Maternity Experience

Helen Calvert

Induction – Cascade – Caesarean Section?

I have great pleasure in introducing a guest blog from Kirsty Sharrock, a.k.a. SouthwarkBelle.  Kirsty is mum to two girls and lives in London. Her other day job involves biological samples, powerful lasers and badly fitting lab coats. When her first child was born in 2009 she became fascinated, and often infuriated, by the amount of misleading information aimed at new parents. Her response was the SouthwarkBelle blog where she tries to make sense of some of the dubious science or at least have a good rant about it.

Thank you so much to Kirsty for writing for us on the topic of Induction of Labour.

Kirsty Sharrock
Kirsty Sharrock – SouthwarkBelle

It’s a well known fact of modern childbirth: Inducing labour sets off a chain of other interventions which often result in an emergency caesarean.

But is this actually true?

Would you be surprised if I said it’s not? I certainly was. The idea goes against so much that I had heard from other women and from midwives, my antenatal teacher and of course the internet.

When I went overdue with my first baby I dreaded being induced. I’d heard nothing but horror stories saying it was entirely awful and unnecessary, it would almost certainly make the birth more painful and complicated and would probably set off a “cascade of interventions” leading, with grim inevitability, to the one thing I was most afraid off – an emergency Caesarean. It would also completely scupper my plans for a natural birth in a midwife led unit. But at the same time I was MASSIVE, it was August, and hot, I was desperate to meet my baby and had had quite enough of being pregnant. So I agreed to book an induction, then did everything I could think of to make that booking unnecessary. In the event I got my wish, sort of.

IMG_9918
41 weeks and feeling massive

So was I right to fear the induction?

It seems the answer to that is no.

A 2014 study showed that being induced doesn’t increase the likelihood of having a caesarean. In fact women who were induced at term or when overdue were 12% LESS likely to have a C section than those who hung on for nature to do her thing. Their babies were also less likely to be stillborn or admitted to the NICU.

But can we believe this study?

We often see piles of scientific “evidence” that contradict each other. One minute coffee causes cancer the next it cures it etc. etc. so how reliable is this publication, given that it goes so strongly against the generally accepted view?

In this case the authors of the paper didn’t set up their own experiment or trial. Instead they did what is known as a meta-analysis. This is important because a meta-analysis is far more reliable than most of the scientific studies that make it into the media. The authors took the data from 157 different trials and did some serious number crunching. Looking not just at the results of those trials but at their weaknesses too. For example, many of the individual trials were pretty small, meaning their results are less reliable than bigger studies. Others were quite old or asked slightly different questions to the rest. But this variation is the whole point of a meta-analysis. By putting it all together it’s possible to overcome many of the errors and biases that inevitably influence the results of individual studies and to find a more reliable consensus.

We rarely get perfect answers in anything associated with biology. For obvious ethical and practical reasons we can’t do loads of enormous, randomly controlled trials to answer questions about human childbirth. So a meta-analysis, although still imperfect, is about as good as it gets.

But how can it be true when it contradicts so many people’s experiences?

This is the really tricky part. These results fly in the face of something many of us have learned to be true: In the experience of many women, midwives, etc. inductions tend to end in C sections. As yet I don’t know of any scientific studies to explain this difference, but if we step away from numbers and statistics for a moment, there are a few, very human, possibilities:

Relying on personal experiences is tricky. We’re all inclined to notice and trust things that confirm our existing beliefs. That’s just human nature, and it happens to everyone (I’ve known a few, usually logical, scientists get carried away over flimsy results that fit their current theory). In this case perhaps midwives and doctors who expect inductions to end in c sections are just a little more likely to remember the ones that do. Those births may also stick in the mind more than the less eventful, straight forward ones.

A similar thing can also happen with women’s own experiences. Even with everything seemingly perfect, births don’t always go to plan. Difficult births happen and sometimes they happen after an induction. If a woman has heard many times that inductions cause c sections, then it’s only natural to assume the induction was to blame if she does end up in theatre. Maybe that was the cause, but there is no way to be completely sure that the same things wouldn’t have happened with a spontaneous labour.

There is also the risk of self-fulfilling prophecies. It’s possible that some women are ending up in theatre just a little earlier than they need to because they, or those caring for them, suspected it was inevitable. Perhaps most importantly, there is the issue of fear. It is thought that fear can be a big cause of problems in childbirth. If a women is induced, and terrified of the procedure and what she’s been told it will lead to, then it could be the fear itself which causes the problems.


So should every woman be induced at full term?

What this study doesn’t do is prove that all women should be induced the second they hit 40 weeks.

There are many reasons why a woman may decide to delay or refuse an induction. I went into labour naturally but still ended up having some of the interventions that can be used in an induction and I found them pretty unpleasant. Every woman and every birth is different and each comes with a unique set of considerations. Meta-analysis and big data sets give us a clearer and more objective view of the big picture but they can’t say what is right or wrong for any individual mother. That choice must be hers and to make it women need good, evidence based information and often help from skilled, knowledgeable, health care professionals.

This paper also doesn’t give us is a very clear picture of just how likely it is that an individual induction will prevent a c section, still birth or NICU admission. What I hope we will see in the future is more user friendly data. Every women will have their own tipping point for where the numbers add up to choosing induction.

P1010492
Looking pretty rough after a labour that started naturally, but still ended in an emergency caesarean

So what now?

Like many pregnant women I was taught to fear induction of labour and the cascade of interventions it would cause. Now it seems that fear was based on a myth. So it’s important that the evidence, challenging though it may feel, gets out to pregnant women and to those giving them advice. Unnecessary fear in childbirth is potentially harmful and certainly unfair. All the more so for those women who feel they have little choice but to be induced for urgent medical reasons.

This study also has implication beyond individual decisions. There is often a binary division of births. On one side the “low risk”, “normal” births that can be handled entirely by midwives and on the other “high risk” births, which are, effectively, everything else. Being induced can push an otherwise low risk woman over that line.

In the hospital where I gave birth this made a big difference. The Midwife led unit didn’t just have lower all round intervention rates, it also housed built in birthing pools and lovely en-suite rooms where mum, dad and baby could recover together after the birth. If I’d been induced I wouldn’t have been allowed on this unit. So, in choosing weather to be induced or not, I wasn’t just weighing up the risks of induction v continued pregnancy. I was also deciding if I should risk higher intervention rates, sacrifice the more welcoming facilities and deny my husband the opportunity to share the first precious hours of his child’s life. Now we have strong evidence that induction can reduce C section rates and in some cases save lives, should it really be the determining factor in where some women can give birth? Or in the standard of care they receive?

For me, spontaneous labour didn’t prevent an emergency C section. Perhaps I’d have stayed out of surgery if I had been induced? I doubt it, although I’ll never know for sure. But I can be glad that when other new mums are overdue, concerned about their baby’s health or just hot, heavy and sick of being pregnant, the myth of induction-cascade-caesarean section will be one less thing to fear.

Kirsty Sharrock / SouthwarkBelle

2015

Kirsty MatExp pals
Kirsty with #MatExp pals Leigh, Louise and Jen

A version of this blog first appeared on the SouthwarkBelle website: http://www.southwarkbelle.blogspot.co.uk/2014/09/induction-cascade-caesarean-section.html

Share the Word About MatExp!

It is time to talk about the ‘perinatal’ aspect of Perinatal Mental Health (PMH): the ‘missing link’ in the national campaign

I am delighted to be able to publish today a guest blog for the #MatExp campaign from Mr Raja Gangopadhyay.  Raja is a Consultant Obstetrician and Gynaecologist with special area of clinical interest in Perinatal Mental Health (PMH) from West Hertfordshire Hospitals NHS Trust. He is a member of the Royal College of Obstetrician and Gynaecologist (RCOG).

Raj capture

I would like to take this opportunity to share my views on why I feel so strongly about the role of the Maternity Services in Perinatal Mental Health (PMH).

Perinatal Mental Health (PMH) has two important components in its terminology: ‘Perinatal’ (period during pregnancy, delivery and post delivery) and ‘Mental Health’. Therefore the care of mums in the Maternity Services during this vital period is of utmost importance in PMH: it should be a no-brainer.

But sadly, PMH is the only one area of Maternal Health where I do not see a strong voice of the Maternity Services in the national campaign.

This has remained ‘Cinderella’ within Maternity Units in spite of the glaring facts:

  • PMH is still one of the leading causes of maternal death in the UK.

  • This is one of the most prevalent conditions mums suffer from during their pregnancy and postpartum period (at least 10% of mums suffering from this).

I strongly believe that without robust ‘perinatal’ care, women would continue to suffer and die from PMH illnesses, no matter how much we spend to expand specialist Mother and Baby Units (MBUs).

Therefore this is the time when we must recognise this important area and raise awareness.

I am trying to address this issue through my campaign on social media and as the Royal College of Obstetrician and Gynaecologist’s (RCOG) Representative to the Maternal Mental Health Alliance (MMHA).

What do I mean by PMH ‘within’ Maternity Services?

Suffering and deaths from PMH illnesses are often preventable if appropriate measures are taken during pregnancy and in the immediate postpartum period.

A prevalent health condition like PMH must be managed with the same readiness as managing other medical conditions in pregnancy such as diabetes, high blood pressure (pre-eclampsia) or heart disease.

The only way to ensure that the women with PMH are appropriately cared for according to the NICE guideline (2014) is to have:

  • A dedicated PMH team within every Maternity Service:

A Consultant Obstetrician, Specialist Midwife, a Perinatal Psychiatrist, a Specialist Psychiatry Nurse and a Paediatrician should jointly lead this service locally. The service should be easily accessible to the mums.

  • A dedicated Obstetric-Psychiatry Antenatal clinic

  • Communication with Community Team:

This Maternity Service should have clear links with GP, Health Visitor (HV), community MH Team, Liaison Psychiatry services, Mental Health Crisis Team, Children and Young People services, Peer Support groups and other charitable organisations.

  • Robust Care Pathway:

There should be a clear pathway for risk assessment (at the booking visit and at every consultation), early identification and treatment. There also should be provision of a multi-professional team meeting on a regular basis.

  • Dedicated specialist service and support:

For conditions such as PTSD / birth trauma, fear of pregnancy and child birth (‘tocophobia’), bereavement and support for mums and dads whose babies are admitted to NICU.

  • Pre-pregnancy advice service:

It is important to have specialist advice and support for women (with PMH illness/ traumatic experience in previous pregnancy) who are considering pregnancy.

  • Patient involvement : ‘Patients first and foremost’

PMH is an area where patients’ opinion must be considered in developing local care pathways. Services must be evaluated on a regular basis based on patient experience.

I firmly believe that all the health conditions should be treated in the same way with professional expertise and kindness and without any prejudice. I am not sure why we still classify health conditions into ‘physical’ and ‘mental’ when there is often an overlap.

Psychological care in pregnancy, delivery and beyond…

It is unfortunate that psychological care has remained a very neglected part within Maternity Services. The reason given for this is ‘the staff are too busy’.

However pregnancy is probably a period of life where psychological support from the HCPs is needed the most.

It is especially important when mums could potentially have severe stress during pregnancy and the postpartum period due to the following factors:

  • Previous history of miscarriage, ectopic pregnancy, IVF, traumatic childbirth.

  • Any other family member or friend has had complicated childbirth experience.

  • Sudden life event such as breakdown in family relation/divorce, loss of employment, bereavement in the family or loved one, relocation/migration and domestic violence.

  • Sexual abuse in childhood or pregnancy as a result of sexual violence.

  • Associated pregnancy complications (for example premature rupture of membrane, high blood pressure, diabetes, concerns on baby’s growth or SPD).

PMH is not only PND and Puerperal Psychosis (PP)…

Many believe that PMH is a term equivalent to the care of Postnatal Depression (PND) and PP.

PMH includes specialised care for women (during pregnancy and one year after the childbirth) with any mental health condition (such as anxiety, depression, bipolar illness, schizophrenia, OCD, eating disorder, and personality disorders).

PMH must include bereavement care (miscarriage, still birth and neonatal death), traumatic birth experience/PTSD, support services for mums and dads whose babies are admitted to NICU and tocophobia (fear of pregnancy and childbirth).

Another important component should be the psychological care of mums and dads throughout the journey of pregnancy, delivery and postpartum period.

PMH, in my view, must be recognised as a separate subspecialty in the training of Obstetricians and Midwives.

Womb

Why is identification in pregnancy and immediate postpartum period so important?

  • Effects of psychological stress in pregnancy:

There are now plenty of research results, which indicate the long-term impact of stress during pregnancy on the brain development of the baby while it is in mum’s womb. Prof Vivette Glover, an eminent Professor of Perinatal Psychology from Imperial College London, explains this: http://www.beginbeforebirth.org/for-schools/films#womb

Therefore timely intervention and adequate support during pregnancy can prevent long-term effects on the child.

  • Care Planning to prevent serious illness:

All pregnant women with risk factors to develop worsening mental health conditions should have a plan of care during delivery and postpartum period.

Confidential Enquiries into Maternal Deaths have repeatedly pointed out that in the majority of cases of deaths from suicide, there is a lack of care planning during pregnancy.

This is only possible through appropriate care within the Maternity Services and multiagency communication.

  • Enjoying the journey of pregnancy:

Experience of pregnancy and birth creates a lasting memory for the mums and dads for the years to come. Therefore this should be an enjoyable experience for the woman and her family to cherish in happiness in the future.

As HCPs our role is to ensure we support and empower women to make informed choices for the safety of her and the baby and most important of all a very positive birth experience.

  • Helping mums to make informed decision regarding medications:

Mums should get proper advice regarding the use of medication in pregnancy and after delivery.

Pregnancy is a short window but an excellent opportunity to address health conditions.

  • Bonding and attachment:

PMH conditions can adversely affect the bonding with the baby and the mum.

‘A stitch in time saves nine’: Prevention of serious PMH illnesses is only possible through good care in Maternity Services.

Guardian capture

Having discussed the importance of the role of Maternity Services in PMH, now let us find out what is happening in the Maternity Units……

A journey of revelations…

I contacted many Maternity Units across the country to find out the provision of PMH services within their Units. What I found was extraordinary.

I raised my concerns in a letter published in The Guardian: http://www.theguardian.com/society/2015/oct/14/perinatal-mental-health-provision-badly-lacking .

I raised this issue with the Maternity Review Team, during my meeting in September (2015).

Although there are examples of good service, the overall structure within the Maternity Units is very poor:

  • Often there is no dedicated Lead Obstetrician and/or Specialist PMH midwife

  • Many Units do not have formal debriefing services (for traumatic birth experience), specialist bereavement midwives and support system for parents with babies admitted to NICU.

  • There are hardly any dedicated services for women with fear of childbirth.

Delving deep into the challenges….

To have a better understanding of the need, I embarked on a journey to meet professionals from all the relevant Royal Colleges (RCOG, RCM, RCPsych, RCGP), Health Visitor organisations, Maternal Mental Health Alliance (MMHA), MPs and All Party Parliamentary Group (APPG), NHS England, CCGs and other national Campaign Groups.

It was revealed that overall there is very little understanding of the vital role of the Maternity Services in PMH.

Thankfully RCM is campaigning for a Specialist Midwife in every Maternity Unit.

But the main barriers are the following:

  • Lack of Mapping of the existing services in PMH within Maternity Units (such as the MMHA map of the available Perinatal Psychiatry services).

  • Lack of a national standard of the service provision within Maternity Units (according to the number of deliveries and complexity of cases).

  • Poor collaborative work among HCPs: as often the Maternity Electronic record system is not accessible to other HCPs and vice versa.

  • Lack of standard Training programme for the Obstetricians and the Midwives.

  • Lack of adequate focus on PMH illnesses in Antenatal Education.

I have concerns that unless these issues are resolved appropriately, we cannot provide the best quality of care for women with PMH illnesses.

With the best of my abilities, I am currently working closely with other national organisations to address these areas.

Maternity HCPs: Please, please do something and don’t wait for things to happen….

Charles Dickens

It is true that funding is necessary to set up specialised PMH services and Mother and Baby Units (MBU). However Maternity Units should not wait for the approval of their business cases.

In my humble opinion, funding is not everything. Our professional values are the most important factors in patient care:

  • Kindness:

Simple measures such as a smile, empathy and a willingness to listen to the concerns of the mums and dads could make a huge difference in patient experience.

  • Communication:

Take every opportunity to explain the situation and ensure that appropriate wording is used during communication.

  • Continuity of care:

Try to ensure continuity whenever possible or communicate adequately with the rest of your team.

  • Local Alliance:

Please try to develop Local Alliances with Community Midwives, Health Visitors, GPs, all available community mental health services, Peer Support groups and children’s services.

This could significantly improve communication among the multi-agency teams in caring for mums with PMH illnesses.

  • Listen to concerns:

Please create opportunities to listen to the concerns of the user group. This may be in the form of promoting your local Maternity Service Liaison Committee (MSLC) or Patient Panels.

If possible, please read the real life stories of the Lived Experiences on the Internet: it would help you to think ‘outside the box’, have a better insight into the PMH illnesses and give you inspiration.

  • Raise awareness:

Arrange patient engagement events, Road shows or Community Events with local CCGs.

Participate in Social Media support, such as #PNDHour (Wednesday 8-9pm) and #BirthTraumaChat (Monday 8-9pm):

This would help to raise awareness, remove stigma and give mums and dads a ray of hope.

  • Arrange training on PMH:

Please ensure all staff are adequately trained in your local Units.

  • Get involved in your Regional PMH network:

Many regions now have regional PMH Networks. This could be an important place for information sharing among the Maternity Units.

  • Please do not forget dads:

There is now good evidence to support that dads can suffer from PTSD/PND. Please take every opportunity to support and communicate with dads.

  • Keep yourself updated:

PMH is a rapidly evolving area; therefore HCPs must keep their knowledge and skills up-to-date through continuous professional development.

If unsure, please seek help and escalate to your senior colleagues: an unsafe advice from a HCP could endanger an invaluable life.

Working together to make a difference…

We ALL need to work together to prevent suffering and death from PMH illnesses.

If you have any suggestions for improving PMH services within Maternity Units, I would be very keen to know (Twitter: @RajaGangopadhyay3).

If you are involved in good projects locally or are aware of any good practice, please share with everyone through #MatExp.

Acknowledgement

I am grateful to #MatExp for giving me this opportunity to write this blog.

I am immensely grateful to all the Lived Experiences for sharing their stories, which have enriched my knowledge on PMH much more than any textbook and journal article.

My thoughts are with all the bereaved families who have lost their loved ones due to this dreadful illness.

Raja Gangopadhyay

2015

 

Share the Word About MatExp!

Health Visiting & Midwifery – A Partnership

I have great pleasure in sharing with you a guest blog from Health Visiting Lecturer Charlotte Smith and Midwifery Lecturer Neesha Ridley – a great team from UCLan.

Following our wonderfully informative Twitter chat last week, we were asked to contribute to the MatExp blog – what an honour, thank you!

We are writing as a partnership, because this is what we believe health visiting and midwifery should be. To explain, “We” are Neesha and Charlotte, a midwife and health visitor (in that order!) who recently found ourselves united in a number of ways.

First, we are new to our roles as lecturers at the University of Central Lancashire. We enrolled on our teaching course together, thus embarking on our new career journey together – joint working together is enjoyable, time saving, cost effective and efficient, and our shared “newbie” status allows us to express our vulnerabilities and successes openly with each other. (Also, we discover we have a similar sense of humour which is always a bonus!)

Second, our passion for joint working was discovered when Neesha asked Charlotte to come and speak to midwifery students about the role of the health visitor. Neesha had been aware of the importance of MDT working in the childbearing continuum and had organised a succession of guest speakers, designed to give Midwifery students the knowledge and experience of the services they will work alongside in the “real world”. Charlotte leaped at the chance, and went along to the session prepared to outline the role of the health visitor.

What neither of us had been prepared for was the response. Armed with insightful questions and an obvious desire to learn more about their health visiting colleagues, the midwifery students described the need for closer relationships between the two disciplines, and the lack of opportunity in practice to facilitate this.

On feeding this back to the health visiting students, Charlotte had exactly the same response. Why aren’t we being taught with midwives? Why do we not have relationships with our colleagues if we are to work in partnership with them? Why is it that the first time we “properly” meet a midwife is when our training is over? How are we supposed to understand each other’s roles if we learn completely separately?

Our engagement in the Twitter chat around this issue last week confirmed that parents themselves value consistent, seamless support from services in the perinatal period. It also confirmed that at best this experience was inconsistent across the UK.

Just as it is a privilege to be involved in the journey of new parents and the arrival of their baby in the world, so it is equally a privilege to be part of the journey of a new midwife and health visitor into qualification. As we reflected on and evaluated these sessions together, it occurred to us that there were synergies between the two experiences – and it made sense to us that like in every issue in the 1001 critical days, the answer lies in early intervention.

As lecturers, that means introducing the two disciplines in a more facilitative, educational experience during education. In practice, this could be mirrored by a home or clinic joint contact between health visitor, midwife and the family during the antenatal period.

It is well documented that antenatal contacts are significant in improving the health outcomes of women, children and families – we are currently collating the evidence in a paper on exactly this subject. We are very aware that there are organisational and strategic challenges to this proposal, having worked at the coal face for some time and recently, and from listening to our students, and to the views of parents and commissioners. However our third area of unity is this – we have a duty to our professions and to our students, and above all to the children and families who experience our services. We have the privilege of being on a journey with inspirational, committed and dedicated students and we owe it to them to provide the experiences that they identify as facilitating best practice. As a result we are working together not only to influence the curriculum to include structured facilitative relationship building and education between our two professions, but to encourage students to take responsibility for ensuring they maintain this out in the real world.

Not every family would appreciate a joint visit from services – nor might it be economically or organisationally feasible in some cases. But if we educate and practice ourselves as separate, uncommunicative services, families will continue to see us as such. With more conjoined education and more solid relationships from the outset, at least families will have the choice.

Charlotte Smith, RN, HV

Neesha Ridley, RM

TeamWork

Join the #MatExp conversation on Facebook and Twitter!

Share the Word About MatExp!

Ready, Set, Go! #MatExpOnTour

Where are you off to this month? Where will you be discussing maternity services? With whom will you be meeting? How will you be travelling?

Following the success of #OxyOct we want to focus on the #MatExp journey in November with #MatExpOnTour. Every connection counts – whether you are speaking at a conference or having a cuppa with a friend. If it involves ideas for improving maternity services then we want to hear about it.

Please tweet us your pics and post updates to our Facebook group of your meetings, conferences, tweet ups and events. Will you and your colleagues be discussing the #MatExp Heart Values? Will you be spreading the word about #MatExp on your travels? Will you and your friends be talking about change over tea and a slice of cake?  As always, everyone counts, all voices matter, all connections matter big or small – we are stronger together.

Let’s get on the road. All aboard!

Tour Bus

P.S. Click here to order #MatExp materials to help you to spread the word!

See where we have been on tour in the map below. Want to add something? Just get in touch.

Basic Google Maps Placemarks error: JavaScript and/or CSS files aren't loaded. If you're using do_shortcode() you need to add a filter to your theme first. See the FAQ for details.

Share the Word About MatExp!

#OxyOct BOOM! What have we all made happen?

Leigh Kendall opened this month for #MatExp with a call to action for Oxytocin October. The campaign is always action focused and we are keen to hear from anyone who is doing something to improve maternity experience in the UK, be it something big or something small. Yet we had already put together a number of blog posts with calls to action, back in #FlamingJune. So I decided that my action for this month would be to revisit those blog posts and find out what progress has been made.

Flo Collage

The original blog posts were on these subjects (each subject links to the relevant post):

Having re-shared the posts on Facebook and Twitter I was delighted to see the responses coming in detailing what has changed, what has been started and what is continuing to be done. Take a look!

Perinatal Anxiety

Sarah McMullen of the NCT explained that she invited Emily Slater (MMHA Campaigns Manager) to speak and run a workshop at the NCT national conference – to raise awareness and inspire action. Sarah says that Emily’s plenary talk to 600+ staff, practitioners & volunteers “was incredibly powerful, and we’re meeting to discuss next steps for NCT”. Sarah added “We’ve also submitted two funding applications relating to mental health awareness (thanks to Rosey Wren for support), and have match-funded a PhD studentship with the wonderful Susan Ayres on Birth Trauma, and are supporting another PhD research project on group identity and PTSD”

Midwives on Twitter commented:

Anxiety capture Deirdre

Anxiety capture Jeannine

To read Jeannine and John’s blog post please click here.  “You matter. I care.”

Emotional Wellbeing

Birth Trauma Chat

#MatExp team member Emma Jane Sasaru has been incredibly active over the last few months.  She has launched Unfold Your Wings a place of information and support aiming to raise awareness of Perinatal PTSD, birth trauma, reduce stigma and give sufferers hope.  She has also launched a CoCreation Network community around perinatal mental health.  Emma has then collaborated with #MatExp team member Susanne Remic to bring about a weekly #BirthTraumaChat on Twitter run jointly from Unfold Your Wings and Maternity Matters.

Sue Henry

Also launched this month by West London Mental Health NHS Trust was this fantastic short film about perinatal mental health: https://vimeo.com/143359951 This film has already sparked many useful conversations.

PMH

Continuity of Care

I was speaking to a commissioner from Cheshire this month about the decision to commission OnetoOne Midwives. The company has this month posted an overview of their caseloading model: http://www.onetoonemidwives.org/_news/caseloading-midwifery-an-ever-evolving-model-of-care

In her talk at a recent National Maternity Review event, Baroness Julie Cumberlege made it very clear that the call for continuity of care is being heard by the review team up and down the country. Neighbourhood Midwives led a discussion at the review’s Birth Tank 2 event, and there were a couple of other discussions where options for continuity were also explored.

Support for Midwives

Poem from banksy midwife @JennytheM:

Midwives JennytheM

Midwife Deirdre Munro celebrated the launch of the new Global Village Midwives website this week. The movement is over a year old and Deirdre explains:

GVM capture

global village midwives

Infant Feeding

Lots of news about infant feeding from passionate individuals and voluntary organisations.  On our #MatExp Facebook group Zoe Woodman explained: “In May we got approval from NCT to run a branch funded feeding support group. Started in June with an NCT bfc attending who is also an IBCLC. We are on 3 boundaries in terms of commissioning services so no local peer to peer style support groups were running within 8miles. The only service is an HV clinic once a week and it’s one on one so you have to wait outside the room to be seen. It’s been on our branch aims at our AMM since I’ve been chair (4yrs!) so finally chuffed to see it in action and I will get to use it myself in January for no3! It’s running twice a month currently but hope we can get funding in the future to run weekly. It’s slowly building in terms of attendance. Feedback so far is great!”

Dorking NCT

Claire Czjakowska’s Breastfeeding Advert is coming together and is looking very exciting – watch this space!  Breastfeeding in Trafford launched its Twitter account this month so please follow for local breastfeeding news.  BfN Portsmouth tweeted:

Bf capture

Midwifery students at the University of Worcester have launched a petition around the questionable practices of infant formula companies – follow the hashtag #WeakenTheFormula for more information.

As if this wasn’t enough, this month has seen the launch of the World Breastfeeding Trend Initiative for the UK.  A committed group of individuals from the major breastfeeding voluntary organisations have come together to measure the country’s performance against the WHO Global Strategy for Infant and Young Child Feeding.  Please visit the website for more information on how this project is structured and the indicators against which the UK will be measured.  The project needs lots of input from families and professionals so please follow @wbtiuk on Twitter and find out how you can help.

WBTI capture

Tongue Tie

Doula Zoe Walsh updated us: “We held a North West tongue-tie workshop in Blackpool. It’s now going on the MSLC agenda for Blackpool so that we can discuss local provision and see if it’s meeting the needs of local families.”  

Breastfeeding and Medications

Friend of DIBM helpline

From a personal point of view, I finally got around to becoming a friend of the Drugs in Breastmilk Helpline this summer.  The helpline is absolutely vital for ensuring that women get the correct information about what medications they can use when breastfeeding.  The service is funded by the Breastfeeding Network and the charity once again asked supporters to do a #TeaBreakChallenge this month to help raise donations.

Teabreak challenge

A wonderful #MatExp collaboration has sprung up this month between Angelique Fox, Sarah Baker and Wendy Jones.  These two #MatExp mums who have never met in person have both volunteered to help Wendy to collect data and raise awareness with regards to drugs in breastmilk, particularly where dentists and podiatrists are concerned.  It was discussed on the #MatExp Facebook group that these two healthcare professions are often cited as not having up to date information about breastfeeding and medications so this collaborative project is aiming to tackle that.

Luisa Lyons, the Infant Feeding Coordinator who wrote our original post on this subject, gave us this fantastic update: “Been a busy couple of months. Infant feeding e-learning training for doctors up and running at my unit and both paeds and obstetricians encouraged to complete it. Great support from our obstetric consultant clinics director too. General paed nurses now doing mandatory infant feeding training every year. Been invited to teach general paed doctors face to face. Three GP’s have done the UNICEF 2 days bf management course with us and now writing bf training for GPs in Norfolk. Included info on bf and medications with scenarios to both student nurses and our midwives at keyworker training now, and incorporating into Mt for all maternity staff. Also off topic slightly am putting in a WHO code game to all the above which has generated lots of awareness with student midwives and maternity staff. Need to join DIBM as a friend which I had forgotten to do, so thanks for the heads up.”

Dads & Partners

Mark Williams, co-founder of Dads Matter UK, wrote this blog post for us for #OxyOct, detailing his work and campaigning: http://matexp.org.uk/matexp-and-me/dads-matter/

Men Love and Birth

Midwife Mark Harris launched his book this month, Men, Love and Birth, “the book about being present at birth that your lover wants you to read”.

A Manchester midwife reported positive outcomes around new rules enabling dads & partners to stay over on her unit:

Dads & Partners Mags

When asked how we can best support Dads & Partners, newly elected NCT president Seana Talbot tweeted:

Dads & Partners Seana

Community Outreach Midwife Wendy Warrington tweeted:

Dads & Partners Wendy

I asked Wendy about the work she does with regards to Dads & Partners and she explained “I talk about attachment and being with their baby, skin-to-skin touch. Antenatal and postnatal depression, and fathers’ role in supporting their partner in pregnancy, birth and beyond and how they can do this. I talk about baby cues and the impact of father’s involvement on child’s future emotional and cognitive development.  I have had excellent feedback from parents and when I see them after the birth they say they felt well prepared for feeling and emotions experienced post birth. They love the fact that I talked about it”

Collaboration between Midwives and Health Visitors

Health visitors on the #MatExp Facebook group told us:

My CPT & I have established 6 weekly meetings with the community midwife and the GP (whose special interest is pregnancy/neonates) to discuss cases”

“We already have that in my team we meet at least once a month with the midwife – it was weekly but we are very busy at the moment (both us and the midwife). She will just knock on our door though and share things – she really came on board with antenatal contacts telling parents to be and signposting those with small children with any worries to us.”

With excellent timing Sharon White, OBE, Professional Officer of the School & Public Health Nurses Association, then tweeted the updated pathway for health visiting and midwifery partnership.

partnership

And as a result of discussing all of this on Twitter, Sheena Byrom has invited me to lead a tweet chat with @WeMidwives and @WeHealthVisitor in November on the subject of midwife and health visitor collaboration.  Watch this space!

Birth Tank

And so much more has been happening in #OxyOct as well! #MatExp was well represented at the NHS Maternity Review’s Birth Tank 2 event in Birmingham – click here for Emma’s round up. I spoke at the launch of the Improving ME maternity review for Wirral, Merseyside, Warrington and West Lancashire – click here for my round up of the morning. Leigh Kendall and Florence Wilcock spread the word at the RCOG Conference on October 16th, and Leigh spoke at the Royal Society of Medicine event on October 20th.

RCOG

Leigh capture

Baby Loss Awareness Week took place this month and many important discussions were had around the subject of grief and loss, something which affects a number of #MatExp campaign members.  Leigh wrote movingly about Standing on the Periphery for #HugosLegacy.

BabyLoss

The RCM has this month launched its State of Maternity Services Report. Emma Jane Sasaru has written a series of three blogs about What Matters in Birth.  Susanne Remic has been raising awareness of IUGR. Michelle Quashie created fantastic word clouds for display in her local maternity unit.  We now have #MatExpHour every Friday created and launched by Louise Parry – click here for her round up of Week 2.  So much going on!

IUGR

I have no doubt there is much much more that I have missed from this round up. There is so much energy and passion in maternity services, and so much desire for change. Whatever it is you are trying to achieve, please join up with #MatExp via Twitter, Facebook or the website and get encouragement and input from like-minded people. Together we are stronger! Feel the Oxytocin flow!

 

Helen Calvert, 2015

Share the Word About MatExp!

Dads Matter

As part of Oxytocin October (#OxyOct) I have been revisiting the first set of blog posts we put up calling for people to ACT in certain areas of maternity care. One of these was Time to Act for Dads & Partners, which included a mention of Mark Williams‘ work in this area.

Mark Williams is the founder of a new organisation called Dads Matter UK (Perinatal Mental Health for Fathers). He also founded Fathers Reaching Out, Youngness and Independent Mental Health Campaigners.

Father’s Reaching Out was set up in 2011 to raise awareness surrounding the detrimental impact that postnatal depression (PND) has on both fathers and equally families as a whole. Dads Matters UK aims to raise awareness of perinatal mental health, and educate every dad before the birth about birth trauma and PTSD for men.

We are delighted that Mark has written this blog post for #MatExp as part of #OxyOct.

______________________________________________

Mark Williams 4

Depression can hit up to around one in five fathers by the time the child reaches adolescence. In a published report in 2015, it states that at least 10% of fathers will suffer with postnatal depression, which can include the birth itself and up to a year after. Fathers can develop lots of complications in this period, and this can influence their daily lives as well as affect their role within their family unit. It can impact heavily on their relationships, financial stability alongside lifestyle and emotional states. Emotional problems and psychological health needs are crucial elements to postnatal depression in fathers and need to be addressed. Fathers tend to get forgotten at this important and life changing event of having a baby, with mother and child being the centre of care delivery and rightly so, but we must remember there is a father there too. Fathers often get pushed aside which can result in feelings of isolation, anxiety and confusion at a time when they to need help.

Dads Matter

Dads Matter UK is suggesting that the health service needs to develop a process for the screening and detecting of postnatal depression in fathers. As many fathers, the figures suggest, suffer with anxiety post birth of the child. The birth of a new baby can cause problems such as poor sleep, anxiety and stress. This can lead to problems within the relationship and fundamental communication processes within that relationship. After speaking to hundreds of fathers we are primarily concerned with the health of the father and their families. We feel that postnatal depression in fathers is equally significant and requires important consideration when implementing strategies and screening tools for postnatal depression. Fathers suffering with depression can feel increasingly pushed out and unsure of their role within the family thus affecting the bonding and attachment process between father and child.

Screening is important for men, as they are less likely to seek help and support. Particularly, in relation to their health problems. Due to the associated stigma towards mental health and its associated issues, young fathers are even more likely to be at risk and not seek the help they need. Men are often reluctant to admit that they may have an emotional problem or are unlikely to admit to feeling out of control. If this area of health is not addressed adequately this could lead to further breakdowns in the family structure and have long lasting devastating outcomes for our children.

Mark Williams 3

We must remember that fathers can also suffer from PTSD at the birth. Post-traumatic Stress Disorder can occur following a life-threatening event like military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. Most survivors of trauma return to normal given a little time. However, some people have stress reactions that don’t go away on their own, or may even get worse over time. These individuals may develop PTSD.

People who suffer from PTSD often suffer from nightmares, flashbacks, difficulty sleeping, and feeling emotionally numb. These symptoms can significantly impair a person’s daily life. As we know many suffer in silence and let post traumatic stress disorder effect all parts of their daily living. My own nightmares were what if my son had died and the thought of my wife being pregnant in the past did give me so much anxiety that at the time I didn’t know why.

PTSD is marked by clear physical and psychological symptoms. It often has symptoms like depression, substance abuse, problems of memory and cognition, and other physical and mental health problems. The disorder is also associated with difficulties in social or family life, including occupational instability, marital problems, family discord, and difficulties in parenting.

The “invisible wounds” of birth trauma-related PTSD affect not only the father or the family member, but also those around him or her. We must remember it effects everyone and education is needed to prepare the family for what may happen during and after the labour.

We run the risk of letting our fathers down at a time when we need to build strong families and communities for our future generations. Identifying the right support and providing improved health care in relation to Perinatal Mental Health is a top priority, so let’s ensure our health services have the right tools and services available to help and support fathers in relation to their partners’ postnatal depression. When screening fathers we must be mindful to remember that individuals are unique and have developed different styles of coping. It is important to respect the individual, involve them in their care and offer support to them as a person rather than just treat the illness.

Mark Williams, 2015.

What will

Share the Word About MatExp!

Safety, Experience, or Both?

A blog post from #MatExp founder Florence Wilcock.

Flo

There has been much discussion recently about safety within maternity services including a discussion on #MatExp Facebook group. A particular issue that bothers me is the idea that safety and experience might be two separate and mutually exclusive issues and it is this thought that drives me to write today.

Safety is paramount. The purpose of maternity services is to provide safe care through the journey of pregnancy and early newborn life. Every appointment in the NICE pathway is designed to screen for potential problems and ensure they are managed effectively. Every healthcare worker know this is the aim. The 20 week ‘anomaly’ scan might be considered the time to discover the sex of your baby if you wish and to get some photos but the medical purpose is to ensure the baby is growing well, with no abnormalities and to check where the placenta is localised to exclude placenta praevia (low lying placenta) which can cause life threatening bleeding.

But there is more to pregnancy and becoming a parent than safety isn’t there? I am currently reading Atul Gawande ‘Being Mortal’ where he eloquently demonstrates that keeping elderly people ‘safe’ is not enough, there is more to life and living than safety alone. He describes a number of times when giving elderly people purpose such as a plant or animal to look after or more freedom to live the way they wish despite disability it makes a significant difference to their wellbeing. Sometimes this path may deemed ‘less safe’ but for that individual may make all the difference. This comes back to choice. Safety & choice can be tricky ones to combine successfully.

This does not mean I am belittling safety. As a consultant obstetrician it falls to me to talk to couples when the worst has happened and their baby has died. I also care for women who have had unexpectedly life threatening complications. I know I am with them during probably some of the darkest hours they will ever experience. I cannot pretend to understand how they feel but I do know I have been part of those intimate moments of grief and with some families that has followed through into supporting them sometimes for years. As a hospital we have a robust process of incident reporting and the feedback from a Serious Incident investigation (SI) again will sometimes fall to me. In some cases there is nothing that we think could have been done differently in some cases I have to sit and tell an anguished couple that we have failed them and that maybe things could have been different. It is a devastating thing to do, there is absolutely nothing that can be said that will make the situation better. It feels as if you have personally have taken their existing despair and dragged them into an even more unthinkable place and the only thing you can say is ‘sorry’ which feel hopelessly inadequate and trite for such a situation.

So if I could guarantee safety I would in a flash but it is not that simple. Maternity care is delivered by people and unfortunately to err is human. We cannot design a system free of risk because however hard we try the variable of human error gets in the way. We can introduce systems that help minimise the impact of these errors but we can’t eliminate them. My favourite analogy for risk management is James Reason’s model of Swiss cheese. The event only happens when the holes in the ‘cheese’ line up the rest of the time the barriers put in place prevent the error. An example in maternity care might be the introduction of what we call ‘fresh eyes’. A midwife looking after a woman on electronic fetal heart monitoring might misinterpret this or not see the subtle changes over time if she has it in front of her constantly. ‘Fresh eyes’ means another midwife or obstetrician comes and looks at the trace on an hourly basis. This means if unusually the first midwife has made an error there is a system that means it is more likely to be corrected.

The concept of a ‘No Blame’ culture is another example designed to minimise human error. The idea that if one sees or makes an error one should report it without fear so that learning can be gained from it. It may be the learning will be the need for some individual training but equally it might be something totally different. If staff are fearful of consequences then under reporting might be the result and safety gaps may not be identified. Encouraging openness about mistakes and errors is vital but difficult. In maternity it isn’t as if we can just operate our way out of this problem .We know the huge rise in Caesareans sections in the last 30 years has not improved the outcomes for babies but has instead cause maternal health problems. So in maternity as other medical specialties we have to constantly refresh and re-invent what we are doing to try and improve safety. As obstetricians we tread a difficult path trying constantly to call correctly just the right amount of intervention at just the right time.

BirthJourneys

So where does experience fit in I hear you ask? There is abundant published evidence of positive association of patient experience with clinical safety and effectiveness, in other words if your patients (or I prefer users) are having positive experiences then you are running a safer service. It’s hardly surprising if we communicate and explain things to women and their families that we will be more likely to communicate effectively to other members of the multidisciplinary team. If we are open and honest then woman can challenge assumptions and make sure we haven’t missed something critical, a woman knows her own history inside out whereas we might omit a key point. To me one of the most shocking things that was said at our ‘Whose shoes’ #MatExp workshop last year was that women can feel intimidated and unable to ask questions. Trust and understanding between health professionals and those we care for are vital. We cannot possibly hope to improve safety in isolation, experience has to improve too.

There are two specific elements of #MatExp of which I think epitomise the safety -experience overlap. The first is an on-going ever growing constructive conversation between women, families, obstetricians, midwives, health visitors, paediatricians, families and anyone involved in maternity services. Only by tackling the difficult conversations without hierarchy in an equal and respectful way can we improve maternity care. Listening and talking to one another is critical not only as we work with women but in dissolving those barriers and difficulties that sometime exist between different professionals. Flattening of hierarchy, team work and the ability of anyone to challenge is a well-recognised component of a safety culture. We are doing this both locally using the workshops and board game and more broadly via social media and the website.

The second element of #MatExp is that personal sense of responsibility to take action. Own what you are doing and why you are doing it. ‘Wrong is wrong even if everyone is doing it’ that doesn’t mean leave it to someone else. It means that health professionals and women can take action and influence maternity experience up and down the country and through that impact on and improve the safety of maternity care. So in final answer to my question I do not think it is a choice safety or experience I believe the two are fundamentally intertwined. So what will you do to improve #MatExp?

What will

Florence Wilcock, 2015

Share the Word About MatExp!

“I was told I was going to have a big baby….” And then what happened?

A while ago on a Facebook birth forum I saw the phrase “you won’t grow a baby too big for you to birth”. It was a familiar phrase as it was something I would hear regularly on the homebirth e-group I was a member of back in 2010 when I was pregnant with my first. Back then I accepted it as the truth, but having been involved in #MatExp for nearly a year I have learned that few things to do with birth are that simple. So I asked the question on the #MatExp Facebook group:

Big Baby Capture

What followed was a fascinating discussion. Information was shared from lots of different quarters, and evidence was linked to. Experienced birth practitioners shared their views and a few themes started to appear. All along I knew I was intending to write up the discussion as a blog post so I was trying to keep up with the information and understand what was being said. As I opened up links to studies, trials, journal articles and so on my heart sank as I am not the best at analysing that kind of thing and it seemed at first glance that the evidence shared was somewhat contradictory. So I was concerned that I would end up inadvertently talking rubbish in this post.

And then I realised that this is exactly the problem. I am a woman of childbearing age who has had an education to degree level, English is my first language and I discuss birth and maternity pretty much every day. When we talk about informed choice we mean sharing all of the evidence plus the benefit of experience with pregnant women and their families, so that they can go through it and make their own decisions. Yet if I were writing this today as a woman who had been told she was likely to have a “big” baby I would be confused. And a little scared.

So it’s a good job I didn’t know any of this when I confidently went on to give birth to my 8lbs 13oz son on all fours on our bathroom floor.

From http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/
From http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/

Let’s pretend for a moment that I am in my third trimester and have been told by my midwife that she suspects baby is going to be a big ‘un. Probably a bouncing 9lbs tot. Before I go down the route of “doing” anything about that, or amending my birth plans, I have asked the #MatExp group for some information. What have I discovered?

Well, firstly we need to know a little bit more about this fictitious me. Do I have gestational diabetes? Am I classed as overweight? No? Okay then, we can stick with our issue being only the predicted size of my baby and keep questions of GD and BMI for another day if we may. Similarly, we will assume that I am physically able. So why are people sucking their teeth and looking concerned that baby might be of a generous size?

This is where we come to shoulder dystocia. “Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body. If this happens, extra help is usually needed to release the baby’s shoulder. In the majority of cases, the baby will be born promptly and safely.” (From https://www.rcog.org.uk/en/patients/patient-leaflets/shoulder-dystocia/

In the majority of cases, the baby will be born promptly and safely?  So what’s all the fuss about then?  Well let’s look at this passage from the abstract of this article:

“Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16–48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common.

The majority of shoulder dystocia cases occur without major risk factors. Moreover, even the best antenatal predictors have a low positive predictive value. Shoulder dystocia therefore cannot be reliably predicted, and the only preventative measure is cesarean delivery.”

Ah, okay.  So whilst MOST cases are not a problem, when there is a problem it can be very serious.  And most experienced obstetricians will have seen this happen, inevitably influencing their perception of the risks involved.  The teeth sucking is a bit more understandable now.

Apparently if I have a small pelvis it is more likely that baby will get his shoulders stuck. How do you know if you have a small pelvis? Small compared to what or whom? I have no idea but it appears to be a consideration.  One birth professional observed that “to me that ‘big’ is subjective in a lot of cases. A 7lb baby could be big to one woman whereas a 10lb baby could be average to another. There needs to be far more than just the picture provided by a (often inaccurate) scan. Woman’s own birthweight for example, her stature etc.” It was mentioned that pelvimetry used to be widely used but has been abandoned in favour of scans, due to a Cochrane review that found these measurements did more harm than good.

There is a higher likelihood of shoulder dystocia in bigger babies, that much is undisputed. Yet the language used when discussing this risk makes a big difference to how a pregnant woman might view the risk.  Contrasted with the passage above is this from Evidence-Based Birth:

Death capture

I suspect as with so many birth choices, women are likely to get the reassuring language from midwives who have confidently dealt with many instances of stuck shoulders, and more wary language from obstetricians who have seen first hand what can go tragically wrong.  

So in summary shoulder dystocia is more likely in bigger babies but on the whole it can’t be predicted and can usually be dealt with. It turns out that there are arbitrary cut offs for recommending Caesarean to prevent SD – 5kg in a non-diabetic woman. That means nothing to me but a quick Google tells me that is an 11lbs baby. My hypothetical nine pounder doesn’t warrant an automatic recommendation for a c-section then. So far so good.

But what position is my baby in? This is an important factor. I would argue that all pregnant women should be aware of foetal positioning and how to optimise it, but in this case it is particularly important as a malpositioned big baby could cause trouble. Let’s assume though that I have been on spinningbabies.com, haven’t been reclining on the sofa, have been doing headstands for nine months or whatever it is that is recommended. Baby is now head down and engaged and we’re ready for the off.

At this point it’s good to know that there is no evidence to suggest that it hurts more to give birth to a big baby. I cannot comment as my firstborn is the only child I have birthed vaginally so have nothing to compare it to. But the midwives on the group have been reassuring that being predicted a “big” baby does not mean increased pain in labour. Good stuff.

What I haven’t done (but what might have been recommended to me) – I have not had a growth scan. It appears that growth scans should be used to identify small babies (a discussion for another day no doubt) but not big ones. One group member commented “Ultrasound scans become increasingly unreliable the further along in pregnancy they are performed. Weight is an ESTIMATION can be up to 25% out either way. They base it on the abdominal circumference, head circumference & femur length – try doing it with yourself & see how accurate it is!”  

A birth professional went on to say “Growth scans are pretty hopeless in the third trimester – the only thing that is useful is a regular plotting of growth to try to identify a sudden growth spurt that could indicate a problem. A one off growth scan late on in pregnancy basically just leads to unhelpful fears on all sides.”

Which begs the question, how do we identify the potential 11lbs babies who “require” a c-section birth?

So I haven’t allowed anyone to worry me further with a most likely inaccurate scan reading. We think baby is going to be big but not so big that I am going to be encouraged to have an elective c-section, so I’m happy to go ahead with my vaginal birth.

This is where we come to the issue that dominated the discussion. The position that women labour in can make a HUGE difference to the outcome when they are birthing a large baby. Labouring on their back is most likely to be unhelpful. Labouring on all fours is most likely to enable them to birth without intervention. Certainly my experience – I could not bear to be in any position other than kneeling up for my entire labour, simply could not bear it. Lying down was absolutely out of the question.

One group member had a wealth of information to contribute and commented “There’s plenty of evidence to support programs like birth ball use, not just gentle bouncing but using as a structured exercise plus also designing maternity units/rooms to encourage movement and position changes and upright movement.”

A midwife explained “I worked with a lovely obstetrician a few years ago (I have worked with many wonderful obstetricians). She was leading the skills and drills component for obstetric emergencies of the yearly mandatory training. We were practicing what to do in the case of a shoulder dystocia with a mannequin. She looked at me and said, of course we all know that if we do this (turning the model over in to what would be an all fours position) we wouldn’t have to be doing this at all.”

And one of our obstetricians added “in terms of labour progression, size is not nearly so important as baby’s positioning and flexion.”

The impact of pain relief was also mentioned:Of course this is impacted by maternal position too, often compounded by an epidural that softens the pelvic floor muscles reducing the baby’s ability to rotate on the pelvic floor.”

Let’s recap. My midwife has said that it is her experienced opinion that I am going to have a big baby. I have declined a growth scan but we are both confident that baby won’t be topping 11lbs. So we’re going for a vaginal birth, and have done everything we can to ensure baby is in a good position. I am then being encouraged to be active in labour, labour on all fours and so on. There is no reason to believe that I will experience more pain due to baby’s size. There is an elevated risk of shoulder dystocia but my birth team are trained to deal with that. Hmm, okay, on reflection I would make the same choice I made back in 2011 when I hadn’t had this conversation. Home waterbirth with experienced midwives please! Especially, for me as an individual, “big” babies are normal – I was 9lbs 11oz at birth myself.

Does the above sound like the experience most women have when a big baby is predicted? Let’s ask some real life women shall we? Here I am indebted to the fabulous women on my other Facebook group who have shared their stories with me.

I was told I would have a big baby. The midwife measured me way off the chart at 36 or 38 weeks can’t remember which. Went for growth scan. Again measured me pretty big. Appointment with consultant, he measured me big. Straight aways did a growth scan. I was then booked in for an induction the following week. Was in from the 25th and had him on 29th (due on 5th July) he was only 8lb 2oz.” What was the reason for the induction? “Not sure. They said as it was my first I probably would go over so as he was measuring big now it could be more of an issue in 3 or 4 weeks.”

My 1st baby was 9lb 14oz and got stuck with shoulder dystocia and born with the ventouse.” And what positions were you labouring in with baby no. 1? Were you on all fours at all?  “No! I believe position/ventouse were what caused her to be stuck! I was dehydrated so they made me stay in the bed on my back to be monitored!”

“I was told my little boy was a big baby and I had to have a growth scan. I was then induced a week early due to his size. He weighed 8lb 15oz and I had a 4th degree tear and had to be rushed to theatre.” What did they say were the risks with him being big? Did they explain why they wanted to induce you?  “The explanation for me being induced was if I was left and went over I would have had a tough time, but looking back now I wish I had opted out of being induced as I blame that for the complications.”

I was measuring big for dates at my midwife appointments from about 24 weeks. I was eventually sent for a scan to rule out polyhydraminos at about 32 weeks. The scan results were ok and showed that my baby’s measurements were on the 95th centile. I was then changed to higher risk consultant led care. They told me it was due to the baby’s size and the increased need for intervention during delivery, e.g. forceps, etc. My baby was predicted to be 9lb 9oz maximum and she was actually 10lb 6oz. I was in slow labour for 6 days. I had to have an oxytocin drip to get me from 7cm but I couldn’t get passed 8cm as her big shoulders meant her head wouldn’t press down on my cervix! As a result of being on the drip, I wasn’t able to get in different positions in labour and was mainly confined to the bed. I then had an emergency c-section due to failure to progress.” How did all the talk of having a “big” baby affect how confident you felt in being able to give birth?  “To be honest, it did affect how confident I felt giving birth. I was then very nervous at the prospect of tearing or that I’d have difficulties during the birth and would need forceps, etc. I was very worried that something would go wrong. To be honest, I felt very relieved when the consultant said I needed a c-section.” 

I commented that I wondered whether that was the reason the mum above struggled to dilate. Rather than failure to progress perhaps her caregivers should be have been labelled with “failure to encourage”.

There was one rather different story, although the mum in question was surprised by how her consultant’s advice varied from what others were experiencing: Was told based on my daughter being 10lb that my little boy would be big. The midwife referred me to a consultant as my fundal height was bigger than even my little girl was! Tested me for GD which I didn’t have. Consultant said he was going to do absolutely nothing about it which varied massively from my peers at nearby hospitals who were being induced early. He said inducing a large baby is dangerous as they’re more likely to get stuck and if I got my little girl out this one would be fine! Bit worried but I trusted him.”

And what of those women who had not been told to expect a big baby?

“I had a 9lb 4oz baby but wasn’t expecting him to be ‘big’ I had a tiny bump and was told he was only going to be about 7lb.  I had him naturally with no complications at all. A few stitches externally but that was all.”

“My 2nd baby was 9lbs 6oz and no one knew he would be that big as my first was 7lb 11oz. Labour was very quick and vaginally delivered with 1 stitch.”

If 9lb2oz is classed as a big baby then mine was! He was 13 days over so probably wouldn’t have been so big if I’d gone on time. Nobody told me he was going to be big at any of the extra monitoring appts I had the week before he arrived all on his own, no help, drugs or hospital. I did tear slightly but midwife was happy for me not to go to hospital if I didn’t want to.”

I wasn’t told I was going to have a big baby, I was tested for diabetes at one point because my bump had grown quite quickly but I didn’t have it. My little boy weighed 9lb 15oz, I was in labour for 6 and a half hours and didn’t have any complications. I had a few stitches afterwards but nothing major.”

What can we say in conclusion?  When a baby is identified as potentially being “big” are all families given the information that we have discussed here?  Do all birth professionals agree with the general thrust of this post or have some important points been missed or misrepresented? And if I have got it all wrong what does that say for the idea of “informed choice”?  Because this is my best understanding of the issues following a detailed discussion with experienced birth professionals.  There are plenty of other birth stories from the mums on my group which make it clear that women are routinely being encouraged down the route of induction without fully understanding why, only that baby is going to be “big” and that is some kind of a problem.  And so many of these stories end in instrumental deliveries, emergency c-sections and, at worst, traumatic births.  Would it not be preferable for women to have the issues fully explained to them and to be encouraged to have an active birth where, in all likelihood, they will be capable of giving birth to their child?

I am just glad that my “big” baby is here, safe and well, and now in his second week at primary school.  Decisions always seem simple in hindsight.

Big Baby

Some of the links that were shared as part of the discussion not already linked to above:

Shoulder Dystocia – RCOG green top guidelines

Rebozo Technique for Foetal Malposition in Labour

The Effect of Birth Ball Exercises during Pregnancy on Mode of Delivery

Reducing Length of Labour and Caesarean Surgery Rate Using a Peanut Ball for Women Labouring with an Epidural

After Shoulder Dystocia: Managing the Subsequent Pregnancy and Delivery

Share the Word About MatExp!

When “Normal” Seems To Be The Hardest Word

Expo Capture 2

 

On Wednesday I attended the NHS Expo in Manchester as part of the #MatExp team.  During our session a few of us stood up to explain what the campaign means to us.  My personal bit went as follows:

Expo Capture 1

It is this combination and collaboration of so many different people, from across the maternity world, that makes #MatExp so exciting to me.  So many conversations are being had within established communities – midwifery conferences, positive birth groups, obstetric organisations, mother & baby groups, but with this campaign these communities are coming together.  And as I say, we are not shying away from the difficult conversations.

With this in mind, I decided to broach some subjects on the #MatExp Facebook group that could be considered “difficult”.  I was unsure with which to start, and then this tweet from Emma Sasaru launched a conversation this morning and I just went with it.

Normal1

 

What has followed today has been a thought-provoking discussion that has challenged many of my assumptions and made me change my mind more than once.  As with the best discussions, I am still not sure what my conclusions are but it has given me new perspectives.  The original question posed was:

Normal2

The blog posts I refer to are Sheryl’s birth story on my own blog, and Southwark Belle’s piece entitled “Normal Not Normal“.  I then went on to observe that when I hear the phrase “normal” birth I am imagining that people simply mean “vaginal” birth.  Is it as simple as that?

Well no, no it isn’t.  It quickly became apparent that there are a couple of definitions of “normal birth” available.  One group member explained that “Interestingly, one of the first definitions of normal birth came in 1997 from AIMS, the radical women’s organisation, who defined it as ‘a physiological birth where the baby is delivered vaginally following a labour which has not been altered by technological interventions’. So this was a movement that was led from a women’s organisation to counter the over-medicalisation of birth.”

And from this 2010 publication:

Normal4

Normal3

And from this in 2007:

Normal5

Normal6

It seemed that the word “normal” had specific meanings for groups researching and monitoring maternity outcomes, and that this was a discussion that had been had many a time.  Indeed, Sheena tweeted this morning

Normal7

So why is it such an important and emotive discussion?  Well because we have learned time and again in #MatExp LANGUAGE MATTERS.  Words have huge power and different people understand things in different ways, depending on their experience, perspective and knowledge of the subject in hand.  Declaring that some types of birth are “normal” begs the question what are the other types of birth then?  And if the opposite of “normal” is “abnormal” are we comfortable telling women that is how we define their experiences?

It was clear that for many women the term “normal” is perceived as carrying a value judgement.  It is not simply a medical or scientific definition, it is a statement about them and their experience that allows for feelings of failure and inadequacy (as with so much to do with the massively emotive subjects of maternity care).  Comments included:

where I work in a different area of healthcare, it’s understood that everybody’s normal is different, my normal vary vastly from your normal, but there is a range of normal we would expect that to be in. Having babies is different imo because you are doing something you don’t do very often so it’s difficult to define your ‘normal’ and where that might fall on the large scale of normal within birth. It can lead to people feeling inadequate.”

“the feeling of doing it wrong, not experiencing a normal birth can put people off  a second time. A friend of mine is terrified because last time it all “went wrong” and she’s adamant that she won’t get pregnant again unless she can have an elective section because her body can’t do it properly.”

Who has set the definition for normal. How do we know what normal is? How did women birth 20, 50, 100, 1000, 5000 years ago? What about culture? What is normal here may not be normal in other lands, races etc. Normal is an awful word because it gives the idea everything else is abnormal so therefore not right or not as good or missing the mark. But that is harmful label to add to a birth experience for many many reasons.”

By terms such as ‘normal’ we make women believe that if they don’t attain that they have not done something they should. That in turn may make them feel they have ‘failed’.”

Emma kindly provided a dictionary definition of the term and observed that “its definition doesn’t relate to birth in any way”.

Normal8

 

And of course there is also the fact that our definitions here do not match up.  The definitions of “normal” birth explained above are not currently “standard, usual, typical or expected” in the UK as per the dictionary definition of the word.

Normal9

One doula observed “Normal is the wrong word to use because right now a positive physiological vaginal birth is NOT the norm”.  So is there any value in naming it as such when by a simple dictionary definition that could not be further from the truth?  I think there might be, but more of that later.

BirthChoiceUK addresses the issue on their website (read the full page here) and explain that “The term normal birth is not meant to be judgmental in any way. We are instead trying to produce some measure of how much technological intervention is currently used in birth. These statistics of course do not tell us anything about a woman’s experience of birth which is likely to be of far more importance to her than whether she was induced or had an epidural or had her waters broken. It is hoped that every woman can have a fulfilling and positive experience of birth regardless of the interventions she has received. This is, of course, much harder to measure!”

And where does birth trauma come into all of this?  What of the women who have had negative experiences of birth?  What can the word “normal” possibly mean to them?  And for those women who have had a “normal” birth as defined by the NCT and AIMS, are they still entitled to feel traumatised if their experience was not a positive one?  It was discussed at length that so many apparent problems with the language come from individuals conflating the words “normal” and “positive” but throughout society we find people and cultures who believe that the two are one and the same thing.  “Normal” is a generally positive term, meaning good things, which is of course a whole discussion in itself.  Nevertheless it is easy to see how a woman with a negative birth experience will not thank you for telling her the birth was “normal”, and how a woman who has had a positive experience will be unhappy with the idea that hers was not a “normal” birth.

So apart from the need to gather statistics across maternity units, what other uses does this idea of “normal birth” have?  Midwife Jenny Hall was kind enough to explain “The need to differentiate what is ‘normal’ and not does come down to the legal responsibilities of a midwife. A midwife is in law able to care for women without other health professionals until the process moves into areas outside the boundary of ‘normal ‘. She then legally has to refer to someone else for assistance.”  There is then an important legal issue here, and other birth professionals on the group emphasised that for them the term held no value judgement at all:

I think of normal birth as a spontaneous vaginal birth with no intervention at all, but I’m a midwife and we use these terms as classifications rather than attributing any value to them…… When I talk about normal I’m not using it in a judgemental way, just descriptive, but I am mindful that many find this term difficult.”

Yet throughout today I have had the creeping suspicion that two of my viewpoints don’t match up.  I was questioning the use of the word “normal” for a maternity experience that is how human females have been designed to birth their children, yet I am constantly banging on about the need to “normalise” breastfeeding.  An uncomfortable feeling of double standards was edging up on me.  Giving the whole subject a bit more thought, I commented:

Normal11

For the #MatExp “heart values” please read Emma’s blog post.

This angle is well articulated by Professor Soo Downe in her interview with midwife Sheena Byrom:

Normal12

Miranda Dodwell of BirthChoiceUK was keen to emphasis the historical perspective: “having been working on the ‘normal birth’ agenda since about 2003, I realise how far we have come to be having this debate.”  She recommended further reading in the shape of Practising childbirth activism: a politics of evidence “about the importance of introducing the concept of normal birth in terms of childbirth activism in driving change.”  However, she and others were happy to discuss the idea that it may now be time to move on from the concept of “normal birth”, despite “the power it has had in creating a change of perspective towards women’s experience of maternity care“.

If we are to move on from this terminology, what are the alternatives?  Both in terms of new words and in terms of new approaches?  There were a number of suggestions from birth professionals:

Unassisted birth would probably be closer to the mark but the meaning is associated with ‘free birthing’ these days. l guess for me ‘normal’ could be what the woman was expecting and not our version of normal.

When I hear the ‘normal’ discussion and how heated it gets I don’t have a satisfactory alternative to the word ‘normal’. Physiological?…bit of a mouthful and a challenge to spell. Vaginal? Many struggle to include the word vagina in general conversation so possibly unacceptable?

Rather than focussing on ‘normal’ l tend to look at how satisfied the woman is with the outcome. It’s her birth so she should define it.”

I tend to use words like ‘physiological’ and ‘needed help’ or ‘complicated by’. Rather than normal, which has different connotations.

I use SVD (spontaneous vaginal delivery), assisted (instrumental) delivery or Caesarean

And from parents:

From the point of view of mums talking to each other about their births… I’d say ‘normal’ is too vague, fairly meaningless, and not generally used. ‘Natural’ is used a lot.

Physiological’ may be technically correct, but sounds so much more excluding than a two syllable simple Anglo-Saxon word. ‘Natural’ also has a lot of judgemental baggage.”

Personally, I think maybe the accessibility of the term normal is what’s become problematic about it? ‘Physiological’ seems more medical, so perhaps using this term would prevent women feeling judged?

But as you can see consensus was hard to come by.  Amy Prodgers (@BirthSalford) summarised, I suspect, the feelings of many in the discussion:

Normal13

As a possible, and remarkably simple, solution, one of the group’s midwives suggested “Why not use the term birth? And let the categories be an additional ‘box to tick’ not together with ‘birth’ am I making any sense??? So ‘birth of baby boy’ (male infant etc etc) then tick, vaginal/forceps/water-pool/home/hospital and so on and so on) – the word birth describes the event – that’s exactly what took place #languagematters. It’s just habit in maternity services, it could easily change – the hospitals/birth centres/ organisations etc could still get the much needed figures”.

Southwark Belle furthered this thought “I think we’re now at a stage where defining one set of choices/circumstances as ‘normal’ / best and using that to set targets just risks swapping one dogma for another. I much prefer treating it all as birth and each intervention individually rather than lumping a whole lot of things in together.”

So is birth just birth?  Each instance its own unique set of circumstances and experiences?  Can hospital notes and databases possibly be built with this in mind?  Can statistics be gathered on this basis?  Does the biological, historical way of giving birth need to be normalised to the benefit of families or are all modern options equally valid and ‘normal’?

This comment stands out for me, from Seana McCoy Talbot (an NCT volunteer who is standing for election as NCT President):

“Our starting point always has to be compassion and empathy, but also to know the evidence.
It’s instincts plus knowledge.
Heart and head.
Art and science.”

 

@HeartMummy 2015

Share the Word About MatExp!

Time to Act for Continuity of Care

There have been some fantastic conversations taking place on the MatExp Facebook group, with lots of ACTION threads being posted to generate discussion. The aim of these discussions is to identify ways that we can ACT to improve maternity experiences. Big, long-term actions that might require system change or a change in culture. And small, immediate actions, that professionals and individuals can take today to improve the maternity experience of those around them.

Over the last six months two big themes have emerged from #MatExp for me. The first is WHY are so many age-old issues still a problem for maternity care in this country? The answer to me is the working environment midwives face, as discussed here. The second is HOW can we make a real difference to family’s maternity experiences? So many actions have come out of #MatExp but the one that stands head and shoulders above, in my opinion, is continuity of care.

I don’t mean Ed Milliband’s diluted version of “the same midwife throughout labour”. I mean the same midwife antenatally, during labour and postnatally, or the same team of two or three midwives for the whole of that period. Women who hire independent midwives or who have access to OnetoOne Midwives have this type of continuity antenatally and postnatally, but they only have those same midwives during labour if they give birth at home. IMs and OnetoOne are not insured to act as midwives in hospital settings, although they can accompany women to hospital as advocates. Doulas are also with women as advocates and support for the whole of their pregnancy, birth and postnatal period but they are not qualified to act as midwives.

Continuity

When I brought up continuity of care as an ACTION thread on Facebook, I asked the following questions:

  • What are the barriers to providing continuity of care on the NHS? Is it as simple as not enough midwives, or is there more to it than that?
  • As an anxious person I really prioritised continuity of care, so used an independent midwife in my first pregnancy and a OnetoOne midwife in my second. What would my options have been on the NHS, under what circumstances can women be put onto a one-to-one care pathway?
  • What ACTION can we take to make continuity of care a reality?
  • What ACTION can we take to build good relationships between women and their midwifery teams where continuity of care is NOT a reality?

The suggested actions from the discussion that followed were:

  • Demonstrate the benefits of caseloading to NHS midwives
  • Strong leaders at the helm of trusts who themselves understand how to implement and lead their midwives into wanting continuity of care
  • NHS trusts to talk to independent midwives and social enterprise midwives who are the knowledgeable ones when it comes to providing continuity
  • Think about options for a team approach. One group member directed us to look at the Streatham Valley midwife team: “They were part of a pilot scheme for community midwives where you saw the same midwife and often they came to you for booking in and later appointments. They also checked you at home when in labour to avoid wasted trips to hospital and they have an excellent home birth record. Out of my ante natal group of 5 first time mum’s none of us had anything stronger than gas and air we had one home birth and only one use of forceps. They are amazing.”
  • Understand the positive impact that continuity of carer can have on patient safety and infant mortality
  • Find ways to care for midwives and avoid the “burn out” that is often associated with a caseloading model of working
  • Women with more complex pregnancies to be caseloaded by a team expert in their complexities – in other words, being at a higher risk of complications should not exclude women from continuity of care, in fact if anything these women need it more
  • Consider personalised budgets ( i.e. the NHS would allocate a woman funding to choose the service they wish) and whether or not this concept could help in delivering continuity of care
  • If continuity is not available then note-keeping needs to be excellent so women don’t always have to repeat themselves (which can be particularly hard following baby loss), and so that plans can be discussed and followed up
  • Women who are vulnerable or at risk of perinatal mental health problems should be at the front of the queue for continuity of care
  • Ensure that families are aware of and understand any choices they do have when it comes to their maternity care team

One healthcare professional commented “The commonest refrain you hear from mothers these days is ‘I never saw the same midwife twice’; this is a great sadness to me as surely the greatest gift to mediate the stressful vocation that is midwifery, is the relationship you develop with your ladies.”

Another woman who had opted for independent midwifery care in her second pregnancy commented “I just needed to know that someone was going to know me personally and take my wishes/needs seriously.”

Continuity of care was the strongest theme in the feedback to the National Maternity Review provided by my private Facebook group. It comes up time and again in discussions – I was discussing it today with student midwives at Salford University and they agreed that many midwives want to work to a caseloading model as much as families do. It just has to be constructed in a way that makes it feasible for midwives, many of whom have young families themselves.

Campaign for Choice
Campaign for Choice

This is not news. The RCM’s Better Births campaign has continuity of care as one of its key themes. The demand for caseloading from families accounts for the popularity of OnetoOne midwives in the areas where they are commissioned. A group of mothers in Greater Manchester is campaigning for the local CCGs to make this service available to women, and as someone who has benefited from that company’s care I joined them on a demonstration in Manchester city centre. If continuity is not going to be available on the NHS then OnetoOne might be the best option for families, although as this post of mine shows not all women find that the various services work together. 

What I find striking is how much continuity of care would impact on other areas where the #MatExp campaign has asked for ACTION. Anxiety is reduced if women know their carers. Emotional well-being is improved as are infant feeding outcomes. Dads & partners have more chance of being involved and having their own struggles recognised if they are able to get to know the family’s care team. It will be far easier for midwives and health visitors to collaborate if it is clear who is looking after which families.

I was delighted when an insurance solution was found for independent midwifery in this country. I also have high praise for the model of care provided by OnetoOne. Support and advocacy from a doula can be invaluable. But continuity of care should not be on the periphery of the UK maternity experience. It should BE the UK maternity experience.

 

Helen Calvert

@heartmummy

2015

Share the Word About MatExp!

1 2 3 4 5