Maternity Experience

Informed Choice

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

 

 

Share the Word About MatExp!

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

MatExpblogbadge

 

 

 

Share the Word About MatExp!

Women’s Voices in #MatExp – your Antenatal Teacher

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 seventh of those. This is Fleur Parker’s experience as an antenatal teacher – thank you so much to Fleur for agreeing to write for us.  You can read the other blogs in the series here:

Your Midwife

Your Doula

Your Breastfeeding Supporter

Your Sonographer

Your Obstetrician

Your Anaesthetist

And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

*********************

I am putting my head above the parapet to say I am an Antenatal Teacher.

Fleur Parker

I’m not sure why, but recently we have been getting a lot of flak.  Sometimes it feels as if everything that is wrong with birth is the fault of the antenatal teachers.  On Twitter famous names berate us and newspaper columnists lampoon us

So writing this piece is taking quite a lot of courage and I hope I can do us proud.

There are many, many antenatal teachers – those of us who work with expectant parents during pregnancy to help them prepare for labour, birth, the fourth trimester and the early days as a parent.  We come in different sizes, shapes, colours, languages and approaches.  There is not a one size fits all approach.

antenatal prep

There are three ways to prepare for labour and birth – intellectually, physically and emotionally/mentally.  In my experience it is those who prepare a little every day in each of these ways that feel most able to cope with their labour and birth experience. There are a lot of options for antenatal preparation – yoga, pilates, aqua natal, hypnobirthing, NCT classes etc.

I have absolutely no idea why I am an antenatal teacher.  I didn’t go to antenatal classes myself.  My son is now 20 and I think I’ve finally come to terms with the fact I am a Mother – I will not be the first in the queue to cuddle your newborn.   I will however, have freshly baked cake and a lovely cup of tea and all the time you need to talk, explore and work out what the £$%^@* just happened.

I support men and women, over 1,300 have attended antenatal classes I have facilitated.  First time mums, fourth time dads, same sex couples, single mums, surrogate mum and dads, young mums, old mums, surprised mums and reluctant dads.  We’ve all sat together, in a circle not knowing quite what to expect.

I have taught classes on my birthday, my husband’s birthday and my son’s birthday.  I’ve taught when I’ve been happy, sad, ill and well.  I’ve sat before a group after finding out my mother-in-law had died, unexpectedly on the operating table, on Christmas Eve and there was still four hours of a six-hour class left – and not told them because it isn’t about me.

It isn’t about my birth experience (caesarean in case you’re wondering) and there isn’t an NCT way to have a baby (whoops I’ve let the cat out of the bag I am an NCT antenatal teacher).  The way to have a baby is the way that’s right for you, in the moment.

If I have an overarching aim as an antenatal teacher it is to disrupt the story of birth.  To take the perceptions of expectant parents and give them the tools and skills to reimagine, to question and to put a story together that belongs to them – nobody else.    By the time people are having babies they have heard at least a couple of decades of birth stories – perhaps it’s Daphne on Neighbours whose water’s broke, contractions started and she gave birth ten minutes later still wearing her tights and with Bouncer the dog sniffing around.  Perhaps it’s a documentary, a soap or in films – there is a whole generation who have grown up with the story of pregnancy and birth from Twilight!

I hear hundreds of birth stories and often as I listen I’ll be thinking ‘okay, yes I could do that, it sounds hard work but okay.  I understand that and it was straightforward enough.’  But the new parent telling their story is in tears, sometimes shaking and upset.   Another time the story I’m hearing is one that shocks me, where I am, quite frankly, horrified.  In this case the mum or dad is happy ‘oh it was great, we had a chat with the Dr and decided to do this and that and when that didn’t work we went for the other – oh and the blood!’  It’s not hysteria or false memory it’s just that they were okay with their experience, it was, in the moment, entirely appropriate.

The research shows us that that is what matters to new parents.  It is less about the actual birth or in many ways the outcome but their satisfaction of their experience and perception of outcome that is most important.

There are also parents who because of the actions of others are traumatised and angry with the care they received – feeling abused and violated.  I’m not sure any of us can prepare for those eventualities.  Those are the parents I spend most time with, talking, understanding, signposting …… simply listening.

During classes we share stories, knowledge and experience.  We look at straightforward physiological birth and we look at birth that is anything but.  We think about becoming parents, relationships, cognitive, physical and emotional development of babies.  We play nappy roulette (sometimes I like to fulfil the NCT stereotype) and speed parenting.   We laugh and we cry and we eat cake.

I love my job – it is my passion and my purpose and I bring to it my head, heart and soul. I make lasting connections with people who are entering a whole new phase of life and I walk alongside them.

I don’t have the answers and I don’t always get it right.  But I have a lot of knowledge, rigorous CPD and I am an experienced and skilled adult educator and group facilitator.  But I am not the answer and I am not the problem.

MatExpblogbadge

Share the Word About MatExp!

Women’s Voices in #MatExp – your Breastfeeding Supporter

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 third of those.  This is El Molloy’s experience of supporting breastfeeding.  Thank you so much to El for agreeing to write for us.

You can read the first two blogs in the series here and here.  And yes, I will be doing a “Men’s Voices in #MatExp” series too.  Because this campaign is about all voices.

Helen.x

*********************

I am an NCT Breastfeeding Counsellor in Coventry, and a Peer Supporter on the Infant Feeding Team (run by Coventry City Council).  I sit on our local MSLC (Coventry and Rugby CCG) and was a member of the Coventry Breastfeeding Strategy Group.  I am also a Babywearing Peer Supporter for Coventry Slings, and am about to do my Consultancy through Slingababy at some point this year. Probably after I finish the dissertation for my MSc in Child Health (through University of Warwick). I also help to facilitate the Coventry NCT Birth Choices (after caesarean or traumatic birth) Group after it was set up and run successfully by one of our amazing local Antenatal Teachers.

El Molloy

This is supposed to be a blog about Breastfeeding Support. Which means it also has to be about being a Peer Supporter – and being a Breastfeeding Counsellor. And now I don’t know who knows what those roles entail, or what we do in either of them. Is there a difference? Can parents tell the difference? Do they care? To be a Peer Supporter, or a Breastfeeding Counsellor – that is the question…I think?

I make a damned good cup of tea (and coffee – because I drink a *lot* of coffee). And at a push I can do cake, but usually I have biscuits. However this is all the icing on the cake or at least bribery, to encourage new mums to come to our groups, have a drink, have a biscuit, and stay a while. Let us listen to your story. And I carry tissues in my bag – always.

Cup-of-tea-and-biscuits-327974

As a peer supporter I have had UNICEF training in breastfeeding support (for most projects this is between 6 and 10, 2-hour sessions, delivered by someone who may be the local Infant Feeding Lead Health Visitor or Midwife/IBCLC/NCT Peer Support Trainer). I am a mother who has breastfed her own children. If you want to get technical I *am* a peer supporter – I am still breastfeeding my youngest. I can walk alongside you in your journey, I can tell you that things were and are occasionally tough for me – that despite the official badge and t-shirt (purple this time round, blue before – I declined the hot pink – it clashes with my hair!) I am not an “expert”. I don’t know all the answers – and I’ve yet to meet anyone who does. But as a peer supporter I can tell you what ‘normal’ breastfeeding should look like. I can tell you that there are no rights or wrongs, except what works for you and your baby. With the caveat that baby is happy and you are not in pain. And I can offer you information about what you need to look for in your babies feeding patterns so you can feel confident things are going well.

Does Peer Support make a difference? I’d like to think so – and I can see locally that overwhelmingly most families find us useful. There are always the other stories, the one about the PS who said to use baby rice at 4 months, but that’s no different to the story about the Midwife who said baby should sleep for 4 hours between feeds, or the Health Visitor who suggested controlled crying… One poor piece of information shouldn’t tarnish a whole section of support. This is something we are seeing every day on #MatExp. There is a world of difference between midwives and *this* midwife; between Peer Supporters and *this* Peer Supporter. And the supporters are only ever as good as their training and ongoing Continuing Professional Development (CPD) and supervision.

And this Peer Supporter is also a Breastfeeding Counsellor. Specifically, I am an NCT breastfeeding counsellor. This means, for the uninitiated, that I am trained in person-centred counselling skills, that I am a sign-poster to other information, other options, other Health Care Professionals. But that always the mother is front and centre. This too means that I have breastfed my own children (for a minimum of 6 months – though extenuating circumstances may apply for others). It means that rather than the UNICEF training, I have spent 3 years distance learning through a University accredited course, writing essays, going on weekend workshops. Debriefing my feeding experiences; embedding my counselling skills in practice as well as theory, understanding and training in group facilitation (for both antenatal sessions on courses, and in running breastfeeding groups). Parents aren’t interested in the Diploma that I have, or the ongoing CPD that I have to fulfil, including regular supervision, or the fact that my CPD is specific to each of my roles within NCT. Parents just want to know what I can advise – what I can do to ‘help’. The honest answer is “nothing”. Because in either of my roles, that is not part of my job description. Advising would indicate that, again, I know best – and I do for me, but not for you. I have being trained as a reflective practitioner, and I have recently realised that I have moments of conscious and unconscious competence – I am, as we all are, a work in progress.

NCT-BF-2

If I am visiting you, or welcoming you at our group, I will sit and listen to you talk about your options, and maybe offer suggestions. We might talk about how you feel about what you’re being asked to do, until you come up with a plan that is going to work. Reading the previous blog by Maddie, some of her descriptions about working with parents in labour – asking – what do they want to do, how do they feel… This too is how we work. And the general mistrust by other HCPs feels all too real.

As a peer supporter. I might come to your house on day 1, or day 2 after your discharge. Maybe you called, maybe your midwife referred you because she thinks you need a bit more time, someone to sit while you feed, time that she just hasn’t got because her caseload is so much higher. I fill in forms, I offer to register your child with your local Children’s Centre. I will ask you how your birth was (because this might affect feeding). Maybe your Health Visitor has referred you because you are 12 days in and feeding still isn’t ‘right’ for you. Perhaps your baby still isn’t back to birth weight. We have time. I have time to stay to the end of the feed and see how your baby slips down because the cushion could be in a better place…

As a Breastfeeding Counsellor I also have time to sit and listen to your worries about how feeding didn’t work well with your older child. You might have called me because I facilitated your antenatal session; or maybe you’ve been searching on the internet. You might have called the national line, and they have given you my details. Maybe you have come to the Drop In that I run with another colleague. I might visit you at home, where you apologise for going round in circles about whatever is worrying you – but I sit and listen, and reflect your words to you, or maybe ask the one question, or make the observation, that triggers the understanding in you that your worries are not all feeding related, that you’re concerned about your relationship with your partner.

I too go home and worry; did I say enough, not enough. Did I miss a subtext. I am all too aware of the responsibilities that the midwives and health visitors have. The understaffing, overstretching. We will refer in parents who are struggling. “If you are still concerned talk to your midwife, is this something you feel you can ask your Health Visitor about…”. We will make the phone calls where we are concerned about parents mental health, those feelings where things just feel slightly ‘off’. We trust that you will support families, and we ask that you trust us to do the same. Trust that we have the experience with breastfeeding, that we can and do support mothers long after they stop attending baby weighing clinics, long after their regular assessments – all still breastfeeding. We support them to continue, and to stop when that’s right for them. At 2 months, or 2 years, or even longer.

I want (I want?) I can say it in this context… I want all women to have confidence in their decisions, and to have the right information for them to make the decisions that work for their family. Whether that is because they understand that breastfeeding past 9 months isn’t tantamount to child abuse (yep, that old chestnut); or whether it’s because I signposted her to the information they needed about their anti-depressants which meant they had confidence in continuing to feed even when she felt her world was falling apart. Whether that’s because we worked on positioning until she finally hit that sweet spot and it finally clicked that no, breastfeeding does *not* have to be painful; or whether after seeing 6 other HCPs and being told that she had ‘forgotten’ how painful feeding was, I mentioned tongue tie as another possibility, and lo and behold division did result in huge improvements. We have time, I tell the women I see, don’t worry (often as I’m glancing at the clock, thinking, I’m going to be late to my last visit, and I know that’s 20 minutes away, and it’s already 4.45pm on Friday, and I finish in 30 minutes). When baby won’t latch, or has just fed before I arrived and won’t be woken. “How have things been?” “What have you tried?” “Some parents find…” I joke that all babies sleep for me, except my own. We talk about previous miscarriages, we talk about the joy in feeding her firstborn, and the fear that it won’t work this time. That she’s been told it’s just a “small” tongue tie, but she’s worried about him swallowing blood; we talk about how to deal with engorgement, and how can she ease the cramps that accompany her let down. How can her partner bond with baby, so when can she start expressing; we talk about shared bath times, and babywearing. And how will she cope when he goes back to work. We have such a fluid society that we don’t often live close to our mothers, and can’t learn from them the way we used to. My visits span the world, from South Africa to Vietnam, to Latvia, Canada or Scotland. The accents change but the worries and fears are all the same.

It gets easier, you can do this. And particularly in the light of the media frenzy unleashed by the Breastfeeding Series published by the Lancet. We can do this. Together we can change the world.

MatExpblogbadge

Share the Word About MatExp!

WhoseShoes Confirmed That My Shoes Have Climbed A Mountain

This post is from Michelle Quashie, and originally appeared on her blog site Strong Since Birth.  Our thanks to Michelle for agreeing for it to be reposted here.

Michelle

The day had finally arrived! After contributing to #MatExp and interacting with many conversations surrounding ‘WhoseShoes’ throughout the year, I was finally going to experience the magic in real life.

Laura, the chair of our MSLC has written a fantastic post that captures the excitement of the day perfectly, you can read it here: When WhoseShoes Came To The PRUH

I was not disappointed, the day was everything I had dreamed of,  but for me it was so much more.

I was asked to open the event by sharing my Maternity Experience. I have spoke at several maternity training events in the past but my audience has always been Midwives. I was aware that this was a multi discipline training event and it was to be the first time I would share my story in such detail with Obstetricians and everyone else involved in Maternity. The thought made me feel anxious but I knew how important this opportunity was.

I had planned to stay in control and not let the emotions attached to my experience be displayed in the form of tears. It was so important to me to remain composed and in control.

My heart pounded through the showing of the MatExp film, this film moves me every time. It is so powerful and very thought provoking. Sadly I can resonate with many of the situations displayed in the film. I knew I was about to be discussing some of those memories any minute with all those surrounding me.

My name was called and I made my way to the front with my heart pounding. I decided to be honest and share how I was feeling with the room.

‘Please bare with me, I am feeling very nervous. I’m sure once I start talking I will warm up and I will be fine!’

Automatically I felt more relaxed and felt more able to share my story without the anxiety overruling my thoughts.

Michelle1

It’s amazing how every time I share my experience it comes out slightly different, or I find myself saying things that I hadn’t thought of before? I had missed a couple of important bits out but neither the less I was very happy with the way I had presented and gauging by the feeling of emotion in the room I had touched the hearts of nearly everyone around me. For the first time I was able to keep my tears to myself even though I had noted that tears were shed by many in response. The room fell silent but the atmosphere spoke volumes.

I wasn’t aware of the tweets that were being circulated on social media but looking at them them later along with the emails I had received It confirmed that my talk was a positive part of the day.

Michelle2

“Also a massive well done to Michelle for her heartfelt and emotional story, I could see it touched many people as there were certainly a few tears in the room. That took huge courage to stand there in front of so many people and share such a personal experience and to tell it so well. Huge WELL DONE Michelle.”

We began to play the the game and interesting discussions were had in response to the thought provoking questions that are key to the WhoseShoes success.

Michelle3

Some of the discussions that stick in my mind were:

  1. A woman wanted a home birth but her husband wasn’t convinced. We had discussed that there wasn’t enough support or information given during antenatal care to ensure that the couple felt safe,supported and empowered to fulfil the woman’s birth choice.
  2. Consultant Obstetricians are normally addressed by other members of their team using their title i.e., Sir, Mr, Mrs or Miss as a mark of respect. I may be wrong but it feels hierarchical, unlike the power slogan and barrier breaker behind WhoseShoes and #MatExp ‘No Hierarchy, just ordinary people’.
  3. It was also discussed that consultants were on site until 9 pm, after that they are on call for emergency situations only. Now I understand why during my appointment to discuss my VBAC, the registrar said ‘ I mean, we don’t know when you will go into labour or who will be on duty should you rupture’. I now understand that my birth choices were  influenced by staffing levels at the hospital.
  4. Other key themes were Empathy, Language, supporting and facilitating informed decision making and just how important it was for everyone to be cared for individually based on their individual situation and needs.
  5. Midwives are able to have time to build a relationship with women whereas doctors are often called for the emergency situation and do their best to resolve the medical issue as it arises. This can sometimes make it hard for them to be able to connect with the woman that they are caring for and are not always able to fully appreciate the long lasting effects the experience can have on a woman.

The day was coming to an end and Anna gave us fabulous evaluation of our morning using the comments that came from the discussion at each table. It was fabulous to visualise the discussion using the graphic that Anna had been working on through out the morning.

Michelle4

We each made an individual pledges. Here is my pledge:

“To provide a platform for women to share their Maternity experience.  I would like to ensure that women’s voices are heard as part of training and development.”

Michelle5

I am currently planning a conference called ‘Women’s Voices’. More details will be available soon.

As the morning came to an end and people were leaving someone tapped me on my shoulder. I turned round and my tummy flipped. The face before me took me straight to a place of feeling vulnerable, feeling panicky.

‘Michelle it was me wasn’t it?’

Stood before me was the registrar that I had my consultation for my vba2c with. Unbeknown to my self and the organisers we had shared the morning. I had shared an experience that changed my life but had also been a time that left me feeling scared, vulnerable, isolated and questioning my mental health. The person that was responsible for those feelings was standing here in front of me, for a moment the feelings came flooding back, I battled to keep them contained.

Michelle6

She apologised for the way she had cared for me. She admitted that she had been wrong and has since ensured that she was fully aware of her professional guidance. She was now fully supportive of  women’s choice regarding their birth and ensured me that since having to write a statement in response to my complaint, she is fully aware of the impact of the care she provides a woman.

She actually thanked me for highlighting the error of her ways promising me it had changed her attitudes. I could see that she was overwhelmed with emotion and had spoke to me honestly. She asked if she could hug me and we both held each other for comfort.

I told her that I admired her for taking the time to come a talk to me and for apologising. I also explained that I was aware that she was not entirely to blame for the care I had received and I now understood that her response to me wanting a vaginal birth after two caesareans was due to the cultural belief of the trust she worked in.

It was clear that my birth wishes would not be supported and neither would anyone wanting to support me at that time. I know this because many attempts were made to provide me with the support I needed and no one stepped out of their comfort zone to provide me with the support I needed with regards me birth choices. As a result I had no choice but to transfer my care.

She empathised and promised me that as a result of my experience things were changing.

We said our goodbyes and I was trying very hard to contain my emotion that the meeting had evoked.

A consultant midwife that has walked by my side through this maternity experience and others and who has been a pillar of support to me came to see me. ‘Are you OK Michelle?’

The flood gates open and I broke down. I couldn’t talk at that moment. I was just overwhelmed with emotion. I couldn’t make sense of it at the time but now I think I can.

That meeting with the registrar brought some closure. I admire her ability to acknowledge the error of her ways.

The meeting took me back and reminded me of the scared women I once was sitting in her office, trying to persuade her that I could give birth, pleading with them to allow me. Feeling so horrible when it was highlighted that I had never given birth and they wasn’t sure if I could. I was subjected to a number of negative comments that effected my mental well being and left me questioning my sanity. Comments that left my family feeling unable to support my decisions in fear of my safety. it was a meeting that left me feeling isolated.

Here I sat after coming full circle with the same women but this time I was a different woman. I am a now a woman who has had the most amazing journey and have achieved some incredible things;

I gave birth, not only did I give birth but I bloody rocked that labour ward!

I came back and I told the story, I sang it from the rooftops!

I learnt to believe in me and my abilities.

I joined their MSLC and contributed to so many fantastic improvements within the Maternity service.

I have spoke at training events within maternity with an aim to improve maternity care for women.

I have written and had my views published here and in The Practising Midwife .

I have contributed to #MatExp campaign and connected with some fantastic people as a result.

I have met, received support and been inspired by many fantastic people. too many to mention.

The realisation that my shoes have climbed a mountain has happened!

I received the following email from a Consultant Obstetrician following the Whose Shoes event. It confirmed that this journey has been worth every little step:

“Dear Michelle,

I just wanted to reiterate how touched I was by your story and how impressed I was by the way you delivered it. You will be responsible for improving the practise of every obstetrician in that room today which in the end will improve the care of tens of thousands of women.

If anyone is amazing it is you!”

This is one of many mountains.

I hope to be climbing a mountain near you soon.

 

Michelle Quashie

2016

Share the Word About MatExp!

Induction – Cascade – Caesarean Section?

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

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

Kirsty Sharrock
Kirsty Sharrock – SouthwarkBelle

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

But is this actually true?

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

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

IMG_9918
41 weeks and feeling massive

So was I right to fear the induction?

It seems the answer to that is no.

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

But can we believe this study?

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

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

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

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

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

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

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

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


So should every woman be induced at full term?

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

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

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

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

So what now?

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

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

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

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

Kirsty Sharrock / SouthwarkBelle

2015

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

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

Share the Word About MatExp!

Safety, Experience, or Both?

A blog post from #MatExp founder Florence Wilcock.

Flo

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

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

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

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

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

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

BirthJourneys

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

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

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

What will

Florence Wilcock, 2015

Share the Word About MatExp!

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

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

Big Baby Capture

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

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

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

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

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

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

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

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

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

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

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

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

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

Death capture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Big Baby

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

Shoulder Dystocia – RCOG green top guidelines

Rebozo Technique for Foetal Malposition in Labour

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

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

After Shoulder Dystocia: Managing the Subsequent Pregnancy and Delivery

Share the Word About MatExp!

When “Normal” Seems To Be The Hardest Word

Expo Capture 2

 

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

Expo Capture 1

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

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

Normal1

 

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

Normal2

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

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

And from this 2010 publication:

Normal4

Normal3

And from this in 2007:

Normal5

Normal6

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

Normal7

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

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

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

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

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

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

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

Normal8

 

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

Normal9

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

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

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

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

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

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

Normal11

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

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

Normal12

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

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

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

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

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

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

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

And from parents:

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

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

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

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

Normal13

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

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

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

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

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

 

@HeartMummy 2015

Share the Word About MatExp!

Putting the Heart into Matexp – Heart Values

Cloud 2

A while ago we decided to pick six words that we felt really summarised Matexp. As with the healthcare six C’s, we very much wanted our values to reflect what we feel is important to a good maternity experience both for families and staff. So with this in mind, the six values we chose were;

Choice

Kindness

Language

Respect

Dignity

Compassion

We set about asking everyone on facebook and twitter what each of the values meant to them.

FullSizeRender (17)

Choice

Our first word was choice and we knew when it comes to maternity experiences is so important to families. So what did everyone say about choice?

“Choice to me means having the same services and facilities available to all women. Birth experiences shouldn’t be a postcode lottery.”

“Choice to me means being presented with the correct information so you can make an informed decision. An informed decision is an empowered one.”

“Choice means to me, that all women whether low risk or high risk have access to the same facilities & are given the opportunity to make an informed decision to choose how & where they birth without judgement or pressure even if it is not medically advised.”

“Choice to me means that we give families accurate, unbiased info so they can make a informed choice that is right for them. Then support them in that choice. 

“Listen, really listen to women and let them pour out their heart and get to know what they need to make their birth what is right for them.”

“Choice is about being given all the information you need to make a decision in an unbiased, non-pressurised way.”

“Choice is being told the benefits and risks associated with each option. Choice is being told the benefits and risks with your alternative options (it’s very rare that there is no alternative option).
Choice is being told what happens if you simply do nothing. Choice is knowing how decisions made now will effect your future, I.e.surgery can have implications on future pregnancies. Choice is being able to consider all the information in relation to your own individual situation/ beliefs/ personal history, allowing time for you to make a rational decision. Choice is having balanced open informative discussions feeling that your decisions are supported and not judged. There is no ‘we are just going to’ or ‘we will’, choice is the individual making the decisions.”

We were reminded of nice guidelines for discussing risks and benefits and also CHOICE top tips for maternity care providers.
11792102_10153574985857193_8347680927398254148_o

Another really interesting point was raised about choice,

“In some circumstances there are no choices, and support needs to be given to those mothers who have had their choices limited or removed.”

Sometimes we may have no choice, in that due to circumstances beyond our control we may have to give birth or accept a situation that is far from the choice we would have made or choices have to be made for the wellbeing of mother and/or baby.

“Following my daughter’s death I have questioned the decisions we made many times wondering if a different choice may have meant she’d lived. In my subsequent pregnancies the feeling of responsibility to make the right choice has at times overwhelmed me and made me very anxious. In lots of ways I’d have preferred to have just been told what was going to happen.” 

It was also raised that choice means accepting the consequences of the choices we make, both as staff and as families. Sometimes this can mean impossible questions that may never be answered.

“Sometimes we are given the illusion of choice. How information is presented is so important. Manipulated or coerced compliance can be made to look like choice. Yet, within maternity services, it’s hard to challenge this. Some caregivers reveal their own opinions in how they phrase information – about whether induction, or cs, or epidurals have risks, for example. This sometimes is presented differently to data about home birth, or vbac, or physiological third stage.”

What did become clear was choice must be Clear, unbiased, informed and not an ‘illusion’. That families didn’t want those responsible for their care to manipulate information or data to coerce a choice that they felt was right. Instead information given should allow for families to make choices that were right for them.

Yes when it came to choice, it was evident how important this was to a good maternity experience.

Kindness

Next we chose kindness. While many things matter during birth, simple acts of kindness can leave lasting impressions and mean so much.

“True kindness is something you give without expectation of any kind of return, not even a thank you. It’s instinctive and comes from the heart and will always benefit another heart. You don’t have to touch, smell, see or hear it but it can awaken your senses and light up your soul. It’s something that both the giver and receiver benefit from.”

“Kindness to me also includes understanding- even if you don’t make sense or or thoughts are irrational. It’s such a confusing time, someone being kind and saying ‘it’s ok I understand’ means the world.”

“Kindness is SO important. I have met many kind midwives and each time a small gesture has been performed it has meant so much. I will never forget the midwife who made me a cup of tea in the small hours after Luka was born. I was literally (emotionally and physically) broken and her kindness fixed me up enough to carry on.”

“In order to be truly kind one needs the time to be kind. How many people are in such a hurry during their day, under too much pressure or thinking of the next job, to afford true kindness? Kindness means kind words but it also means listening, accepting & acting on the kind thoughts. If you see a person in distress, true kindness is actively easing that distress both verbally and practically.”

“Kindness should be in everything we do. We should treat all women with kindness because it’s the small things that matter too. Even the most difficult, hard and situation can be made a little easier when we are shown kindness. People remember kindness and if we truly seek to show kindness it will affect how we care for women. I believe it should be one of our inner values that we keep and not allow the culture to eat away. It costs nothing and yet can have the biggest effects.”

“Kindness is being empathetic and showing the person that you understand how the person is feeling and showing that you care and that you understand.”

11694833_1174657542551515_3353916665407566971_n

“A quick Google search says “Kindness: the quality of being friendly, generous and  considerate.” Generous is an important one. To be kind, in my opinion, means to give of yourself, to do something that takes a bit of extra effort. To deliver a home cooked meal to a family with a new baby is kind. To offer to take baby for a buggy walk whilst mum has a nap is kind. To make a busy parent a cup of tea is kind. To be generous with your time and your abilities is kind. As for “considerate”, this is the one where language is important. Consider what language you are using and the impact that can have on a person. Speak with kindness, aim to boost a family’s confidence and pride rather than to leave them confused or with feelings of inadequacy. Consider how you would wish to be treated in the same situation. Consider what you know of the family and the impact those things might have on their experience.”

So kindness was a valued part of maternity care and many expressed that kindness had made a real difference to them, however small the act.

It was also raised that it is important to also show kindness to those who care for women.

“As families we must not forget that there are times for us to be kind. To be friendly or at least polite. To drop off a box of chocolates on the ward to say thank you. To donate some items to the hospital. To raise money for units that have cared for our children. If we have been fortunate enough to receive kindness we should remember to pass it back or pass it on.”

Yes Kindness in words and deeds really does make for a good Maternity experience for all.

11828579_868688516513214_5187333956910331388_n

Language

Language is something that is discussed a lot in Matexp, and something that is very important to so many. Language has the power to build up, encourage and empower or to tear down, increase doubts and intensify fear. The words we use can leave lasting impressions.

“Language sets the tone for every experience. What is said, translates into what we hear and that affects how we feel. Being told I was 2-3cm and could go home if I wanted to it was ok. But what I heard was, I’m a failure, I’m not progressing, I’m wasting everyone’s time. It didn’t matter what was said to alleviate those worries, they were now engrained. Also, the word normal is a horrible word and should be replaced with various other descriptive words that can resonate more with the mother. Language is communication, understanding and respect.”

“Language is about reducing the distance between provider and parents and creating a collaborative ‘us’ rather than ‘them’. It’s as much about listening as talking, and it’s about choosing words that come from kindness, even if we can’t avoid the risk that they’re not always received that way.”

“It’s not just the words themselves (although these are important!) but also how it’s delivered. Positive phrasing is important we need to ban certain phrases IMO! A big cultural shift around certain stock phrases is needed. It’s about having a two-sided conversation/discussion in relation to decision making ultimately with the individual involved making the decision with all the facts available, I.e. looking directly at a person when talking, hello my name is campaign, doing admin once individual left room rather than spending lots of time looking at screen or doing paperwork etc.”

“For me language and the way we use language can convey so much. It should always be used in a kind way mindful of the person and their situation. Listening is so important as is thinking about the words we use. Our language should convey that we care, are interested, want the best for that person and that we are genuine. It shouldn’t be harsh or critical or brash.”

“If you can’t say anything nice, don’t say anything at all. Don’t fill silence with platitudes. Judgement is implied in so many statements unwittingly uttered when they fall on the ears of person who is suffering / has suffered a trauma. Instead hold a hand, mop a brow, smile, rub a shoulder but be so careful. It’s easy to say “well you are mum now you’ll put your baby first…” wh
en a new mum admits she feels awful, it’s said without malice, as a statement of fact as you see it BUT to the traumatised mummy it can say something different. To me it said “selfish mum, thinking about yourself, crap mum can’t do it” and so I hid how bad I felt and went home with retained placenta and developed sepsis. Think before you speak.”

“Words need to: be positive, encouraging, soothe, be honest, kind, compassionate, open, have empathy, be professional, clear and simple and always respectful. 

 

11886136_1178669428816993_3536750296379664307_oWords without: 
Attitude
Contempt 
Judgement or jargon 
Chat ‘with you’ not ‘to you or above you’
Words should not be dismissive or exclusive 
Words of kindness always…Words are but leaves, deeds are the fruit.” 

“The words we use provide the framework for our thinking. I can tell by the words you use what you think and therefore feel about me. Language is about communicating. We need to develop and agree a shared language to do this well. I don’t really care what your “correct terminology” is unless we have established what it means to us in this relationship. If you are not sure what words to use let’s talk about it. It’s a great way of building trust.”

“Language for me is one aspect of communication and facilitation and if we use it with the aim to facilitate then we are on the right track- this means personalising for atmosphere, experience, individual on a moment by moment level. And we must match the language with all other aspects of communication otherwise it is hard for women to trust in us as the words we use seem at odds with body language etc. Language should be used to empower, inform, educate, provide choice in a non judgemental safe, exploratory non defensive manner. That is the ideal. Consent, not coerce, create chances for inclusion in the care relation ship and take care in the words we choose- as said above we all take things in different ways, but if we are authentic in what we say then that’s a good start.”

Two words in particular that came out as needing to be thrown into room 101 and these were;

Failure   and   “incompetent”

 Language is a very important Heart Value. We need to think about the words we use, but also the way those words are used. Language can greatly affect birth because words are so powerful.

Respect

We would think that respect would be an obvious part of a maternity experience, but sadly many women and staff say they feel it is lacking.

“To me respect means an absence of any type of prejudice. It means getting to know the individual, not treating everyone the same. Acknowledging the family’s history, experience and their knowledge and understanding without making assumptions. Respecting the mother’s decisions as much as her body.”

“Respect is valuing people and listening to/valuing their opinions even if they differ from yours. Finding a way to use these collaboratively when making plans. This respect should go both ways too, no point looking for respect if you’re not giving it.”

R … Respect
E … Every one’s
S… Sensitive soul
P… We are just people
E…Eager to do our best
C… Careful how you say things
T … Two way communication needs kindness & respect.

“Due regard to the feelings or rights of others is where respect really hits in #MatExp. We must give due regard to the feelings and rights of families, whatever our personal views or experiences.”

“Avoid harm or interfering with” – another crucial one. Sometimes these feel mutually exclusive in some areas of #MatExp – can we avoid interfering with mothers and babies but still avoid harm? If in doubt, we go back to respecting the feelings or rights of others. And of course we have to consider whether the baby has rights as well.”

“Respect is valuing the person’s point of view and valuing them as a person. What they want, what they feel and this should be discussed with the woman. Actually to define respect is not that easy. I was thinking how the medical profession has commanded respect and still does and it is very aligned to value.’

“Based on my personal experience, respect is knowing and understanding that this is MY body, MY pregnancy and MY baby NOT yours (health practitioners); hence LISTEN to me, give me OBJECTIVE information to help me to make ‘INFORMED’ decisions and FIGHT/ADVOCATE for my wishes. Don’t give me your opinion if I haven’t asked for it and recognise my birth doesn’t fit round your schedule but the other way. And everything everyone has said so far.”

Respect also encompasses staff and the environment they work and care for women in.

“The first part is the respect I hope all birth professionals command, as they are doing an amazing job.”

“Agree to recognise and abide by”. Do all of the guidelines and protocols in your hospital or birthing centre command respect? Do you respect family’s birth plans? Do families respect your recommendations? Can all of these things be married together? Respect encompasses a huge amount of concepts. We all want it and we’re often slow to give it.”

“It also means respecting each other as staff, working as a team and supporting each other’s roles. Respect also included speaking up when we see wrong attitudes or treatment. It also means the respecting of other view points and realising we can all have different perspectives and that’s ok.”

Respect for women, their families, beliefs, choices and needs MATTERS. Staff too need respect for each other and but also afford respect for the amazing job they are doing.

Dignity

How can we respect a woman’s dignity in birth?

“For me dignity means, allowing me to make decisions without health professional over riding them and making you feel as though you’ve said something wrong.”

“For me respect and dignity come hand in hand. Whatever happens if you have treated me with respect I will be able to preserve my dignity. Labour and birth put you on a very vulnerable place and being respected means whatever procedure or conversation takes place involving very intimate issues, I will feel like I am a human being rather than a problem or hinderance, or worse still, like there is something wrong with me, which is my fault, not a result of the circumstances.”

“Dignity is treating me in a way that doesn’t make me feel I’ve outstayed my welcome on the maternity ward.”

“For me, dignity is about human rights, and human rights are about being treated with respect…a pregnant woman or a woman in labour is entitled to her human rights being respected at all times, and she is entitled to be treated with dignity…there!”

“Recognise that respecting privacy, DIGNITY and autonomy is not an addition to care provision, but an integral part of good care…”

“Being spoken to as a competent adult rather than a naughty child, people introducing themselves before touching me, people remembering I am a person not just a uterus on legs.”

In fact this summed Dignity up perfectly.

11960247_10153569166825070_6804610869793329297_n

Compassion

Last of our Heart Values, but by no means least, is Compassion. Some would argue that compassion alone is the single most important thing we can shown women in a maternity experience, if all care is based on compassion then it will encompass all the other Heart Values.

“To me compassion is seeing a person, realising that they are in need of not just your medical care but your emotional support, kindness and often just to know you actually care. It involves thought, as it can be such little things that make a difference. Think, if this was my daughter or sister how would I want them to be cared for ?”

“Compassion to me is always about time, the extra couple of seconds to smile at someone who looks worried; the couple of minutes to listen to someone who has a question or to ask someone who looks lost on a corridor if they need help; right up to the tasks that take a lot of time.”

Do we see compassion in maternity?

“When I was very sick waiting to have Joseph no one had any time to just sit with me, so the staff got a student midwife to sit and hold my hand. I’ll never forget her kindness. So even if there is no time sometimes there is another way.”

“I was really surprised when I was critically ill. I had a midwife refusing to leave as I was so poorly, she made sure she was my midwife 3 nights in a row. I had so many hugs from so many doctors, midwives, health care assistants I can’t count. I had my 27 weeker in an LNU rather than a Level 3 and they pulled out all stops so we could be cared for close to home.”

“One of my favourite consultants wasn’t even one of mine. Every day he would see me going to Joseph (over ten weeks) and give me a hug and tell me what a lovely mum I was. He was a huge support to me and probably had no idea.”

“For me, it was when one of my consultants told me “your baby *will* be premature”. I started to cry and she put her hand on my arm. It was such a human touch and I was so grateful. But I’m guessing that’s generally not encouraged, whereas for me, it meant so much: it said, I understand and I know this is hard. For me as well, it was when I finally left the hospital and one of my midwives gave me a big hug.”

“It was the array of midwives who looked after me for 10 days talking to me and making me feel almost as if I was just in a second home (ha I was in for 2 weeks which felt like a long time).”

“It was all the consultants who I had come across, always stopping when they saw me to ask how I was and how baby was doing. It was consultants who came to find me the next day to see how I was doing post c sec.I didn’t really expect that, as they must all be very busy people, but they never gave that impression of being in a rush etc.”

“I had so much kindness and compassion when I was in hospital with Joseph, my favourite was the day after Joseph was born, he was ventilated in NICU and I was in my room. I knew I couldn’t see him that day, and had been warned it would be Monday, this was Friday. I quietly crying and the obstetrician reg Charlie came in and said “why are you crying” and I said “I’m fine, I’m hormonal and still very ill and just feeling a bit sorry for myself”. He said “Nonsense, you need to see your baby and I WILL make it happen”. He spent hours organising everything to get me to NICU to see my baby, I will never forget his kindness and him realising that was what I needed, and being prepared to make it happen.”

Can we as families show compassion to staff?

“For staff I believe we should remember the hard work they do and commend them for that. Also be respectful to them. Also compassionate towards each other as a team. Help each other, treat with respect, and value each other’s gifts and abilities. Compassion I truly believe goes a long way when it comes to improving Matexp for all!”

“Immediate thought: always offer your midwife or health visitor a brew when they come to your home, coz they work bloody hard smile emoticon And we know that in the UK tea = compassion.”

“Give thanks and praise where it’s due, people are so quick to complain but never to give thanks. For HCPs, spend 1 moment before each meeting to take a deep breath, rid yourself of other thoughts and allow all focus to be on the couple/Mama you are going to speak with/assist.”

“One of the biggest revelations I’ve had this year, during a fairly turbulent time, is that it is impossible to practice compassion as a HCP towards women day in day out unless you also practice self-compassion.”

“This thread has inspired me. Tonight the children and I are going to bake a big chocolate cake and then tomorrow deliver it to the Labour Ward as a thank you to all the exceptional midwives who work so hard there.”


So those are our six Heart Values. These values are the heart of Matexp, they permeate the actions we make to improve maternity services everywhere.
The Values will continue to grow and expand as Matexp does too.

Thank you to everyone who shared their thoughts and ideas with us. We had so many it was impossible to include every single one here, but we hope all the above comments capture the thoughts of women, families and staff.

Matexp is amazing and will make changes for families everywhere. A woman will remember her birth for the rest of her life so lets make sure we do all we can to make her maternity experience one she remembers for all the right reasons, which we can if we remember our Matexp Heart Values. Lets but the heart into Matexp.

 

Emma Sasaru

 

 

 

 

 

Share the Word About MatExp!

1 2 3