinburgh. As part of her practice, she treats children from birth (including those born prematurely) to age 16. Her main areas of interest include colorectal paediatric surgery and urology, however she is routinely involved in the treatment of children presenting with emergency paediatric surgery conditions. To her, paediatric surgery a wonderful speciality - the patients are interesting, young children tend to heal well and quickly, and she has the opportunity to work as part of a large team of health professionals dealing with not just the medical but also the social and psychological aspect of the child’s health.
After medical school in Sheffield, Mrs Clark applied for postgraduate medical training in Scotland due to her love of the country’s hills, many of which she has walked. After brief periods in paediatric medicine and neonatology, which were required experience to pursue a career in paediatric surgery, she commenced her surgical training first in Glasgow, and later in Edinburgh. She is married to Consultant Adult Colorectal Surgeon Andrew Clark and has three children.
The Antenatal Surgical Clinic in Edinburgh serves the entire South-East region of Scotland. It is a safe space for parents to ask questions, and where possible, have specific anxieties relieved. Mrs Clark specifically deals with urological problems detected in-utero; she developed this service as a Senior Registrar when she realised that antenatal surgical clinics at that time mainly catered to other surgical abnormalities, with no dedicated service for disorders of the urinary tract. The present Antenatal Urological Clinic is a multidisciplinary service involving neonatology, fetal medicine, paediatric renal medicine, and paediatric surgery. Depending on defined MDT pathways, the number of scans an expectant mother needs, who sees the family and how often, timing and place of delivery is decided. The service in its present form took years to develop.
Current clinics are held on an ad hoc basis, usually fitting around Mrs Clark’s busy clinical schedule. Eligible families, who are picked up at the 12-week dating scan or 20-week anomaly scan are contacted with available dates. There is an opportunity for Mrs Clark and the MDT to look at all antenatal scans with the family, and also, with the help of the fetal medicine team, to conduct real time scans during the clinic appointment to aid explanations and decision making. Mrs Clark spends as much time as is needed by each individual family explaining the surgical pathology identified, and how it differs from normal anatomy and physiology. This is facilitated by the use of pictures, and she finds it important to get a clear idea of what the parents understand about the situation. This can occur in a single visit if the pathology is straightforward, but often multiple clinic appointments are needed.
Planning delivery of the child is an important part of the antenatal process. Mrs Clark believes a clear plan individually tailored to each patient is the key to a favourable postnatal outcome. One aspect is location of delivery - the child needs to be delivered where there are facilities available to manage their surgical condition. If the pathology is minor, delivery at the family’s local hospital with later follow-up by the relevant clinician can occur. If major, however, delivery needs to occur at a tertiary or quaternary centre where paediatric surgery is readily available. Safe delivery planning is achieved through regular communication between the multidisciplinary team. A ‘day of delivery’ plan is agreed as soon as possible, with clear instructions on immediate interventions needed after birth, scans and the timing of these, contact details of key team members and any medications needed included in the maternal notes. A copy of these instructions is also sent to all members of the clinical team that may be looking after the child following the birth.
The detection of any pathology on antenatal screening is associated with a significant amount of stress and anxiety for the child’s family. This can be particularly difficult to manage for the counselling surgeon, especially since some urological antenatal anomalies resolve spontaneously. It can be difficult to determine how much significance to attach to certain pathology such as mild vesico-ureteric reflux, and thus how to balance information given to parents in order to not heighten anxiety. Mrs Clark believes the best approach is to be honest about uncertainty, and make it clear to families the potential for the team to be occasionally wrong about diagnoses or prognoses. Despite this, Mrs Clark feels antenatal screening and counselling forms a vital part of safe paediatric surgical care - she recalls a case of a child with posterior urethral valves that were missed in the antenatal period, as he was born at a time where 20-week anomaly scans were not routinely performed. He ended up in severe obstructive renal failure in infancy, requiring renal transplantation. If his pathology had been picked up in the antenatal period, early intervention would have likely meant preserved renal function.
The lack of availability of routine antenatal screening, and indeed health professionals/centres capable of dealing with identified surgical pathology in the developing world, remains of concern to Mrs Clark and the antenatal surgical team. She is grateful for the facilities available in the Royal Hospital for Children and Young People, and for the opportunity to interact with families and hopefully relive their anxiety and thus better enjoy the pregnancy and birth of their child.
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