I am an avid follower of #TheObsPod and I was excited when #FabObs Florence Wilcock, who tweets as @FWmaternity, said she was producing an episode around disability in pregnancy. You can listen to it here: Episode 56: The Obs Pod – Maternity Experience (matexp.org.uk)
I found it really beautiful and it gave rise to so many thoughts. Wheelchair-user Emily Yates and her partner CJ decide whether they want to be parents and what it would mean for them. Practicality and perception.
I enjoyed it so much, it prompted me to write a few reflections:
What amazing parents these two would be – their strong relationship shines through. I love the humour, the depth of thought about the stuff that matters without overthinking the stuff that doesn’t; the sheer humanity
What a great way to explore a topic in depth, looking at it from different perspectives. Being real. What if Emily ended up as a single parent? What does it mean, as a disabled mother, to have a baby or for a child to be raised by a mum in a wheelchair?
Finding out how modern equipment can help. How brilliant that you can have a plastic baby delivered in a box and find out whether you can physically look after it – a bit like a Tamagotchi!
Societal attitudes. Stereotypes. The need to break stereotypes.
The Dad’s perspective. CJ is really keen to become a Dad, but will he ever be able to get out of the house again? But then don’t ALL would-be parents worry about how much their freedom will be curtailed.
Making clear that it is not all about worries that arise disability, but verbalising the worries all new parents have – how will I feel about the house being covered with poo and milk?
Availability of information. Why is there so little information to support disabled parents? What can we do about that? I’m sure some of our #MatExp community can make some good contributions here?
What an amazing series this BBC Sounds is – how lovely to dip into such a well-made piece of active research and get insight into other people’s lives.
Proud that our very own #FabObs Flo was the consultant obstetrician helping the couple on their way. So important to explore realistically what would be involved medically and find ways to support people to live their lives to the full and fulfil their dreams.
A really uplifting experience listening to this, and I wish Emily and CJ well with whatever life brings to them.
Ever since Flo first phoned me, back in 2014, asking ‘if Whose Shoes would work in maternity services’, I have been impressed by her person-centred approach, her ability to challenge the status quo and push boundaries and to work WITH women and families. She lives and breathes her powerful ‘Wrong is wrong …’ mantra.
‘The Obs Pod’ will appeal to everyone who has an interest in maternity services. Everyone will be able to take something away from each episode, due to Flo’s wide-ranging experience, gentle reflective style and ground-breaking practice.
Gill Phillips, Creator of Whose Shoes? and co-founder, with Flo, of the #MatExp social movement
As a young Mum who was totally blown away by the inspirational obstetricians who delivered my baby nearly two years ago, I am excited to start following ‘The Obs Pod’. The first episode was fantastic; so interesting and captivating. I am sure the podcast will be hugely popular with pregnant women and maternity staff alike, along with so many other people who will find it fascinating to gain an insight into the thoughts and experiences of someone who shares the beauty and intimacy of pregnancy and birth as part of their working life.
Jenny Thirlwall, young Mum and member of #MatExp community, West Midlands
One of the things I have enjoyed the most over the last five years of #MatExp is the opportunity to get creative. From being ‘just’ an obstetrician, I have branched out and added: writer, poet, facilitator, film maker, speaker, campaigner to name just a few new skills.
Gill encouraged me to write a blog. I promised my husband it would be just the one, resulting in a nickname now from Gill ‘One blog Flo’. as I have lost count now of how many I have actually written after dipping my toe in the water.
I’ve enjoyed making Steller stories after a quick demo on a train journey, particularly our #MatExpAdvent series and my Nobody’s Patient monthly project reports. I have made videos, my contribution to our series for #MindNBody launch being one of my favourites, reading my poem ‘Reassured’. All this is alongside my day job and I find these creative outlets re-energise me, develop me and feedback into my day to day working in maternity care.
In December, I was lucky enough to meet Natalie Silverman @FertilityPoddy at RCOG women’s network meeting in Manchester. https://www.thefertilitypodcast.com/ She talked enthusiastically about podcasting. She made it sound both interesting and achievable. Something that wasn’t too challenging but that might reach a different audience. She was inspiring and willing to offer advice. I went home enthused.
I spent the next couple of months thinking and exploring, I decided I have things I would like to share. Adam Kay’s book ‘This is going to hurt’ has been a runaway success, but I want to voice a different perspective of the maternity world. One that would be accessible to women and staff alike. One that might ignite change and action as well as entertain. So, I have rolled up my sleeves, listened to a podcast series on making a podcast, taught myself the lingo, attempted the editing and technical bits and loved every minute.
So here goes, I am launching my next adventure: The Obs Pod. I hope you enjoy listening as much as I am enjoying making it!
Here are the episodes so far and new ones will automatically be added here. If you wish to access the programme notes Florence refers to each week, find the episode you are interested in on The Obs Pod (buzzsprout.com):
We are living in extraordinary times. Hardly any of us have ever faced the likes of this before. We all react to the stress and anxiety in different ways as we make huge adjustments to our daily life.
I want to reassure women, we’ve got your back. Each person in maternity services is working hard to try and keep mothers and babies safe. We need to care for women with all the normal medical conditions, complications, anxieties and social situations. Then we must multiply that by two to think of how we would manage all the same problems if the woman had Covid19. Then we must add in what if she is in isolation, what if her partner or her child has it? Then we must add to the equation: staff being ill, in isolation or unable to work due to pregnancy or a medical condition.
We have new procedures for almost everything; protective equipment is not a trivial affair, we must learn how to don and doff correctly to protect ourselves and the women we care for. We need distinct levels of protection for different circumstances. We have turned our rota on its head; some of us have been deployed to other wards and areas. We now have the rota, the backup rota and the back up back up rota, all to be certain we will have the people you need to care for you. We have national and local guidance changing almost daily. We are fortunate that the RCOG & RCM are updating guidance frequently – this is helpful for us & the women we serve. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/
So when we have to make difficult choices that we never imagined would be needed, please be tolerant. We have to plan for every situation meticulously, not only within our own service but within the health economy as a whole and we have to take decisions at an accelerated rate, the likes of which I have never experienced. We bear in mind not only the impact on individual women and the maternity population but also the surrounding community.
When a woman comes into hospital, she will be greeted with care and compassion and kindness. We know this is a challenging time to birth a baby and become a parent. We may be wearing masks and gloves, but we are there behind them with hearts and minds to do the very best we can. We are fighting to protect the things we know are important. We are encouraging you to come for your scans and appointments that are essential and adapting to contact you by phone when less important to see you in person.
We are one of the few parts of the organisation maintaining a degree of normal outpatient care. Pregnancy and birth can’t be put on hold. Many of us have set up specific Covid pregnancy helplines to answer your questions and are working hard with local Maternity Voices Partnerships to give women the information they need.
We know for some, life at home is increasingly difficult. School, childcare, work has all been thrown in the air let alone worries about other family members, food supplies and money. As NHS Maternity workers, we are giving all that we can give. When we talked at work about the NHS #ClapForCarers, most of us missed it. We were too tired, working or busy feeding our families. Yesterday in my clinic, a few women ‘gave back’. Just a simple ‘how are you?’, or ’thank you for being here’ is enough. We don’t need you to clap us, we just need you with us, together to get through this.
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…
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 126.96.36.199 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.
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
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.
‘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!
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.
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.”
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.
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
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”.
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:
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.”
I was asked to do a talk to student midwives at Salford University in January on the topic of “Women’s Voices” in maternity care. As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience. “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.
So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the sixth of those. This is Carolyn Johnston’s experience as an anaesthetist – thank you so much to Carolyn for agreeing to write for us. You can read the other blogs in the series here:
And yes, I will be doing a “Men’s Voices in #MatExp” series too. Because this campaign is about all voices.
Carolyn is a consultant anaesthetist in St George’s hospital in London.
Anaesthetics is usually the biggest department of doctors in most hospitals. We cover services including intensive care, operating theatres for all specialties and patient groups, resuscitation teams, pain management, and many other areas as well as maternity care. For those of us with a special interest and training in obstetrics are usually on the maternity unit for the day, but on other days we may be working on general (abdominal) surgery, transplant or any other kind of surgery, intensive care or whatever our other specialty interests may be.
In our unit, my day starts with a handover from the night team. The registrar (senior doctor in training) who has been on the maternity unit overnight tells us who has had anaesthetic input with pain relief (usually epidurals), any women who have been to the operating theatre and require ongoing care and highlighting anyone who may require extra vigilance during the coming day. This might be because of a pre-existing medical issue or developments in labour that may make care more complex. Because all anaesthetists have training that includes caring for people who are critically unwell and are part of resuscitation teams, we have the skills to help the maternity team care for lots of conditions that maternity teams may see very rarely (like heart disease) or those that are more common but might be serious if not treated early (like infection/ sepsis or heavy bleeding).
We also start the day by checking our equipment in the operating theatre and emergency medications. We must be ready to move at a moments notice if the situation arises, for urgent surgery or some other intervention, as we all know, maternity situations can change rapidly! These are scenarios we practice and refine until we can do them as safely as possible. Safety is a key part of anaesthetic practice, in our training we learn a lot about teamwork, safety theories such as ‘human factors’ and communication, and we check and practice a lot, so when we need to act quickly we can do so safely.
We will be involved in any planned (elective) caesarian sections during that day, in my hospital there are usually 2 or 3 cases planned per day. It must be so intimidating for a woman to come to the operating theatre; such a foreign environment and the idea of surgery whilst you are still awake must be so daunting. And then of course the nerves and excitement about finally meeting your baby! I see it as a big part of my job to help make that experience as positive as it can be, and help make women and their partners feel welcome, secure and hopefully even relax. Maybe even some skin-to-skin contact in the theatre.
Maternity work is very different from all other anaesthetic practice because unlike most of our other work, our patients are (usually) awake. This adds to the challenge: undertaking potentially difficult anaesthetic procedures, communicating with the theatre team, maintaining safety by monitoring and reacting to any changes in your patient’s condition but all whilst being mindful that the patient and her partner have holistic needs. Reacting to these needs and helping them to feel safe and secure is very important. There is always a balance to be struck with maintaining our best and usual practice for safety, and providing individualized holistic care. I think this is best achieved by talking and understanding each other’s perspectives. Perhaps we don’t do this enough.
We will, of course, respond to any requests for pain relief for epidurals, which is what most people think of when they think of anaesthetic involvement on delivery suite. It can sometimes be the case that women is distressed, distracted or even scared; so there is a real need for thoughtful communication and co-operation to help her and undertake the epidural safely. This balance of technical and people working skills is a common theme for us in obstetric anaesthetics.
I am lucky that our maternity team values co-operation and team working, and anaesthetists are an important part of that. It isn’t always the case that we are fully included in the team, and this can be a real source of frustration, because so many patients tell us our involvement is very helpful. We have a reputation (unfairly?) of being the epitome of intervention, so I guess we aren’t welcomed by some who hold strong views that birth should be natural. I have no desire to force my interventions on anyone- I would much rather put my feet up! Ultimately, I think the woman can make up her own mind, and as we pride ourselves on knowing the evidence, she should always get impartial advice about risks and benefits from an anaesthetist.
I’ve been trying to avoid the word ‘risk’- I know it’s becoming unpopular in maternity discussions. There is no avoiding it: anaesthetists deal in risk. We train and work in very high-risk areas including emergency surgery, trauma teams, heart surgery, intensive care and in those roles we’ve all seen someone die in front of us as we care for them. Anyone we look after is a patient, and rarely a client- it’s hard to switch this off when we come to maternity and so we often use terminology and even a more risk-based attitude that can clash with the modern ethos of maternity care.
I guess the solution to improving this is to talk more- to all our colleagues in maternity care and to our patients- we all have the same aims and aspirations to provide the best care for healthy happy mums, dads and babies. We also have a reputation for loving coffee, so my suggestion is to grab an anaesthetist on your precious coffee break and ask each other: “why are we all here and what skills do we bring to make that happen?”
I was asked to do a talk to student midwives at Salford University last month on the topic of “Women’s Voices” in maternity care. As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience. “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.
So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the fifth of those. This is Ruth-Anna Macqueen’s experience as an obstetrician in training, and it includes an introduction and follow up comments from #MatExp founder Florence Wilcock. Thank you so much to Ruth-Anna for agreeing to write for us. You can read the other blogs in the series here:
And yes, I will be doing a “Men’s Voices in #MatExp” series too. Because this campaign is about all voices.
Florence Wilcock writes:
“One of the strengths of #MatExp is to try and hear all voices with respect and understand different perspectives so that we can work together to improve maternity experience.
Obstetricians have been an especially hard group to involve , I have written before about the traditional ‘bad press’ we seem to receive. I included it as a topic in the #matexpadvent Steller series you can read it here https://steller.co/s/5AduBaxWL6v
I am therefore especially delighted to introduce a brave #FabObs blog, one of a couple that are hopefully coming our way. Some of this may be distressing, some of it may be unpalatable but I ask you to take a deep breath challenge your assumptions & read! Don’t ‘bash’ the author she is giving you a peek into her world, a world fairly typical of many obstetricians in todays’ NHS . Take this unique opportunity to have sight of what it is like to be in ‘our shoes’ that way we can have the difficult conversations that move us forward.”
My name is Ruth-Anna, I’m 32 and a Mum of two busy, lively and opinionated little people aged 2.5 and 5. I’m also privileged to work as a doctor in obstetrics and gynaecology. My official title is ST5 doctor, which means I’ve been specialising in obstetrics and gynaecology for 5 ‘years’ (after 6 years at medical school and 2 years of moving around specialities). However it’s actually nearer 6.5 years since I started specialising, because of having time out for having babies, and working part time (I work 35 hours a week and spend two days at home with the kids). At the end of my ST7 ‘year’ of training, all being well, I’ll be able to apply for jobs as a Consultant but right now that feels a long way off!
This is a day in my life… (all events and women are fictionalised, of course)
My alarm is set for 6.45 but the kids usually wake me up first. I get up & dressed, grab some breakfast (if I’m organised enough!) wave goodbye to the kids & husband and jump on my bike. It’s a Saturday so the cycle into work is pleasantly peaceful and I enjoy a bit of headspace. My job is incredibly varied and over the course of a week I could be seeing women in antenatal clinic, gynaecology clinic, on our day assessment unit (walk in for pregnant women with concerns about themselves or their baby), operating in gynaecology theatres, scanning women, looking after women who are inpatients for any gynaecological or pregnancy-related problems, seeing women in A&E with acute gynaecological problems, or covering the Early Pregnancy Assessment Unit.
Today, however, I’m working as the Labour Ward ‘registrar’. I’ll be working with an ‘SHO’ (in newer terminology, this could be an FY2, an ST1 or ST2 doctor), who may or may not be specialising in obstetrics and gynaecology, as well as my Consultant.
I’m in work by 7.45 and change into my scrubs, to head into our handover meeting for a prompt start at 8am. All the midwives, obstetricians and anaethetists for that day on Labour Ward are there. Our night team counterparts inevitably look pretty knackered and relieved to see us.
Some days we take over and there are only one or two women on the Labour Ward but today it’s a busy one. As we talk through the women, one by one, I’m thinking what the risks might be for that woman and baby, predicting and preventing any problems and pre-empting potential issues. Hopefully none of those will happen but our job is largely about predicting problems that never happen, so that we can be prepared for when they do. Even so, a day on Labour Ward is unpredictable and filled with surprises. My current hospital saw around 6000 babies delivered here last year and it serves a fairly ‘high-risk’ population, with above average numbers of women with a high BMI, older mothers, women who may have come into the UK recently, women with multiple pregnancies or concurrent medical problems. We also have women who are transferred in to us from other places where the NICU or SCBU don’t have the facilities to look after the smallest or sickest babies.
Women expected to have totally uneventful labours are normally on our Birth Centre and I won’t generally be involved in their care unless there’s an issue that the midwives ask me to help with. Myself, the Consultant, SHO, the Anaesthetist and the Labour Ward Co-ordinator (Midwife in charge) do a ‘ward round’ of all the other women – to introduce ourselves, find out more about her and how things are progressing, and make a plan, if anything else needs to be done. This morning there are 12 women on Labour Ward. The first woman we see had a Caesarean section overnight and lost a lot of blood. She’s having ‘high dependency unit’ care and is currently having her third unit of blood transfused as she had a very low haemoglobin level due to the blood loss. We assess whether she has had enough blood replaced, whether there are any signs of further bleeding, and whether she needs any further treatment. She’s understandably shell-shocked and we go through the events of the night with her and her husband. Her baby was taken to the NICU and her priority is getting well enough to get into a wheelchair so she can go and see him there.
Next we see a woman who’s tragically had a stillbirth. She attended the day unit at 38 weeks into a normal pregnancy with reduced fetal movements, and it was confirmed the baby had died. Her labour was induced yesterday and she’s spent the night trying to come to terms with what has happened. Understandably she has lots of questions for us, which we do our best to answer. I offer her some medication to suppress her breastmilk production and give her some information to consider about a possible post mortem examination for the baby. We offer her the choice of going home today or staying another day and she will think about it and let her midwife know.
We complete the ward round, seeing a woman with a straightforward labour who is on the Labour Ward only because she has an epidural, a woman who previously had a Caesarean but is in spontaneous labour and all is well, a woman who is being induced for a post-dates pregnancy and a woman who has been admitted in possible preterm labour at 28 weeks.
The next few hours is a whirlwind of emergency buzzers and bleeps. Another woman has been admitted from the day unit – she’s had an uneventful pregnancy so far but at her midwife appointment today at 32 weeks her blood pressure was found to be dangerously high, with protein in her urine. Her midwife suspects she has pre-eclampsia and has sent her in to us. She needs urgent assessment my myself and my anaesthetic colleague, a cannula (drip), bloods taken, and medication to lower her blood pressure. She starts complaining of a headache and when we test her reflexes they are abnormal so we also recommend that she starts another medication (magnesium sulphate) to reduce the risk of having seizures. We need to see how she responds to the treatment but it’s likely we will need to deliver her baby imminently to treat the pre-eclampsia, so we also recommend the first of two doses of steroid to help mature the baby’s lungs. Her midwife calls the Neonatal team to check that our NICU have a cot available for this premature baby. She also asks them to come and speak to the woman to explain what to expect if her baby needs to be born prematurely. I perform a scan under the supervision of my Consultant which shows the baby is small and its fluid is reduced – this is a common effect of pre-eclampsia. We ask her not to eat and drink in case the baby needs delivering imminently (if she needed a general anaesthetic it’s important to have an empty stomach).
I leave my SHO administering the first dose of the magnesium sulphate as the Co-ordinator calls me to see a woman who is in the second stage of labour (fully dilated and pushing) whose baby is showing signs of significant distress. I assess the woman, and the fetal monitoring, and explain that I would recommend an instrumental delivery, to which she agrees. As the baby is already quite low in the birth canal I decide this can be safely achieved in her delivery room, so after giving an injection of local anaesthetic to block the my SHO and I perform a ventouse delivery and her baby is delivered with no complications.
I finally see a woman who has been waiting several hours to progress to the next stage of her induction of labour. We haven’t been able to proceed with things as we would have hoped due to the other situations that have arisen and the effect on available staffing levels. I explain this to her but she’s understandably upset and frustrated, as well as exhausted, and I leave the room feeling pretty downheartened.
It’s 3pm and I suddenly realise I haven’t eaten anything so grab a sandwich and a drink before heading back to see the unwell woman with pre-eclampsia. Her blood pressure still isn’t under control despite high doses of medication and my Consultant decides that we can’t wait any longer and that she will need to have her baby delivered today. At 30 weeks in her first pregnancy, with a growth restricted baby, the team decide that Caesarean will be the quickest and safest way of delivering her baby. She’s shocked – it certainly wasn’t what she was expecting when she headed to her midwife appointment that morning, but her partner has now arrived and she is willing for us to proceed. I talk her through the operation and explain the risks and benefits, before she signs a consent form. The Co-ordinator speaks to the theatre team to prepare everything, as I call my anaesthetic colleagues. Her midwife gives her ‘pre medications’, tight stockings to wear and gets scrubs for her partner to wear.
While with my sick woman I was asked to attend the Birth Centre to check whether a woman who has just delivered has a ‘second degree’ tear (that can be sutured by the midwife in her room) or a ‘third degree’ tear that would need to be sutured in theatre by me. As the anaesthetists perform their anaesthetic for the woman in theatre, I finally make it across to the Birth Centre and thankfully for the woman it’s a second degree tear. I apologise she’s been waiting so long for me – she’s lovely about it but I still feel bad.
I’m bleeped from theatre to say the spinal anaesthetic is working and they are ready for us to start the operation. I do her Caesarean, with my Consultant supervising in view of how sick she is and the fact the baby is premature. Thankfully it is an uneventful procedure and the baby is born in reasonable condition, although he still needs to go to the NICU. His mum comes back to the Labour Ward as she is still unwell and the next 24-48 hours can actually see a deterioration in her condition.
We sit down for a quick cup of tea and I feel guilty I haven’t tackled any of the computer-based tasks I have piling up, and the audit I’m trying to finish before my appraisal next month. Still, they’ll have to wait for another day. I check my phone and see 15 messages from home – thankfully it’s nothing urgent; they are just photos from my husband of the family party he and the kids are at today.
The night team start to arrive and I feel relieved. Today I’ll manage to get away pretty much on time, once we’ve finished handover. I need to send some electronic tickets to my Consultant so she can sign to say what she’s witnessed me doing today, for my appraisal. I know that if I don’t do it now I’ll forget. I’m out of the building by 20.45 and head home to wolf down the dinner leftovers. I spend the cycle home thinking about the women and babies I’ve looked after today, hoping all will be well, and wondering what I could have done differently. After 8.5 years as a doctor I’m pretty good at trying to leave all those thoughts behind – at least temporarily – when I put my key in the lock, although I do drop my night colleagues a quick text before bed to ask how the woman with pre-eclampsia is doing. She’s stable and I finally let myself switch off. Tomorrow is one of my days at home with the kids and I’m looking forward to taking my 5 year old to school and my 2 year old to toddler group.
Florence Wilcock writes:
“When I first read the blog I felt it pretty accurately captured a fairly ‘standard’ day on labour ward for an obstetrician. I recognized it absolutely & have spent many days similar to this over the years. The multitasking, prioirtising, constant juggling of clinical situations is quite typical. Some of it may feel dispassionate and lacking emotion, that doesn’t mean that the author doesn’t feel anything or that she doesn’t treat the women she sees with compassion and care it just means there is an element of self-preservation to enable one to take split second clinical decisions we need maintain an exterior calm. It is also essential so that we are not sobbing halfway through the shift or at the end of the day it enables us to be resilient and get up and do it all again the next day or to care for our own family. Imagine what it would be like if you were trying to do this job pulled from pillar to post how would you feel? This is where working as part of a fantastic multidisciplinary team becomes important, those of us that are lucky have wonderful midwives, nurses, midwifery assistants alongside us. If we are less lucky or those relationships are adversarial that can be very difficult as the support isn’t there. No obstetrician sets out to hurt or upset women or become a barrier they may be under huge pressure, having a bad day, feeling scared of that responsibility, worrying about an exam or appraisal. We are human too.
There is no fluff here , this is obstetrics in reality. There are one or two particular clinical situations that may distress you: such separation of mother and babies is never ideal & making the focus getting a mum to see her baby in NNU sounds so simple but can be harder than it sounds if people don’t work together & make it happen, A bereaved mum seemingly given cursory information and a very short hospital stay after such a life changing event is hard to read but sadly is the current reality , we know this needs improving hugely with better support during and after and a birth environment separate from the main maternity wards. A shocking sudden decision to deliver a baby preterm at 30 weeks. It is hard to write and hard to read and some elements can’t be changed they are clinical reality but amongst that the words we use, the understanding we have of how it might feel both for families and those caring for them there are plenty of things that can be done to improve care.
Look at the campaign to have a bereavement suite in every maternity unit started by Ben Gummer MP.
Think about what language you are using in that short time you have to see someone.
Think about the importance of the team to the obstetrician often junior on whose shoulders there is massive responsibility; if you are a midwife or other healthcare professional support them and work with them.
Think about self-care. What is available to you as a healthcare professional at your Trust, have you had a break, did you eat or drink today? Looking after yourself is the first step to being able to look after others.”
I was asked to do a talk to student midwives at Salford University last month on the topic of “Women’s Voices” in maternity care. As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience. “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.
So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the fourth of those. Unlike the others, this one is anonymous. You can read the other blogs in the series here:
And yes, I will be doing a “Men’s Voices in #MatExp” series too. Because this campaign is about all voices.
I have been a sonographer for 13 years, and I’ve asked to be anonymous because I want to be honest, and I don’t think my managers would appreciate every aspect of this.
I’ve worked in a few different NHS trusts over the years, and now work in a small, rural hospital.
I do both pregnancy and non-pregnancy scans, and enjoy the variety in my work. There are more complaints around pregnancy scans, but my overwhelming impression of pregnancy scans is that it can be very hard to meet parents expectations in the NHS.
For routine, screening scans parents generally expect the reassurance that all is well, without necessarily fully considering that the scan findings may be devastating. I have a moment with the notes (hopefully, if the mum remembered them) to quickly obtain a bit of history which may give me an indication that the parents may actually be extremely anxious- but some things aren’t written down, and I struggle to determine the body language differences between anxiety, or that I’m interrupting an argument between the parents, or there is worry about something unrelated to the scan, all while the mum may have a desperately full bladder.
Once the parents are in the room, its usually only a minute or so before the lights are dimmed, if they were ever turned up in the beginning. Myself, and older colleagues have noted how our eyes adjust more slowly to sudden darkness- I used to have no trouble going from bright light to darkness in a scan room, but now I’m older I can’t see very well when the lights go off- not very helpful for the scan, but keeping the room dim all the time adds more barriers to communication.
I have been scanning a number of years, but I only learned a couple of years ago the importance of eye contact in those first seconds of the scan. I think if I’d learned that sooner, I could have easily made more clients feel more welcome. Right at the beginning is when I’m usually checking I’ve got the right patient on the computer screen or paper details, probably staring at a screen, and I expect I really came across rushed or off-hand, before I knew better. I have asked for customer skills training, but the training I have had has been more about dealing with challenging behaviour, and when I asked for training around breaking bad news I ended up on a course which was more about end of life conversations, which was interesting, but geared to spending a lot more time setting the scene for breaking end of life news without interruptions, rather than sonographers specific task of breaking bad news very quickly, with little warning.
Something that comes up time and again, is how rude sonographers are, prodding bellies and saying how fat our clients are. I’m sure a lot of us could gain from some training in customer service, but there is a reason behind the hurtful words. A scan can be uncomfortable- pressing on a full bladder isn’t great at the best of times, but sonographers end up pressing harder on larger tummies trying to see the detail that is required for that scan. We try not to, not only because we don’t intend to hurt our clients, but most sonographers are in physical pain scanning and pressing harder makes it worse. We are our own worst enemies at times though, because we concentrate so hard on what we are looking at on the ultrasound screen. So, brains may not be fully engaged on saying tactful comments, we may not realise how hard we are pressing (I rarely notice the pain I am in until I finish up the scan, and realise I shouldn’t have pressed so hard).
At the end of the scan, the other vital part of our job is communicating the findings, which usually involves giving a copy of the report to the parents in their notes.
We have to explain what limitations there are on the scan- have I seen everything perfectly like the text books? Usually not, and then we have to explain why. I’m not aware of too many people feeling insulted when its baby’s position that is a limitation, but the various ways we say we lost detail because the sound waves were travelling further (which happens if there is a layer of fat in the way) can be perceived as insulting. I know in my trust the midwives try to mention this to larger ladies before they come for any scans, and I feel that being forwarned helps when the sonographers then are repeating something already said. It doesn’t seem too shocking if I’m trying to explain the extra layers around where I’ve been scanning have limited what I can see, if its already been mentioned, hopefully by someone they trust. Sometimes that hasn’t happened, or the parents haven’t taken it on board, and some of us sonographers manage to say things quite badly. Probably in fear of saying it badly, some of us don’t mention it all, and leave it to the midwife to explain the terms on the report, which can be just as upsetting.
Sonographers sometimes across as grumpy, and one possible reason is that we are usually rushed. My day in obstetrics is divided into 15 minute slots- with double slot for first trimester screening and the 20 week anatomy / anomaly scan (different places give it slightly different names), and a bit extra for twins. In that time we really need to allow about 5-7 minutes for trying to document the findings accurately, and producing a copy for the parents to keep in the notes (IT technical issues can easily double this, and are a regular problem where I work now).
Some scans take longer than the allotted time, and sometimes in that short time interval I have to give devastating news, try to be supportive but also find another health care professional to handle the initial grief and arrange what happens next. With no time to reflect I must carry on and scan a lady who might have been kept waiting longer, with a desperately full bladder. I try hard, but part of me is probably still processing the blow I dealt the previous lady, and hoping that while distracted/upset I am doing my job well enough for both clients, and I really hope the lady who has been kept waiting is kind, because I can’t tell her any of this.
The 15 minute break slot I get each list is rarely a break, but just a little leeway so I can try to take a minute or two extra with with each lady I meet without running too late by the end. My lunch break is officially 30 minutes, where I’d love to step outside and enjoy the beautiful grounds my hospital is in, but many days in obstetrics I barely have time to eat in the scan room, before washing my hands and continuing to run late.
I’d love to spend longer, explaining each part of the report, going into the parents particular concerns and signposting them to the appropriate person if I am not the one who can help.
Officially I need to work on my time management. I take too long, I must scan too slow or talk too much. My rescan rate is too high (at the 20 week scan, if we can’t see everything in one visit we are allowed to offer one rescan, which where I worked previously wasn’t ever counted or limited, but now I use that option too freely apparently and I must have less than 10% rescan rate), but that means I must scan for longer to see everything- it is unthinkable that I would say I had seen something when I hadn’t, but I do wonder what will happen when sonographers who aren’t as honest as I am, or feel more pressured than I do, get to this point.
I have been specifically told to talk less to parents before the first trimester screening test, because after a conversation, some mums decided against it. In my old trust we were told, as Band 7 staff in the process and the person about to do the test, that we had to be sure the ladies really wanted it- and check they have heard the potential outcomes including that the diagnostic test, with a risk of miscarriage, may be offered. Where I work now I may ask if they’ve discussed the test with their midwives, have they seen the booklet, but I must not ask enough for me to be confident about the information they have, because their community midwife takes responsibility for this.
Screening tests are an option, not compulsory part of pregnancy. Many women I meet wouldn’t dream of having a pregnancy without a scan, but its not an informed choice if the mum gets in the scan room before she realises the scan is optional-this is something that happened last week.
My personal choices around scans have changed over the years, going from wanting everything going first time around, to having none with my third. I found the anatomy scan with my second child a hugely anxious time, knowing the potential conditions that could be diagnosed, and the huge number of abnormal but unexplained things that might be seen, and of course the range of conditions that a scan would never detect.
A dear friend had a devastating diagnosis at a 20 week scan before my third pregnancy, which meant baby needed delivering at a specialist centre for the best chance of survival, and I was hugely affected by how the family were affected by the diagnosis and the stress throughout the final 20 weeks of pregnancy. Their experience and my attempts to support them made me evaluate exactly what I would gain or lose from scans in my third pregnancy, and, for me, at that time, the decision was not to have scans. The same events affected other people differently, and they tell me they wouldn’t dream of not having a scan after being involved with such a tough experience, which I can completely understand, appreciate and support. I’m not planning more children, but if I did I would have to consider it all very carefully- I don’t know if I would opt for scans or not.
In the first trimester screening scan, sometimes called the NT scan, sonographers are audited in a few different ways. Where I work we have one 30 minute appointment, and if we can’t obtain measurements that meet the national screening committees criteria, then we must offer the quad test. So, we get audited on how many ladies end up being offered the quad. We are audited that our images meet standard criteria. We are audited that our measurements fit a national expected scale- and steps are taken if we don’t meet all these criteria. It isn’t too hard to meet these criteria in a baby that is lying in the perfect position, but the position of baby is one thing outside of our control.
I imagine this scan will be around for a while yet, though I am glad to know non-invasive prenatal screening has been around in private practices a while and hopefully will become more widespread in the NHS in years to come – this blood test is a much more sensitive and specific screening tool, but it is currently quite expensive.
Something else sonographers do that causes conflict is limit the number of people in the scan room, and warn that noisy or disruptive children may need to leave. If there is an accompanying adult then they miss the scan by having to leave with the child, or the scan may be abandoned if the mum is the only adult with unsettled children. I have tried to continue to scan while a child was working very hard to stick their fingers in the fan, run around, screamed constantly, but these are situations where I have to stop before I make a mistake.
It is also very difficult to concentrate when an excited parent/grandparent has someone extra to talk to. The rare time I break the rules and allow someone extra in, I have usually regretted it. I must need further training in being politely assertive to obtain the quite atmosphere I absolutely need to concentrate on seeing all the structures I need – in the given time.
If I scan in silence, I am complained about for being too serious- so I try to keep a light hearted, pleasant line of conversation going while I stare at the screen intently concentrating, looking for potentially life threatening problems with baby. Its a situation perfect for misunderstandings.
Keeping the chatting going is much harder on those days I have a bit of a headache, or my 3 year old has had a bad night, or my 7 year old had a nightmare. I suppose I might call in sick for not being on top form, but the team I work with is so small so I know parents may turn up for long-awaited appointments and be forced to rebook, or my colleagues might try to squash extra scans in an already full list- with all the usual pressures still standing for making it a pleasant scan, not rebooking, etc. And of course, like any business, sickness records are kept and if you take sick time too often, then steps are taken.
I’m struggling at the moment. Concentrating non-stop, knowing mistakes mean huge potential consequences for families, doing it all against the clock and targets is draining me. By the end of my working week I usually feel too exhausted to cuddle my kids before I crawl into bed, unable to cook or eat tea, straight from work, hoping I can take time out of family life to recover from my week. My head hurts, I keep going faint, but the GP says there’s nothing to worry about. My sickness record is something else to worry about. I can’t cut my hours- I think I could probably cope if I were doing it less. If I could have some time for catching up at the end of my lists, I think I could do a better job.I work with a good team, but the managers don’t seem to get the pressure they are putting on us. But then, I don’t know what pressure they are under. I suspect my manager is struggling, but trying to keep it private. She is taking unpaid leave to try to keep going, but scheduling it has been almost impossible. The needs of the service come first.