Woman in Early Pregnancy Requesting Minimal Antenatal Intervention — Free SCA Practice Case
Woman in early pregnancy requesting minimal antenatal intervention
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Maya Sharma
Age
31 years
Consultation Type
VideoAge
31
Situation
Video Consultation.
Reason for Encounter
"Patient booked a video appointment. Currently 8 weeks pregnant (primigravida). Reception note states: 'Wants to discuss midwife referral but wishes to have a completely natural pregnancy with minimal medical involvement.'"
Medical Records
- ●PMH: Nil significant.
- ●Medications: Over-the-counter Folic Acid 400mcg & Vitamin D.
- ●Lifestyle: Strict vegan for environmental and ethical reasons.
- ●Allergies: NKDA.
Recent Notes
- ●Last BP check 1 year ago: 110/70. BMI: 22.
Patient Script
For the friend playing the patient role
Character Overview: You are Maya, a 31-year-old environmental consultant. You are thrilled to be pregnant with your first child. However, you are deeply committed to a "low-impact," natural lifestyle and you distrust the industrial "medicalization" of childbirth. You have been reading natural birth forums and are convinced that modern hospitals over-intervene, causing unnecessary stress and generating massive amounts of medical waste. You have decided you want to decline all ultrasound scans (you believe they disturb the baby, and you wouldn't terminate for a chromosomal anomaly anyway) and all routine blood tests (you are vegan, feel incredibly healthy, and don't see the point in looking for problems). You want to be referred to a local community midwife for a home birth. You will not volunteer your specific diet or your exact reasons for refusing the blood tests unless the doctor specifically explores your health beliefs, asks what "minimal intervention" means to you, or creates a highly non-judgmental space.
ICE — Ideas, Concerns, Expectations
(Do not volunteer any of the following unless the candidate directly explores your perspective — e.g. asks what you think is going on, what worries you, or what you're hoping to get from the consultation.)
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Ideas: You believe pregnancy is a completely natural process and that a healthy body — especially one maintained on a clean, plant-based diet — does not need medical monitoring. You think routine screening is designed for unhealthy populations and that the NHS over-medicalises normal pregnancies. You've read online that ultrasound waves may stress the baby and that blood tests just lead to unnecessary worry.
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Concerns: Your deepest worry is that engaging with the hospital system will mean losing control of your birth experience — being pressured into interventions you don't want, in an environment that feels clinical and impersonal. You are also concerned about the environmental footprint of repeated hospital visits and disposable medical supplies. Underneath it all, there is a quiet, unspoken anxiety about whether you're making the right choices for your baby, but you would only express this if the doctor creates a genuinely safe, non-judgmental space.
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Expectations: You want the doctor to respect your autonomy, refer you to a community midwife for home birth, and not push you into standard screening pathways. Ideally, you'd like to feel heard and supported — not lectured. If the doctor is empathetic and informative without being paternalistic, you're open to reconsidering specific tests if there's a clear reason tied to your baby's safety.
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Hi Doctor. Yes, I took a test a few weeks ago, I'm about 8 weeks along. I know I need to register with a maternity team, but I wanted to speak to you first to set some boundaries. I want a completely natural pregnancy, and I want to opt out of the routine medical screening."
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Data Gathering (The Layers):
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Layer 1: Defining "Minimal Intervention":
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If asked WHAT exactly you are refusing: "I don't want the ultrasound scans. If the baby has Down Syndrome, I wouldn't terminate, so why cause the stress? And I don't want the routine blood tests. I feel perfectly fine and healthy, so there's no need to go looking for problems."
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Layer 2: Current Pregnancy Viability:
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If asked about symptoms: "I have a bit of morning nausea, but no vomiting. No bleeding or stomach pain. I'm taking my folic acid and vitamin D."
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Layer 3: Exploring Health Beliefs & Lifestyle (The Eco-Angle):
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If asked WHY she wants to avoid the hospital/tests: "Pregnancy isn't an illness. I feel like the NHS treats it like an industrial process. I'm a strict vegan, I live very cleanly, and I just want to limit my footprint and keep things as natural as humanly possible. I want to give birth at home, not in a clinical ward."
If Asked — Medical History and Medications
(The following details are drawn from the patient's medical records. Respond naturally in patient voice only if the candidate specifically asks about these areas.)
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If asked about past medical history or previous illnesses: "No, nothing really. I've always been healthy — I don't think I've been to the GP in years, other than for a routine check-up. No operations, no hospital stays, nothing like that."
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If asked about folic acid: "Yes, I've been taking 400 micrograms of folic acid since we started trying. I read it's important for the baby's spine development, so I started it a couple of months before I even got pregnant."
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If asked about vitamin D: "I take a vitamin D supplement — I've been on it for a while actually. I know vegans can be a bit low on it, and I don't eat dairy or oily fish, so I just take the tablet. It's a vegan-friendly one."
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If asked about any other supplements or medications: "No, just those two. I don't take anything else — I prefer to get everything from my diet where I can."
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If asked about allergies: "No allergies that I know of."
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If asked about last blood pressure or health check: "I think I had my blood pressure checked maybe a year ago? They said it was fine — normal."
Social History and Lifestyle Impact
(Integrate naturally into conversation — these details can be volunteered where they flow from the discussion, particularly when talking about her lifestyle philosophy or her plans for the pregnancy.)
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Occupation and daily life: Maya works as an environmental consultant for a sustainability consultancy. She advises businesses on reducing their carbon footprint and waste output. Her professional identity is deeply intertwined with her personal values — sustainability is not just a belief system but her career. She cycles to work, grows some of her own vegetables, and is active in her local zero-waste community group.
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Lifestyle impact of the pregnancy: "Honestly, the pregnancy has been fine so far — the nausea is manageable. But what's really stressing me out is the thought of being pulled into the hospital conveyor belt. I spend my working life telling companies to reduce unnecessary processes and waste, and then I look at the NHS maternity pathway and it feels like everything I stand against — plastic speculums, disposable gowns, driving to appointments every few weeks. I just want to do this at home, with a midwife I trust, in a way that feels right for me and the planet."
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Partner and support: If asked: "My partner is really supportive. He's on the same page as me about keeping things natural. He's been reading up on home births too and he's keen to be involved."
If Asked — Associated Symptoms
(Respond only if the candidate directly asks about these symptoms. Keep answers brief and natural.)
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If asked about vaginal bleeding or spotting: "No, nothing like that at all."
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If asked about abdominal or pelvic pain: "No pain, no. Just the nausea really."
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If asked about urinary symptoms (frequency, burning, blood in urine): "I'm going to the loo a bit more often, but no burning or anything like that. I assumed that was just normal in early pregnancy."
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If asked about headaches or visual disturbances: "No headaches, and my vision is fine."
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If asked about dizziness or fainting: "No, I haven't felt dizzy or fainted. I feel well in myself."
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If asked about fatigue or tiredness: "Yes, I am more tired than usual — I've been going to bed earlier. But I just put that down to the pregnancy."
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If asked about mood changes or anxiety: "I'm mostly excited, to be honest. A bit anxious about making sure I do everything right, but nothing I'd call low mood or anything like that."
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If asked about appetite or weight changes: "My appetite is a bit up and down with the nausea, but I'm eating well overall. I haven't noticed any weight loss."
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If asked about breast tenderness or changes: "Yes, my breasts are quite tender actually — they feel heavier than usual. I read that's a normal sign."
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If asked about bowel habit changes: "I've been a little more constipated than usual, but nothing major."
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If asked about fever or feeling unwell: "No, no fever. I feel healthy."
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If asked about recent travel abroad: "No, I haven't been abroad recently."
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If asked about contact with anyone unwell or infectious diseases: "No, not that I know of. I work in an office mostly, or from home."
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If asked about vaccination history (rubella, flu, COVID, whooping cough): "I think I had my childhood jabs, but I'm not sure about rubella specifically. I haven't had a flu jab — I don't usually bother. I had my COVID vaccinations, yes."
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If asked about smoking: "No, I've never smoked."
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If asked about alcohol: "I stopped drinking as soon as I found out I was pregnant. I wasn't a big drinker before — maybe a glass of wine at the weekend."
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If asked about recreational drugs: "No, nothing like that."
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If asked about dietary specifics (B12, iron, iodine, calcium, omega-3): "I eat a lot of leafy greens and lentils, so I think my iron is fine. I don't take a B12 supplement separately — I assumed I was getting enough from fortified foods like plant milk. I hadn't really thought about iodine, to be honest. I use oat milk, not always the fortified kind."
Negotiation & Collaborative Management Plan:
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If the Doctor uses scare tactics ("You have to do the bloods or your baby could die"):
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Reaction: Highly defensive. "It's my body and my baby. If you're going to bully me, I just won't register with the NHS maternity services at all." (Candidate critically fails for coercion and alienating a vulnerable patient).
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If the Doctor supports her "natural" ethos and community care (Planetary Health):
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Reaction: "Thank you! Exactly. A local community midwife coming to my house feels so much more sustainable and less stressful than driving to the hospital every few weeks."
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If the Doctor addresses the Vegan diet (Population/Maternal Health):
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Reaction: "I know a plant-based diet is great for the planet, but I didn't realize I might be short on Iodine and B12 for the baby's brain development. Yes, I am happy to buy a specific vegan pregnancy multivitamin today."
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If the Doctor separates the "Scans" from the "Infectious Disease/Rhesus Bloods":
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Reaction: "I didn't realize the blood group test was about my blood attacking the baby's blood (Rhesus). Or that things like syphilis could be passed on even if I feel fine. I thought they were just checking my iron levels. Okay, if I skip the ultrasounds, I will agree to do the booking bloods for the baby's safety."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Informed Consent and Bodily Autonomy in Pregnancy
- ●Under UK law (established in Montgomery v Lanarkshire Health Board [2015]), a competent adult has the absolute right to decline any medical intervention — including antenatal screening — even where that refusal carries risk to themselves or to the fetus.
- ●The GP's duty is not to obtain compliance but to ensure informed refusal: the patient must understand the specific risks associated with declining each specific investigation before her decision is accepted and documented.
- ●Coercive or fear-based language (e.g. "your baby could die") constitutes a failure of the consultation, not a safety strategy — it risks the patient disengaging from maternity care entirely, which is the worse outcome.
Differentiating Antenatal Investigations: Screening vs Safety-Essential Bloods
- ●A critical clinical skill in this case is separating two fundamentally different categories of antenatal investigation that patients — and candidates — commonly conflate.
- ●Fetal Anomaly Screening (patient may legitimately decline): Dating scan, 20-week anomaly scan, combined first-trimester screening (nuchal translucency + maternal serum), and quadruple screening for Down's, Edwards', and Patau's syndromes. Where a patient has stated clearly she would not alter the pregnancy based on chromosomal findings, declining these tests is logically coherent and must be accepted without pushback.
- ●Booking Blood Screen (safety-essential — explain the specific rationale):
- ●Blood group and Rhesus D status: If the mother is Rh-negative and carries an Rh-positive fetus, maternal sensitisation can cause haemolytic disease of the newborn in this or future pregnancies. This is almost entirely preventable with anti-D prophylaxis — but only if Rh status is known. This is not screening; it is identification of a preventable harm.
- ●Infectious disease screen (HIV, hepatitis B, syphilis): These infections can be completely asymptomatic in the mother yet cause severe fetal or neonatal harm. Vertical transmission of all three is dramatically reduced by maternal treatment, which requires identification first.
- ●Haematology (FBC) and blood group antibodies: Baseline anaemia detection and antibody screen are particularly relevant in a vegan patient at risk of iron-deficiency anaemia.
- ●Framing the booking bloods as being "about the baby's safety, not about monitoring you" is often the pivot that allows a patient with this presentation to reconsider.
Vegan Pregnancy: Supplementation Requirements
- ●A whole-food plant-based diet has a substantially lower environmental footprint than an omnivorous diet — this is not in dispute and should be validated. The clinical issue is that unsupplemented vegan diets in pregnancy carry specific, preventable risks to fetal neurodevelopment.
- ●Folic acid 400 micrograms: Appropriate dose for a low-risk pregnancy when started pre-conceptually, as in this case. Confirm adequacy rather than suggesting she is doing anything wrong.
- ●Vitamin D: She is already taking this — appropriate and should be continued.
- ●Vitamin B12: Vegans have no reliable dietary source of B12. Fortified plant milks and cereals provide variable and often inadequate amounts. B12 deficiency in pregnancy is associated with fetal neural tube defects and impaired neurological development. A specific supplement is required — this cannot be assumed from fortified foods alone.
- ●Iodine: Typically sourced from dairy and fish. Vegans using oat milk (particularly non-fortified varieties) are at high risk of iodine deficiency. Iodine is essential for fetal thyroid function and brain development; deficiency during pregnancy is associated with irreversible cognitive impairment. This is the nutritional gap most commonly missed in vegan pregnancies.
- ●DHA (omega-3): Plant sources provide ALA, which converts poorly to DHA. Algae-based DHA supplements are the vegan-appropriate source and are recommended for fetal brain and retinal development.
- ●Practical advice: Recommend a vegan pregnancy multivitamin (e.g. a product specifically formulated to include B12, iodine, and DHA alongside folic acid and vitamin D). Standard high-street pregnancy vitamins frequently omit iodine and contain insufficient B12 for strict vegans.
Maternity Pathway: Community Midwifery and Home Birth
- ●NICE guidance (NG235, 2023) explicitly supports home birth as an appropriate option for low-risk women, including primigravidas, who are fully informed of the additional risks. Home birth is not a fringe preference — it is a supported pathway.
- ●For a low-risk patient who wishes to minimise hospital contact, referral to a community midwifery team is the clinically appropriate and patient-aligned response. Defaulting to a consultant-led hospital pathway without considering this option directly contradicts both NICE guidance and the patient's informed choice.
- ●The one key safety argument for the dating scan in this context: The primary reason to recommend a dating scan for a patient planning a home birth is detection of multiple pregnancy. A twin or higher-order pregnancy substantially changes the risk profile of home birth and would not otherwise be detectable at 8 weeks. This is a specific, value-congruent reason that may resonate with a patient who has already declined anomaly screening for other reasons.
Safety Netting in Early Pregnancy
- ●Safety netting must be provided at every first-trimester consultation, regardless of the patient's screening preferences.
- ●Advise the patient to seek same-day urgent assessment if she develops:
- ●Significant vaginal bleeding (beyond light spotting)
- ●Severe or one-sided lower abdominal or pelvic pain (raises concern for ectopic pregnancy)
- ●Heavy or persistent vomiting preventing adequate fluid intake (hyperemesis gravidarum)
- ●Advise prompt GP review if she develops fever, dysuria, or symptoms of urinary tract infection — UTI in pregnancy carries a higher risk of ascending infection and preterm labour than in the non-pregnant population.
- ●Establish a clear follow-up pathway: referral to community midwifery for booking appointment, with a clear route back to the GP if her clinical condition changes before that appointment.
Common Candidate Mistakes in This Station
- ●Conflating all antenatal investigations: The most common error is treating the patient's refusal as a single block — accepting or refusing all screening together — rather than separating anomaly screening (which she can reasonably decline) from safety-essential booking bloods (which require specific, tailored explanation).
- ●Missing the nutritional audit: Accepting that a patient takes folic acid and vitamin D without exploring the adequacy of her vegan diet overall. B12 and iodine deficiencies in vegan pregnancies are well-established and preventable — failing to address them is a significant omission.
- ●Recommending standard pregnancy vitamins for a strict vegan: Many branded pregnancy supplements do not contain iodine or contain insufficient B12. Recommending a generic supplement without addressing this gap leaves the patient inadequately supplemented.
- ●Failing to mention twin detection as the rationale for the dating scan: Candidates who know the patient has declined anomaly screening sometimes omit the dating scan entirely. The specific value of the dating scan for a patient planning a home birth lies in excluding multiple pregnancy — this is a distinct, targeted reason that should be communicated clearly.
Mapped to the RCGP curriculum topic: Population and Planetary Health.
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