Maternity Experience

Caesarean sections

On Monday, to begin #ExpOfCare week, we had an insightful blog from Dr Sarah Winfield reflecting on her experience of taking part in the ‘Lithotomy Challenge’. And today, to end #ExpOfCare week, another #FabObs, Dr Florence Wilcock – the originator of the #LithotomyChallenge and co-founder of #MatExp – tells us all about Caesarean sections and what really happens…

Dr Florence Wilcock

As we come to the end of #ExpOfCare week, I would like to share a blog about Caesarean sections, to demystify the birth that mothers and partners may unexpectedly experience. I originally wrote this blog at the request of Milli Hill & the positive birth movement in October 2016 , subsequently this has been included as a contribution to Milli’s book ‘The Positive Birth Book’ published 16th March 2016.

Why do we need to talk about Caesarean sections?

Unfortunately, sometimes people can be prone to making value judgements about different types of birth. One of the most common examples is vaginal birth = good and Caesarean section = bad. The truth is that in the UK current statistics show 25% of women will give birth by Caesarean section, 10% planned so called ‘elective’ and 15% unplanned ‘emergency’. We can argue these rates back and forth; we can aspire to improve care and change these facts, but for the moment given that 1in 4 women will meet their baby in the operating theatre it is vital that we talk openly about this experience and how it can be a positive, emotional & fulfilling birth for each new family.

Even in an unexpected ‘emergency’ there are still choices to be made. Nice guidance on Caesarean section CG132 section 1.4.3.4 recommends 4 categories of urgency; only category 1, the most urgent suggests delivery within 30mins. Far more common is the ‘emergency’ caesarean category 2, delivery within 75mins of decision making. This gives a woman time to express contingency birth preferences and ensure that even if she did not plan a caesarean birth it remains a calm and positive start for her and her baby. Skin to skin in theatre, optimal cord clamping, birth partner announcing the sex of the baby, choice of music are all possible. I would love to say these are all standard in every hospital but unfortunately that wouldn’t yet be true, however the more women know and ask, the more these will become universally accepted. As I often say ‘Wrong is wrong even if everybody is doing it and right is right even if nobody is doing it’. I wish you all an interesting and positive month discussing Caesarean birth and would like thank Milli for inviting me to contribute & become part of it. If you want to know more about how I am working to try and improve maternity services do check out matexp.org.uk

Caesarean Section a theatre experience & Who is who in the operating theatre? 

The majority of caesarean sections in the UK will be done under a spinal anaesthetic, that is numb from the nipples downwards. It’s a peculiar feeling as one can feel touch but not pain. It means that women will be awake and aware of people milling around them which can be daunting but it also means they are awake and ready to meet their new baby. Lying on the operating table we tilt women slightly to their left to keep the bump of the baby off the major blood vessels, this prevents dizziness from low blood pressure. If you lie on the operating table in the maternity theatres at my Trust you will look up and find butterflies & cherry blossom on the ceiling, something nice to focus on while you wait for your baby to arrive. I know this is unusual & we are lucky but there is nothing to stop you tucking your favourite picture or photo in your birthing bag so that you have something familiar and relaxing to look at.

It might seem odd that at the start everyone in the theatre will introduce themselves to one another. It isn’t that we have never met but its start of the World Health Organisation (WHO) safety checklist. There is a special checklist just for maternity theatres and it is routine to start by checking simple information such as the woman’s name and date of birth and move onto clinical issues and equipment and it is all aimed at making the experience as safe as possible. So, who are all these people around you and what are their roles, why are there so many people there?

Anaesthetist: At least one sometime two; these are doctors who will administer the anaesthetic ad monitor you closely during the surgery. They will be standing just by your head and often chat to you and reassure you as the operation progresses. 

Operating Department Practitioner (ODP): at least one; their role is to assist the anaesthetist, getting & checking the required drugs, drips or equipment, the anaesthetist cannot work without one being present.

Obstetricians: at least two; one will be performing the Caesarean section (the surgeon) the other will be assisting (the assistant) e.g. cutting stiches, holding instruments.

Midwife: At least one; to support the woman and help her with her newborn baby when it arrives

Scrub nurse or midwife: At least one; To check, count all needles, stiches and instruments and to hand them to the surgeon when needed.

Midwifery assistant or runner: This person double checks the swab and instrument count with the scrub midwife or nurse and ‘runs’ to get any additional equipment required as they are not ‘scrubbed up’ so can go in & out of theatre to fetch things.

Paediatrician: asked to attend any ‘emergency’ situation or if there are known concerns about the baby.

So, you see in theatre there is a minimum of seven people caring for any woman all with specific tasks to perform, any complication may result in us calling in extra members of the team.

So back to the woman, she will be on the operating table with her birth partner by her side and the anaesthetist and ODP close at hand. She can often choose the music she would like her baby to be born to. The anaesthetist needs to monitor her heart with sticky labels but these can be put on her back and her gown left loose leaving her chest free and ready for skin to skin with her baby. A sterile drape will be placed over her bump and this is usually used to make a ‘screen’ so that the woman doesn’t see and surgery she doesn’t wish to see however usually we drop this when the baby is ready to be born.

Many hospitals are starting to explore options of optimal cord clamping (waiting to clamp the cord) and passing the baby straight to the mother if the baby is in good condition. These can be done but need to be thought through so as not to contaminate the sterile surgical area, and the surgeon needs to be confident no harm such as excessive bleeding from the womb is happening whilst these things occur. Surgical lights need to be on so the surgeon can see clearly and operate safely but I know one anaesthetist who works in a hospital where the rest of the theatre lights can be dimmed. The mum and new baby can be enjoying skin to skin whilst the rest of the operation proceeds. Weighing and checking babies can be also done at this time but also can be done later on.

Traditionally if we operate with women under a general anaesthetic (asleep) her birth partner has not been in in theatre as their role is to support the woman. Recently on several occasions I have challenged this so that a baby is welcomed to the world with at least one of its family present and awake rather than by a group of strangers caring for the unconscious mother. There are safety considerations to be talked through for this to be successful but it is possible. However, kind and caring staff are, they are no replacement for a birth partner whom the mother has chosen to support her in the intimacy of birth.  

I hope I have given you a brief glimpse in to life in a maternity theatre. As an obstetrician, I am privileged to help bring many women and babies together for those special first moments. The emotions are always different for me: sometimes it is a couple I know very well and have bonded with over months or years, sometimes a woman I have only just met who has had to put her absolute trust in me immediately. The theatre atmosphere can range from almost party like jollity to quiet intimacy. Every birth is different; each birth is extremely special just as much as the births that happen in a less clinical environment and each birth will stay with that woman forever. 

Useful CS references

Ref NICE CG132 https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#procedural-aspects-of-cs https://www.nice.org.uk/guidance/cg132/ifp/chapter/About-this-information

RCOG Consent advice No 7

https://www.rcog.org.uk/globalassets/documents/guidelines/consent-advice/ca7-15072010.pdf

 

 

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#LithotomyChallenge on #NHSDoAthon day

We are very honoured to begin #ExpOfCare week with a bang, publishing this insightful blog by Dr Sarah Winfield. We have connected with Sarah through the excellent ongoing #MatExp work at Leeds Teaching Hospitals NHS Trust, following the exciting Whose Shoes? workshop last summer. Part of the work in Leeds involves a different #MatExp challenge each month… and January 2017 was ‘lithotomy challenge’ month!

Sarah wrote this a while ago but we held it back to publish here as #ExpOfCare is such an important initiative and one which is central to #MatExp. We are very grateful to Sarah not only for taking the time to do the challenge, but more importantly to reflect so openly on the experience and share with us here… 

The #LithotomyChallenge is a term coined by one of my Obstetric colleagues in Kingston, Dr Flo Wilcock, who wanted to put herself in the position of a patient in lithotomy for an hour and to describe the experience. As part of #MatExp and to raise awareness of it’s existence and philosophy, I wanted to do the same. So I did on #NHSDoAthonDay at the start of January 2017. Here is how I got started.

I used to be sceptical about twitter until my tech-loving husband persuaded me to dust the cobwebs off my twitter account @winners352 (set up tentatively a while ago). David is a consultant in Education and assured me that performing CPR on my twitter account would not only be beneficial for my CPD, but would put me in touch with like-minded people, allow me to tweet the odd journal article, and would help me to raise the profile of the unit that I work in. I wasn’t ‘sold’ but I am an optimist and thought that I should give it a go.

So I changed my profile picture, tried to compose a sassy yet professional catch line and I started to browse for people and things that may interest me. Initially I retweeted posts that would not cause any controversy for my digital footprint or reputation as a member of the medical community, but then I worked out that if people put their opinions out there for all to see, then this provokes engagement and discussion. This conversation would then draw others in. Then information begins to flow, more people ‘follow’ and before you know it, there are people from all over the world tapping in to see what this is all about. Amazing. But also slightly scary.

Of course, I appreciate that there are downsides to having a twitter presence, but this is where the world is going now. I recall an article written for the Health Service Journal by Roy Lilley about STPs (Sustainability Transformation Plans). In this article, to paraphrase, he said that STPs are happening and are not going away, so you can be in the cast or the audience. It’s your choice. I think that the same applies to social media and twitter. So, I made the decision to learn more and make it work for me. This was at the beginning of October 2016.

Through twitter I made contact with Gill Phillips (@WhoseShoes) and Flo Wilcock (@FWmaternitykhft) who are the founders of #MatExp, and it turned out that I had actually met one of this duo before!

As well as being a Consultant Obstetrician with an interest in maternal medicine, I am also the Clinical Lead for maternity services for the Yorkshire and the Humber Clinical Network. This role took me to an event at the Kia Oval in London in July 2016 to discuss implementation of ‘Better Births’ (the National Maternity Review) in each network patch. There were a series of workshops and in one I joined in with a discussion about the “Whose Shoes” event that had been held in Leeds earlier in the year. I did not realise it at the time (probably because I was not on twitter at that point!) but Gill Phillips was one of the facilitators of that group. Professor Cathy Warwick and Mr David Richmond were the other facilitators.

While I had not been able to attend the Leeds Whose Shoes event itself, our LTHT strategy midwife, Sarah Bennett, was very much involved. At the event a cartoonist, Tom Bailey, recorded patients’ views and the conversations taking place. These were very thought provoking and I have to admit that one image in particular made me stop and think. It was of a doctor standing at the top of a hill pointing down to a midwife at the bottom of the hill. It was not particularly complimentary to us as doctors.

None of us set out to make patients and midwives feel like this but with the language we use, the information we need to get across and our communication skills in general, there was clearly an issue. This made me feel uncomfortable (and perhaps a tad indignant, if I am being honest) and I know that a few of my colleagues felt the same as me.

What happened though was that these images stimulated discussion and debate amongst the maternity staff members. While there might have been levels of disagreement about the images and what they portrayed us to be as medical and midwifery professionals, they were ‘real’ views of and we had to reflect here. Importantly these conversations were a starting point to encourage us to look at how we work on a day-today basis, the language we use with patients and each other, how we conduct ward rounds on the delivery suite and the whole experience for any woman and her family using our maternity service.

In other words, we had a platform from which to share our opinions about the maternity experience of patients in Leeds across both sides of the city.

Leeds is a busy tertiary unit. We have around over 10,000 deliveries a year between Leeds General Infirmary (LGI) and St James’s Hospital (SJUH) and we don’t often get to do sit down with our colleagues, whose opinions we genuinely value, and engage in a dialogue about patient experience. But here we were, and I felt like this was a good start.

I spoke about this experience in positive terms at the Kia event and Gill then made contact with me through twitter a few months later. A fortuitous connection for me and, I hope, for her too. I also ‘met’ Flo through Gill on twitter, and the rest has followed.

So who are Gill and Flo and what is #MatExp?

Gill, the creator of the award-winning Whose Shoes?® concept and tools, has a genuine passion and unsurpassed energy for “looking at issues from different perspectives and getting people to talk together as equals and come up with imaginative solutions”. She is also a mum of three ‘now grown up’ children.

Her website http://nutshellcomms.co.uk/gill-phillips-and-the-origins-of-whose-shoes/ is an inspirational working ode to her warm, inclusive and collaborative style. Gill’s passion for helping others is obvious to see and she takes people with her. This is one of the many reasons why she has been quoted by the Health Service Journal as one of the 50 most influential women of the year.

Florence (Flo) Wilcock is a Consultant Obstetrician at Kingston (and mum of two) and, inspired by Gill’s WhoseShoes concept, was keen to use this to improve maternity services and more. Flo is similarly an inspirational force and counts the RCOG and its former president David Richmond as her supporters, amongst many others. She joined forces with Gill and the #MatExp campaign was born.

The #MatExp website is a vibrant, colourful, positive and proactive resource and I would advise anyone working with women and their families. The best explanation of #MatExp is the one from their website, so in their own words:

“#MatExp is a powerful grassroots campaign using the Whose Shoes?® approach to identify and share best practice across the nation’s maternity services.

Then ensued a flurry of tweets between me, Gill, Flo and other #MatExp supporters and I was overwhelmed by the helpful, collaborative and go-getting approach. They are incredibly supportive to anyone on twitter who shows an interest in improving patient and family experience in maternity services.

As my knowledge grew about #MatExp and I had further twitter conversations with Gill, Flo and others, I read a piece by Flo that she wrote about her taking part in a #Lithotomychallenge. The piece is here and Flo explains:

“For NHS change day I wanted something that made a statement that said “#MatExp has arrived, take notice, we are improving maternity experience, get involved!” I couldn’t quite think of the right action until I saw a twitter exchange with Damian Roland back in December and watched a video where he described his spinal board challenge from NHS Change day, 2014. I had a light bulb moment thinking what would be the maternity equivalent? Lithotomy!”

Taking Flo’s lead and transporting #MatExp to Leeds, I thought that a #LithotomyChallenge would be easy for me to set up and would put me in a patient’s shoes (goodness knows the amount of times in my career that I have put a patient in the lithotomy position for an instrumental delivery, a FBS, a perineal repair..) for a short while. I have two daughters, both born by caesarean section, so I had no experience of this, let alone with contractions, CTG leads, an epidural, a syntocinon drip etc.

I chose Wednesday 11 January 2017 as the morning I would do it. This was #NHSDoAthonDay and it seemed appropriate.

In the run up to the day, Sarah and I told people what I was going to do through the strategy newsletter, facebook, twitter and word of mouth. People asked why and asked what #MatExp was. There was also an interesting spectrum of opinion about my desire to do the #Lithotomy Challenge, ranging from people thinking that I was ‘patronising’ my patients and colleagues to others congratulating me for taking the initiative to do something different.

On the day of the challenge I put my hospital gown on, strapped the CTG leads to my abdomen and Sarah fixed an IV line to hand with tape and helped me up onto the delivery bed in Room 10 on LGI delivery suite. Then Sarah left to go across the city to St.James’ hospital where the midwives there were waiting for her to set them up with the #Lithotomychallenge too. I was by myself in the room. In lithotomy position.

I felt undignified and vulnerable. I also hoped that nobody would walk through the door, but they did. In groups, in pairs, alone. Mostly midwives. Each time I cringed as the door opened and I realised that the level of the bed meant that my bottom end was at their eye level. I was in leggings and a sheet. I can’t imagine the indignity and embarrassment for a woman of being ‘al fresco’ when someone comes into the room in that situation.

 

Then I noticed something that I hadn’t before; there was no ‘privacy curtain’ over the door. I now realise that this curtain is a feature of the delivery rooms at St.James’ hospital across the city and in every other maternity unit I can recall having worked in before. Such a simple thing would make a huge difference.

Then the surroundings really began to jump out at me. This room had magnolia walls, a light socket that was hanging off (previously an uplighter), holes and scuffs in the walls and nothing that I would describe as comforting, pleasant or homely. When you sit in a room for over an hour, these details are very obvious. I have been in this room many times during ward rounds, to deliver babies etc. and I had never noticed what an uninspiring and depressing environment it is.

Would I have enjoyed my birth experience in this room? Definitely not. Does it convey an impression of the warmth, skills, knowledge, team spirit and professionalism of the delivery suite staff that I know exists? No it does not. But a woman and her family have this room as the starting point on their personal, special and much anticipated journey to give birth to their precious baby so how is it going to set them up for a positive birth experience? It don’t think it will.

Then something unexpected happened. I felt really cross with this room, if it’s possible to be annoyed with a ‘space’. I know how hard the team work to look after women and their families, so why should the woman and us as the team, with our training, skills, compassion, knowledge and tertiary centre reputation be let down by awful facilities? All women should have a pleasant environment to have their baby. It’s very simple. Some paint, some wall décor, good lighting, promptly repaired faults. The list is not long and is easily addressed. This was the first unexpected result for me of my #Lithotomychallenge and I have to say that it really touched a nerve.

The other unexpected result for me what that when people came in to see me they shared their own birth experiences (good and bad) as I sat there on the bed

with my legs ‘akimbo’. I found this moving because these are people who I have worked with for the last few years, who I chat with when I’m on-call and who I think I know quite well. I heard stories of a fantastic waterbirth, an awful induction, someone struggling to get pregnant plus more. You could say that the ‘barriers’ were down, but I would like to think that me doing this challenge provided an opportunity for people to start conversations with me and each other about their experiences as patients in the maternity service.

My final recollection added some humour to my experience. While I was talking to a group of student midwives (they appeared to be more embarrassed than me), one of our delivery suite domestic staff, who I know quite well, knocked on the door, walked in politely and without ceremony, gave me a glass of water and asked me for the keys to my office so that she could give it a clean while I was tied up! There was no pulling the wool over her eyes. I gave her the key and my thanks.

So, what did I get out of doing the #Lithotomy challenge? There are two things that stand out for me. The first is that I allowed myself to ‘feel’ from a patient’s perspective. I was prepared to give a bit of myself away and open up to the possibility that we may not communicate in a way that enhances a patient experience or consider the importance of the environment that we create to do this. I think that to change culture, the language we use and the way we view the patient experience we need to look closely at our individual practice and challenge our own behaviours and judgements. This is hard and not everyone will want to do this but I have found that doing the #LithotomyChallenge has led me to review my own beliefs and practices as an NHS worker for almost 20 years and this has been like taking a deep breath of fresh air.

As a doctor and a consultant I am familiar with pushing my boundaries professionally and clinically, but can I use any ‘influence’ that I have in a different way? Of course I can be an ‘opinion’, counsel patients, make management plans, perform difficult c-sections, chair regional meetings etc. but working towards improving patient experience may be regarded by some as a ‘fluffy’ goal. Very ‘touchy feely’ and not really hard-hitting or go-getting enough to warrant using precious consultant time in an already busy day where we are here to deliver a service and fulfill the objectives of our job plan/appraisal personal development portfolio. But sometimes it’s not until you experience the ‘other side’ and and allow yourself to ‘feel’, that you realise what needs to change. I now know that I would like to be more proactive in considering the whole patient experience when I am involved in any aspect of a consultation or a procedure.

The décor was the second thing. I have seen many articles and personal commentaries about the effect of surroundings on birth experience, and we already know that the environment during labour and delivery can have a profound effect on how patients ‘experience’ their care. After spending time in a room that has seen better days, I can believe it. Never underestimate the importance of surroundings and this challenge has highlighted that for me. I hope that this piece will result in privacy curtains being put up in each delivery room at LGI. This would make such a difference. But improving the delivery rooms in this unit is going to require funds. I regularly see healthcare workers and patients fundraising for their units and doing the #Lithotomychallenge to spurred me on to do this.

There is one final thing that the challenge has done. By writing this piece I have a voice. I have not asked permission and have not sought the ‘approval’ of anyone. I have just done it and have been supported by most of my colleagues, including Sarah B. I was nervous about doing the #LithotomyChallenge and had a sense of trepidation about what others would think, but I have enjoyed what the experience has brought and have been inspired by Flo and Gill, who have given me a masterclass in wholeheartedly and warmly welcoming others thoughts and diverse opinions. In their eyes no opinion is ‘wrong’ or ‘daft’. If disagreement arises then it is not to be feared or ridiculed. It can be used as the basis of a conversation to challenge the status quo and then move forwards.

“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek” (Barack Obama).

Dr Sarah Winfield
Consultant in Obstetrics with Special Interest in Maternal Medicine. Leeds Teaching Hospitals NHS Trust
Yorkshire and the Humber Clinical Network  Clinical Lead for Maternity Services
NHS England Women’s Specialised Services Clinical Reference Group representative for the North of England

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#MatExp Whose Shoes? update

Some really exciting developments with #MatExp Whose Shoes? at the moment.

Bromley MSLC produced a ‘one year on’ report following up on their Whose Shoes? workshop at King’s College hospital using “I said, I did” as a framework to list all the fantastic outcomes that had come from pledges made on the day.

Language continues to be a big issue for women and families, but some great initiatives are now happening. Building on the Whose Shoes? workshops, Leeds and Colchester in particular are working on specific language challenges. I came up with a ‘Negativity Bingo’ and had great fun with my team at the NHS Fab Change Day #DoAthOn event launching #DumptheDaftWords.

I have been getting some exciting invitations to speak about building social movements and of course gave #MatExp a big shout out in my talk at the launch of #AHPsIntoAction, they have invited me back for a longer keynote session at their annual conference in June.

More hospitals are coming on board with the Whose Shoes? approach – the energy is particularly strong in London, the West Midlands and the South West regions. It has been great to present on several occasions now with Catherine MacLennan and Emma Jane Sasaru and to see people learning so much from their courageous sharing of their lived experience.

Last Friday, 3 Feb 2017, we were invited to present a #MatExp Whose Shoes? session to get some good discussions going as part of a packed event launching #PanStaffsMTP in Stafford. We concentrated specifically on continuity and perinatal mental health. This is the county-wide transformation programme to improve maternity experience in Staffordshire to implement the national ‘Better Births’ vision. This informal film gives you a flavour.

We are proud of the crowdsourced ‘Nobody’s Patient’ project and thank everyone for your fantastic contributions. We now have over 120 new Whose Shoes? scenarios and poems and the new resources will be made available shortly to all the hospitals who were existing customers. Florence Wilcock, Sam Frewin and I are finalising the supporting toolkit and collating the case studies, ahead of our ‘wrap up’ event in March. We are trying to pull together lots of ideas for positive change, with or without a workshop. I hope you are enjoying the regular Steller stories, including Florence’s monthly reports.

Wonderful to see everyone doing such amazing work, speaking all over the place, building networks, spreading the word and generally making great things happen.

Keep up the good work!

Gill Phillips @Whose Shoes

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Music While You Wait

This post has been written for the #MatExp campaign by Claire Flower, Clinical Specialist Music Therapist and Joint Team Lead for the Chelsea and Westminster Hospital NHS Foundation Trust.  Our thanks to Claire and her team for their support for #MatExp.

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‘Music While You Wait’ is the working title of a project we’re recently been running in maternity care at Chelsea and Westminster Hospital, London.

My name is Claire Flower, and I jointly lead the music therapy service here at Chelsea and Westminster hospital.  We have had a large children’s music therapy service for many years in the Trust, but recently we’ve had specific funding to explore how music is used by, and can be helpful for, women through pregnancy and birth.  The project title – ‘Music While you Wait’ – has seemed fitting, both because of pregnancy itself being a waiting game, but also because the project has been based in the antenatal waiting areas of the hospital.

In conversations with midwives, doctors, pregnant women and partners one of the themes which kept popping up was that the experience of attending, or working in, an antenatal clinic can sometimes be extremely stressful.  People told me that at busy times the clinics are often full and noisy, some women may have children with them which brings its own pressures, some may have lengthy waits to be seen, and some may be anxious about being there for all kinds of reasons.  As one woman said to me, ‘not everyone here is happy’.

There was a real, shared interest in exploring together how music might be one way of making the experience of the clinic better for everyone, lowering stress levels, reducing anxiety, and giving different opportunities for social contact and connection.

We agreed that I would attend 6 different clinics, offering live music, as well as talking with women, partners and staff about music in pregnancy and beyond.  And so we started – wheeling an electric piano into the waiting area, playing a range of music, talking, and being prepared to see what unfolded.

Over the weeks, I kept a journal, describing events in each clinic, and thinking about them in preparing for the next one.  Looking back at them now, they give a flavour of some of the moments which characterised the project.

For example, how the piano music was received by women coming to the clinic…..

‘One couple arrive, and as they walk in she looks across and says quite loudly across the room, ‘oh it’s you!’.  There’s surprise from both of them that the music is live, they’d assumed it was the radio.  ‘There’s just something about having the person, you know?’ she said.  

On the same morning….

‘Another woman smiles frequently at me as I play and she waits.  In fact, she moves from sitting with her back to the piano, to facing me and sitting closer.  As I stop to respond to someone’s comment, she agrees that it’s lovely, and says she was just texting her sister to say how lovely it is to sit and listen to.  Makes me think that music is doing its work of rippling outwards to unexpected places!’ 

In this busy clinic, women often come with children – quite a challenge if there’s a lengthy wait.  When one woman arrives with two energetic young children, looking quite exhausted, I wonder how I might be able to help with some music for them….

‘I come away from the piano, and bring out some small instruments for us to use, crouching down with them to sing.  Mum joins in, and the children begin to sing and dance, moving rhythmically to the music.  Looking around, I see other women smiling at the children, or even moving a little to the music…. After a good play, we agree to put the instruments away (I’m really not sure how the sound levels will have been for the poor midwife in the room nearest to our impromptu band!), and somebody in the room suggests it’s ‘time for a lullaby’, I return to the piano, and we have a gentle rendition of Twinkle Twinkle, one of the children ‘twinkling’ at the top of the keyboard.’

And then there was the morning when this happened…..

‘As I’m playing, one woman, quite heavily pregnant, walks in, looks towards me smiling, and walks towards me.  She approaches so confidently, and with such a smile that I wonder whether we know each other, or that I’ve forgotten meeting her here previously…..’

What unfolded from that point was one of the highlights of the project for me, but she’s best placed to tell you about it herself….

“I am a professional violinist. In July 2016 I was almost 9 months pregnant with my second child and was suffering from gestational diabetes. So every Tuesday until my C section I had to go to C&W and be assessed by a diabetes specialist nurse or consultant. I was very anxious and tired beyond belief. On top of that, more often than not there was a rather long wait for the appointment.

Needless to say I wasn’t looking forward to Tuesday…until one day when I walked in and heard music. There was soft classical music coming from a speaker or two (I thought for a few seconds until I spotted the real source, at the back of the room). SOMEONE (not something!) was playing that lovely music. How amazing, and how very rare…

I walked straight towards her with no doubt in mind of what I was going to do. I had to come here, bring my violin and play with her, even if it was just for a few minutes! I had been pregnant and breastfeeding for three years by then and playing the violin had LOST ITS place in my life. I did miss it desperately and said it. To my absolute joy Claire invited me to bring some music as well the following Tuesday, before my appointment and play with her for almost an hour. We discussed the music in detail (not everything suits so I took her advice and offered to also bring something a little different to see if and how it might work).

I counted the days until my next appointment, even managed to practice a little for the first time in years, searched for my beloved but long forgotten music and didn’t think of anything else other than how wonderful it will be to join Claire and play for everyone there who was going through the same hard times as I was. It was also the first time my daughter listened to me play the violin in public. I felt like the luckiest and most privileged woman on earth (no exaggeration here!).”

For everyone who was lucky enough to be working, or coming to the clinic on the day when this happened, it was a magical moment.  It certainly ticked the box of seeing how music might make the antenatal clinic experience better for everyone there.

We’re writing the project up now, using, among other things, the comments which were written and drawn for us by women, children, staff, and partners in each session.

And we’re discussing what we do with it next, which might mean developing it further in the waiting areas, as well as thinking about how it might translate to the wards.

As Viki Girton, Lead Midwife for Antenatal Clinics says ‘Music While You Wait helped to create a relaxing environment for staff and patients… having more would be fabulous to improve maternity experiences and patient satisfaction here’.

I love being a music therapist, but being able to step into the maternity world and work with such a great group of women, staff and families has been a new pleasure.  We’re really excited to have conversations with anyone interested in where we take this next, and how music therapy might play a part in #MatExp!

 

Claire Flower
February 2017

 

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Bedsharing, Breastfeeding and Family Centred Care

It started with a thread about infant feeding that the lovely Lucy began on the #MatExp Facebook group.  It was a fantastic discussion with a realistic and compassionate look at all kinds of barriers and problems, but one comment from student midwife Amy Prodgers stood out for me the most:

“Have found this discussion really fascinating as have been reflecting on similar issues after my first week on postnatal ward as a student midwife. I could go on about loads of things but a key point for me is the conflict between safe sleeping advice and facilitating breastfeeding. Women are exhausted from their birth experiences and their babies just want to feed but can’t sleep together. Women then end up feeling a failure for not being able to settle their babies in the cot, whilst also feeling guilty for wanting to sleep. This is when women start asking for formula and when midwives begin to doubt their intentions. Totally undermines confidence.”

I started a new thread with this comment at the top, and tagged in Gill Phillips as I felt it would make an excellent scenario for the WhoseShoes game that is used in #MatExp workshops around the country.  We then had a discussion about bedsharing that raised some important points, and I felt it important to capture that discussion and share with you here.

sidecar-cot
Via https://www.facebook.com/BellyBellyBaby

What was quickly brought up was the co-sleeper cots that used to be available to women on some postnatal wards.  This article was linked to: http://www.scarymommy.com/hospitals-everywhere-should-have-this-amazing-co-sleeping-bed-for-new-moms/ and I remembered that midwife Jenny Clarke had been tweeting about them this year.

jennythem-side-cots

An IBCLC on the group explained that “The old co-sleeper cots don’t fit the new beds (which were needed to reduce back strain on staff). However there are several new designs that fit the new bed, and research starting up too. Helen Ball’s research and videos of mothers clearly showed that the co sleeper cots made things *much* easier for mothers, much happier for babies, and didn’t add to staff’s workload.”

jennythem-side-cots-2

But would co-sleeper cots solve the problem?  A paediatric consultant commented “I had co-sleeper cots after both my deliveries but actually my babies just wanted skin-to-skin for the whole first night. I think we really need better hospital beds in maternity and children’s wards to facilitate bedsharing.”

The important thing to bear in mind here is that these babies are displaying completely normal behaviours.  It is our maternity wards that need to be “fixed”, not the babies.  For a lot more discussion about expectations and reality when it comes to infant sleep, please see this blog by Alice Amber-Keegan of the Infant Sleep Information Source: https://growingfamilies.co.uk/2016/09/04/infant-sleep-expectations-and-reality/

Founder of the Positive Birth Movement, Milli Hill, agreed that “co-sleeper cots imply that at some point your baby will not mind being put down separately from you, and that you won’t mind putting them down separately either! Not always what mum or baby wants or needs.”

And of course, not having baby on the same surface as you can make life very difficult for post-birth mothers, as Polly Rogerson pointed out: “I was in hospital for a week after birth [due to post-partum haemorrhage], I was so weak that I couldn’t even lift my baby out of the cot – even with it right next to the bed. Yet somehow I was expected to do exactly that to try to feed him.”

Bedsharing when Baby is Unwell

The conversation then went in a couple of different directions – one discussion of bedsharing on children’s wards when a baby is ill, and one discussion of the guidelines that trust’s expect health visitors to follow when discussing bedsharing with the families they support.

current-logo

Anyone who follows my hospital breastfeeding campaign will know how excited I was to have a paediatric consultant say that it would be good to have bedsharing facilitated on children’s wards!  The consultant in question went on to say:

“Because in real life, I’d say close to 100% of families bedshare when children are ill. Banning it on hospital wards is just stupid. Having informed discussion about it is sensible.”

She clarified that her reservation for bedsharing with unwell children “is smoking parents and small babies and children with respiratory illness, as it is unrealistic to expect parents to stop smoking at such a stressful time, but the smoke clinging to clothes and hair definitely seems to exacerbate the children’s respiratory problems.”  However this doctor confirmed:

“I spend a lot of time at work putting babies and children back into parents’ arms. That’s where they are usually happiest, but most importantly for me, most physiologically stable!”

This issue came up on my own private Facebook group today, as a member explained that her niece was hospitalised (and will likely be so for some time) and is refusing to sleep anywhere but on mum.  As mum is unable to bedshare in hospital due to lack of facilities, mum is getting very little sleep.

A paediatric nurse on my group explained that from her professional perspective “we never advocate or advise co sleeping in our hospital as the babies are with us due to illness & therefore it can increase the chances of problems. However it is a parent’s choice and some still do, but we are bound by our duty of care to highlight the implications.”

She went on to say though:

“I’m a big believer in family centred care (which all children’s wards/nurses/professionals should be) so if a parent still wants to co sleep (and they would do so at home) I feel it’s my duty to help that parent as best I can so their wishes are upheld, but in a way that I feel most comfortable with in my work setting. As a children’s nurse you’re not only nursing the child but the whole family too, so to keep things as they would do at home or in regular life is important; the change of circumstance by being in hospital is bad enough for the child and family never mind then saying ‘well sorry you can’t keep your normal routine whilst here’. I think sometimes as a health professional we’re so focused on making that child better medically it can be forgotten how big a change being in hospital can be on them emotionally; even though they may not outwardly show signs of distress it is definitely affecting them psychologically, and therefore keeping things as much to their norm as possible is very important.”

 

Bedsharing when Baby is at Home

latter-beverley
Image courtsey of Beverley Latter and the Infant Sleep Information Source

The discussion about what health visitors can and can’t say to new parents was prompted by one mother explaining “my health visitor at 6 weeks (1st baby) gave me info about safe co-sleeping and it was the reason I continued to breastfeed.”

I then shared the discussions that mothers from my group have had with health visitors online, including a discussion specifically about bedsharing: HVe-COP newsletter  The two quotes from that discussion that summarise the issues for me are:

“We are very constrained sometimes. We have to follow Trust policy…..even if we believe that bed sharing can be very beneficial and are up to date (with evidence)” (health visitor participator)

“Just to put this out there…….we have a responsibility to our NMC Code of Practice and the clients…after that Trust policy is important. The day health visitors do not provide evidence based information to their clients because of Trust policy is a grave one indeed” (health visitor participator)

On this thread in the #MatExp group, one health visitor explained: “Trust guidance is the Lullaby Trust safe sleep recommendations, and signposting to NICE for bed sharing…..personally I don’t advocate it but I talk about if [you are] bedsharing [how to] minimise risks.”

This conversation took place before the launch of the new Baby Friendly “Co-sleeping and SIDS” guidance for healthcare professionals, which has been developed in conjunction with the Infant Sleep Information Source and the Lullaby Trust.  This guidance focuses on helping healthcare professionals “to take a sensible, proportionate parent-centred approach in order to find practical solutions to this complex issue”.

bfi-cosleeping

We can hope that this guidance and the continued expansion of Baby Friendly training for UK health visitors will put an end to less nuanced campaigns such as this one from Bolton, Wigan and Salford that Amy Prodgers highlighted:

safe-sleep

As you can imagine, this heavy handed campaign elicited a strong response from those on the thread!  Amy herself commented that “reducing SIDS by telling people not to bed share is a bit like reducing road traffic accidents by telling people not to use cars! And of course we’ll also avoid the issue of how much more dangerous it is to fall asleep on the sofa (whilst presumably trying your best to follow this advice and stay awake).”

One mother’s experience explains the reality of what happens when health visitors advise against bedsharing: “When I told my HV I was co-sleeping, on purpose and in accordance with safety instructions, she gave me leaflets on ‘cot death’ and strongly discouraged me from doing it. She then arranged another visit for a few weeks later, after advising me to ‘keep trying with the moses basket’. When she returned I just lied and said that my baby was now sleeping in the basket as I couldn’t be arsed with having to defend my conscientious parenting decisions.”

 

For information on the practicalities of sharing a bed with your baby, please see this detailed post by Elena Abellhttps://growingfamilies.co.uk/2016/06/15/the-practicalities-of-sharing-a-bed-with-your-baby/

Or see the “Safe Sleep Seven” from La Leche League:

safe-sleep

And for the latest research on bedsharing, infant sleep and SIDS please see the Baby Friendly website: https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-bed-sharing-infant-sleep-and-sids/

 

Midwife Sally Goodwin said at the end of the thread that she was “grateful to all for highlighting this issue. I think this subject comes up erm…… every day for me as a midwife.”

Certainly a topic we need to continue to discuss then.

 

Helen Calvert
November 2016

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#MatExp competition – win a ‘Whose Shoes?’ workshop!

Launched today by Sarah-Jane Marsh

at NHS Expo…

File 06-09-2016, 22 56 47

When you think of a competition, what do you typically think of?

  •  An application form with lots of dull questions ✅
  •  A raffle ticket with a lucky number.  Not necessarily yours.  ✅
  • A dodgy  message flashing on your phone saying you have won £1 million.  Claim your prize  NOW!!

Well, as many of you will know, ‘#MatExp Whose Shoes? ‘is a bit alternative. So we are giving you endless alternatives as to how you would like to enter the competition.  We are not big fans of labels, boxes and standardised formats   So just take a look at the link below to see the areas we would like you to think about and then let your creativity loose as a goose and see what you and your people come up with!

And if you don’t know what ‘#MatExp Whose Shoes?’ is about, where have you been  for the last two years? 😉 Loads of material here on matexp.org.uk or by browsing the web.  And one of these days Gill Phillips, creator of ‘Whose Shoes’  will get round to updating her website –  but she has just been far too busy tweeting and building momentum on Twitter @WhoseShoes.

Please also help spread the word. We are hoping that lots of people who are not familiar with social media will get involved and will get drawn in by the MatExp magic and find that it is fun to link with others who share their passion, way beyond the confines of their department, hospital or local area.

Click the link below to download a PDF file which contains further information and an entry form.  Good luck!

Entry form – Nobody’s Patient competition

Please visit this page again as we will add our launch video once it has been shown live at NHS Expo!

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Optimal Cord Clamping

This post has been written by Amanda Burleigh for the #MatExp campaign.  Our thanks to Amanda for contributing to our blog, and for her continued work to raise awareness of the need for Optimal Cord Clamping. Please check out her Facebook page here: https://www.facebook.com/Optimal-Cord-Clamping-WaitforWhite

BloodToBaby

Conception to birth is a miracle, but many parents and practitioners are not aware that immediately following delivery of the baby the placenta and cord continue their function in transferring approximately 30% of baby’s intended total blood volume via the cord to the baby whilst the baby transitions to life outside their mother. Uninterrupted transition is extremely important whilst baby uses their lungs to oxygenate their body for the very first time.

For approximately 50-60 years most birth attendants have clamped and cut the cord immediately the baby has been born, often before the baby has taken its first breath. There has never been any evidence to support this practice. UK national and international guidance (including resuscitation guidance) now recommends where possible the umbilical cord should be left intact for at least one minute. Immediate cord clamping can deprive the baby of their intended blood volume and research shows that babies can gain up to 214g in the first five minutes following birth if the cord is left unclamped. (Farrar 2010) Further research shows that babies who have immediate cord clamping have a greater incidence of iron deficiency anaemia as valuable red cells are left behind and that out of this same group of babies some male babies have decreased fine motor and social skills at the age of four, which can impact negatively on a child’s mental health. (Andersson 2011) Cord blood also has a very high concentration of stem cells, important in development throughout the baby’s whole life.

New NICE guidance published in December 2014 recommends delaying cord clamping for at least one minute for all babies regardless of delivery unless the baby’s heart rate is less than 60bpm and not getting faster. This is an extremely rare occurrence. Some babies can be a little stunned at delivery but it is important to remember that the placenta and cord are still transferring oxygenated blood through to the baby as they did when baby was in the uterus and the majority of babies will spontaneously recover without any intervention when the cord is left intact. Your birth attendant will dry the baby to stimulate them and place the baby in skin to skin to help with transition, temperature control and bonding. Early feeding can help this process along and can also aid placental delivery and reduce blood loss immediately following delivery.  All of this can be done with the cord intact.

Placental delivery.

When the cord and placenta have fully completed their function, the cord will stop pulsating and the baby will have received all their intended blood volume and the cord will be empty and white. As this is the healthiest way for the baby to be delivered we have started a campaign called #waitforwhite to raise awareness.

Active management.

With informed choice it is a common practice to administer an oxytocic (hormone) drug by injection after the baby is born to help deliver the placenta and reduce the incidence of post-partum haemorrhage. Historically this injection is often given immediately after delivery but in uncomplicated births, it can be given a few minutes after birth (or when the cord has stopped pulsating) and the cord clamped a few minutes after administration of the injection. This way the baby gets their full transfusion with minimal interference. Some birth units have reviewed all the evidence and have adopted this method of managing the third stage of labour and are referring to this practice as delayed active management.

Physiological third stage of labour.

After informed choice many parents are choosing to have no drugs to aid the delivery of the placenta and allow the placenta to deliver itself. The cord should be left intact throughout the whole process with no handling, clamping or cutting. Normally the placenta delivers within the first 20-30 minutes, although some can take longer.

Lotus birth.

Some parents opt to leave the placenta and baby attached to each other until the cord dries out and separation occurs naturally. This takes a few days.

 

Farrar D, Airey R, Law GR, Tuffnel D, Cattle B, Duley L. Measuring placental transfusions for term babies: weighing babies with cord intact. BJOG. 2011;118:70-75.

Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 2011;343:d7157.

Andersson, O., Lindquist, B., Lindgren, M., Stjernqvist, K., Domellöf, M. and Hellström-Westas, L. (2015). Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age. JAMA Pediatrics, 169(7), p.631.

NICE (2014) Intrapartum care: care of healthy women and their babies during childbirth.  http://www.nice.org.uk/guidance/CG190. Accessed 13th August 2016

 

 Amanda Burleigh. Aug 2016.

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#MatExp evaluation – it is official. #MatExp rocks!

We are delighted with this evaluation report, compiled by the London Strategic Clinical Network (Maternity) summarising the outcomes of the original five pilot workshops across London.

235 staff attended (in addition to women and families using services) .

Highlight: “93% of attendees said that the workshop changed the way that they think about maternity services and have spoken about seeing situations from new perspectives, thinking differently and reframing their actions. Attendees have commented on this positive shift in their perceptions.”

Link to evaluation report: Whose Shoes report Maternity SCN

MatExp poster - RCOG conf

MatExp RCOG Poster

Other key quotes and testimonials:

“Whose Shoes?® brings people together to have conversations that matter, the resources stimulate thoughts which lead to new insights and importantly to actions through the power of human connection and the use of narrative. The energy generated is tangible during the events but it’s sustained long after as the creativity of both the public and professionals in unleashed. I’d really recommend the approach as a vehicle for any service committed to ongoing improvement”

#Hellomynameis… Kath Evans, Experience of Care Lead (Maternity, Infants, Children and Young People), NHS England

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Gill2

” Whose Shoes?® is a creative opportunity to engage staff, women and patients in a process of improvement and enlightenment, the Whose Shoes?® #MatExp social movement for change was used in our failing maternity service to better understand the experiences of women, their birth partners and our staff.  The creative energy and ideas generated during our session were directly developed into practical actions and we have subsequently used the model of engagement in other clinical areas.  Whose Shoes?® played an important part in our improvement journey and is having a direct impact on outcomes for women, their birth partners and our staff”

Steve Hams, Interim Director of Clinical Governance and Chief Nurse, HSSD, States of Guernsey.

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“Whose Shoes?® has been an incredible catalyst in Maternity care. 5 pilot workshops with the London maternity Strategic Clinical Network led to a tremendous ripple out with further workshops in other Trusts as well as the phenomenal change platform that is #MatExp. Actions from Kingston alone include: a graffiti board for users to give live feedback on services, decorating the maternity theatre ceilings to improve the environment for women undergoing Caesarean section (CS), optimal cord clamping and skin to skin at CS; the list is endless. We have also used Whose Shoes?® successfully in other areas of Kingston hospital. #KHFTWhoseshoes, improving staff attitude & environment and patient experience in our main operating theatres and having a drop in session on administration at our Trust Open Day”.

Florence Wilcock, Consultant Obstetrician Kingston Hospital NHS Foundation Trust, Chair of London Maternity SCN maternity experience subgroup.

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#MatExp poster!

MatExp poster - RCOG conf

Launched today. ‘#FabObs Flo’ Florence Wilcock a.k.a @fwmaternitykhft is at the World RCOG Congress in Birmingham, proudly launching our collaborative poster. Follow  on Twitter. The poster tells the #MatExp story!

Download it here: MatExp RCOG Poster

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The Flaming June of the future

A blog post from #MatExp founder Florence Wilcock.

Flo

Remember #Flaming June? This time last year we asked you to wake up, light the fires and take action to improve maternity experience. We gave you a template and asked you to share your action selfies with us. There were many resulting actions spilling out in all directions & across many geographical areas, some big and some small, some simple and completed, some complex and ongoing. Major highs were the birth of this wonderful MatExp.org.uk website and founding of the MatExp Facebook group. This June will I’m sure be no less exciting. From my own perspective I am taking a #MatExp poster to the RCOG world congress, we are hosting a stand & speaking at the London labour ward leads meeting, and of course we are in the middle of our new project ‘Nobody’s patient’ MatExp 2. I know there are two #MatExp Whose Shoes? workshops planned in June: Homerton & Colchester, the latest Trusts to jump on board, following fast in the footsteps of Cumbria last week. #MatExp certainly never stops moving and I know many of you are busy at work on numerous actions in all sorts of directions. Fabulous stuff!

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I have written a few reflective blogs in the past to look back and take stock of what we have achieved since #MatExp started in October 2014, but for a change this time to mark the anniversary of #FlamingJune, I thought I would instead focus on the future. So here goes!

Flaming June 2017! My hopes:

A year is not long in terms of institutional change especially one as large as the NHS. My hope is that by next June we will have developed robust foundations with which to undertake the work to implement the National Maternity review five-year transformation. The NHS England Maternity Transformation board will be up and running, having fully embraced genuine co-design so that women are driving & leading the national changes in maternity services. Women will be embedded top to bottom or rather as I prefer bottom to top, through involvement at all levels via MSLC, MatExp, & other local and national groups. The seven personalisation maternity vanguards will role-model collaborative working with women and families.  NHS England will support and strengthen this approach by encouraging sharing of best practice and ideas, linking those areas where women’s leadership and involvement is already embedded with those areas where there is more to do. The transformation board will be promoting cross boundary working across disciplines & geographies with much more emphasis on the need to share good practice so that this is becoming expected routine practice. Every organisation involved in delivery of maternity care will be expected to have a Maternity champion on the board. The National maternity transformation board will support these champions gathering them together to exchange ideas and encourage shared vision and purpose twice yearly.

better births

For a true transformation to occur bravery will be essential. So I hope in a year we will be developing collective bravery. Professionals will need to be brave enough to let go of organisational institutional anxiety, we will need to be thinking about working very differently and we need to acknowledge this will be very difficult for some of us. We will need to support one another and openly listen to those anxieties and difficulties so that we don’t leave people behind. We need to retain quality whilst undergoing transformation, keeping the essentials of safety & experience stable on a background of turbulence. We need to be brave enough to fail. We will need to plan and test innovative co-designed solutions and we will need to learn from this what works and what doesn’t, modify and try again. We need to value and support one another whilst being brave enough to take the opportunity to transform care. If we do this collectively we will be successful.

A key part of the transformation planning will be to focus on individualised care for all women. Women with pre-existing conditions or obstetric complications in pregnancy will not be marginalised or feel discriminated against by the focus on continuity & personalisation. Their need for midwifery support is just as great and they should not be medicalised. Alongside the transformation board, the national programme of improvement of perinatal mental health will be a step closer to being properly funded, with appropriate care provision planned in all areas so that the current postcode lottery is coming to an end. My hope is that maternity and mental health leaders have become well integrated through the regional networks, establishing relationships so that there is more joined-up thinking, treating women and families holistically rather than separating mind and body.

In a year, the Department of Health will have finished a review of funding, recognising the fundamental need for obstetric care, neonatal units, intensive care etc. which carry fixed costs and need properly funding. These costs must not be destabilised by the desire to move to a more community based MDT approach. The DH will have created a viable plan as to how the tariff will work to support the transformation and provided adequate funding for the changes to be sustainable.

To achieve these aims by next June is going to take collective purpose and compassionate leadership. By leadership, I do not just mean those traditional leaders at the top of organisations and departments; everyone has a role to play. Healthcare professionals can recognise and support those who are finding this difficult as well as encourage and enthuse those that are ready for change. How aware are we as a workforce of the changes that are coming? How involved do we feel in shaping those changes? Having those conversations in hospitals, in community clinics on a daily basis will help people see the vision and feel they can help shape the changes. Transformation will become an opportunity and part of our jobs, not a threat externally imposed.

Women and families also have a key role in helping and supporting professionals though conversations either one-on-one or at more formal forums, MSLC, birth forums, maternity networks and so on. When women ask for things staff usually respond, so women have a key role not only in shaping the changes but in supporting and encouraging those trying to implement them. We have already seen this approach work in many ways in #MatExp, women asking for skin-to-skin in theatre or optimal cord clamping are two simple examples.

The National Maternity review itself outlines the need for individual responsibility by both healthcare professionals and the women and families in shaping the future, calling for a grassroots movement to improve maternity care. We are that movement; in a year I want to continue to see #MatExp grow and thrive. We need to continue as individuals taking those little steps and actions every day. Together we can own this change.

FlamingJuneposter

 

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