Maternity Experience

The #MatExp Journey

Music While You Wait

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

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

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

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

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

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

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

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

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

On the same morning….

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Claire Flower
February 2017

 

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

Launched today by Sarah-Jane Marsh

at NHS Expo…

File 06-09-2016, 22 56 47

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

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

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

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

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

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

Entry form – Nobody’s Patient competition

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

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Optimal Cord Clamping

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

BloodToBaby

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

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

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

Placental delivery.

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

Active management.

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

Physiological third stage of labour.

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

Lotus birth.

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

 

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

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

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

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

 

 Amanda Burleigh. Aug 2016.

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

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

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

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

Link to evaluation report: Whose Shoes report Maternity SCN

MatExp poster - RCOG conf

MatExp RCOG Poster

Other key quotes and testimonials:

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

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

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Gill2

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

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

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

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

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#MatExp poster!

MatExp poster - RCOG conf

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

Download it here: MatExp RCOG Poster

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The Flaming June of the future

A blog post from #MatExp founder Florence Wilcock.

Flo

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

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

Flaming June 2017! My hopes:

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

better births

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

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

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

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

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

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

FlamingJuneposter

 

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A Shift in Gear

There is a very palpable change in maternity at the moment or at least I think so. A real shift in views and a change of gear. I believe this was in evidence when I was fortunate enough to attend a London Clinical senate forum on 21st April, the first devoted entirely to maternity services. I was honoured to be speaking briefly about #MatExp amongst many illustrious people both speaking and in the audience and I would like to share some personal highlights that both made me think and made me optimistic that there is a change underway.

Baroness Cumberlege started the morning with the National Maternity Review. I have heard her speak before but the concept of personalised care wrapping services around a woman with continuity through the pathway cannot in my view repeated too many times. There are as we know many practical organisational and financial barriers to this at present and the importance of leadership encompassing trustworthiness, competence, reliability and honesty was strongly emphasised.

As co-chairs of the London Maternity Strategic Clinical Network (SCN) the baton passed to Professor Donald Peebles & Donna Ockenden to give an overview of the work undertaken by the SCN in the last 2 years and to introduce some of the work in more detail. Donald set us a challenge to consider how we translate clinical networks that are currently mainly acute provider based into maternity systems with a broader far more integrated approach. Amongst more detailed presentations Jane Sandall presented compelling evidence about the impact of continuity on outcomes & Liz Mc Donald chair of the London Perinatal Mental Health Clinical Network presented both the enormous impact of perinatal mental health and the huge disparity in care across London.

Next we had a panel session with David Richmond (RCOG) and Cathy Warwick (RCM) on their views on the London Quality standards (LQS). These were process based standards e.g. midwifery staffing ratios & consultants’ hours of presence developed 5 years ago to drive improvement, the maternity section being part of a wider piece of work across London health care including emergency care standards. David Richmond spoke of ‘asking what do women want and what makes a difference to them?’ as well as a discussion of the immense workforce challenges facing the specialty. Cathy Warwick spoke of the importance of multidisciplinary culture and gave a lovely cake shop story analogy for women’s choice. If you go into a chocolate cake shop and have a piece of chocolate cake you will say you were satisfied as this was the only choice, however if you had known there was lemon drizzle cake in a shop down the road you may have wanted that and not been pleased with the chocolate cake and annoyed you were not aware of the alternatives. We agreed that the LQS still had purpose in driving improvement but need modification. A discussion flowed on the importance of outcomes rather than process and that we need to move from quantitative to qualitative outcomes. Process can be useful to drive change but should not be the be all and the end all. We talked about the need for different measures for satisfaction as what we currently have is not adequate and the importance of relationship based care.

At one point a question from the audience came as to how women are involved in driving improvement in maternity services across London and what is their role in the implementation of the Maternity Review. The answer was of course that there is far more to do but I was proud that it was also acknowledged that #MatExp both though ‘Whose Shoes’ workshops and virtually is evidence of women starting to drive the change as true collaborators and leaders.

I was the final speaker of the morning and although I was asked if I would like to switch and speak slightly earlier to me this seemed the most appropriate way to finish the meeting. I stood up and spoke to explain: #MatExp Maternity Experience is not the fluff or the afterthought, it is the beginning, the foundation of the future. True multidisciplinary team work and co-production is enshrined in the Health & Social care act, Francis, Kirkup and now the NHS Maternity Review. #MatExp bringing together the grassroots voices of women, families and health care professionals with the energy and enthusiasm for improvement is the future. Join in!

There is an enormous quantity of work ahead to do but it is clear that the work of the London SCN is very much along the right lines in terms of the NHS Maternity Review and the direction of travel. I had never been to a meeting with some many influential people where there was a genuine desire to undertake a wholescale change in maternity services and towards a very much more holistic person centred approach. I left with a real sense of hope and opportunity. On top of this the announcement last week by NHS England of a Maternity Transformation Board make me certain. The future of maternity services is here for the taking so we’d better grab it with both hands. The time to act is now, let’s hope we can do it justice!

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Women’s Voices in #MatExp – your GP

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 eighth of those. This is Louise Santhanam’s experience as a GP – thank you so much to Louise 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

Your Antenatal Teacher

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

Helen.x

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Louise GP

It is a privilege to be included in this series of blogs and to talk about being a GP in the context of Maternity Care. My name is Louise Santhanam and I am a General Practitioner and mum to 3 children under 7 years old. Unlike some of the other voices in this series, I am currently taking a short career break (more on that later). I have recently become involved with the #MatExp community, and it is extremely uplifting as a clinician who cares about the whole person and the family to see so much positive work going on, at a time when the NHS is facing uncertainty and extreme challenge.

Probably the biggest difference between the role of the GP and the other professionals who have already told their story here is that Maternity care is one strand of what we do. A GP will often look after a Mother or a couple prior to conception, then on through their pregnancy into the postnatal period, and beyond. The GP will be responsible for the care of baby, siblings and often Dad too, so we have a unique perspective and a responsibility to promote and protect the health of the whole family unit.

Rather than meaning we just ‘didn’t specialise in anything’, being a General Practitioner means that we have to know a fair amount about lots of things- both medical and social. After congratulating a mother on her new pregnancy, we might be supporting someone with serious mental health problems, diagnosing a possible heart attack or helping adjust a patient’s blood pressure medications- and each case is expected to be managed in around 10 minutes!

stethoscope

We have to be quick to use our common sense and apply our training to help when unusual circumstances arise. We might be dealing with common and chronic conditions one minute and then have to respond with urgency to an emergency the next minute. GPs have specialist training in the ‘art’ of the consultation: good listening, communication skills, negotiation and viewing a whole person rather than just an organ or a medical problem. It is our responsibility to be aware when we have reached the limits of our own expertise and when Specialist input is needed. We have to be good team-mates to our Practice colleagues and work with many people who we will never meet, over the phone, by email and by letter.

A GP might work ‘single handed’ (increasingly less common) or together with Partners to run their own Surgery either with a dedicated list of patients that they know well, or in a Group Practice where patients can see any of the doctors they choose. Alternatively, they can work as employees (Salaried doctors) or do sessional work (Locums doctors). Some GPs develop a special interest and increase their knowledge and skills in a particular area of medicine- for example Dermatology, Women’s Health, GP Training or Clinical Commissioning.

My personal journey to becoming a GP started with five years of medical school with an extra year of Physiology research, followed by four and a half years rotating through different speciality jobs in hospital, and then one year as a GP Registrar seeing patients in a GP Surgery. I am lucky to have been able to work in Paediatrics, Obstetrics and Gynaecology, Mental Health and Sexual Health, all of which have been invaluable to providing maternity care to patients later as a GP.

As a GP an average week might include the following and more- starting investigations for a woman who has been having difficulty conceiving, counselling a woman who has suffered a miscarriage, referring a newly pregnant woman to the Midwives for antenatal care, managing a woman with early pregnancy nausea and vomiting, urgently referring a woman with pregnancy bleeding at 32 weeks to the hospital Obstetric team, giving emotional support to a Mum of 3 who is fatigued in the days before her next labour, diagnosing a breastfeeding Mum suffering from mastitis, seeing a new baby for the 6-8 week check and reviewing a Mum’s caesarean scar during her postnatal check. And the next week it will be different again!

Stethoskop und Baby

All of these interactions with a woman and her baby through the maternity journey are extremely important and our responsibility as GPs is to treat a woman and her family with dignity at this significant time in their lives. Care of the Mother’s mental wellbeing and consideration of any other children and their needs is essential.  The skill of the GP is to identify what is important, what needs to be dealt with today, what needs to be followed up and what does not need to be worried about.

In the community we might signpost women to our Practice Nurse, the Midwives, our Health Visitor colleagues, their local Breastfeeding Support Group, a postnatal Physiotherapist or to not-for-profit organisations which can offer support with mental health problems, practical help at home and financial difficulties. When problems are identified, seeing the same GP can really make a difference to the outcome, as the doctor already knows the story, can quickly assess if things are getting better or worse and has already built a relationship with the Mother. Most GPs want to be able to support a woman to have confidence in her ability to birth and to become a Mother, continuing that support into the postnatal period …often to the next pregnancy and beyond.

As a GP work can be extremely stressful with long surgeries, large amounts of additional admin work and other non-clinical commitments like meetings and teaching juniors. Seeing patients at 10 minute intervals you can often feel like your brain is doing acrobatics moving from one scenario to the next. At the end of the day you can feel exhausted. GPs can feel the pressure of the responsibility they carry being the ‘gate-keepers’ to all the health service can offer, or as the sole person who has to decide whether the problem presented is serious or not. It can be heart-breaking to deal with women who have lost their pregnancy, to see the patient you have cared for over months struggle with postnatal depression or to see a new baby become seriously unwell. GPs are human beings too and many of us are also parents. Our branch of medicine takes gives us the privilege to walk along side our patients through the ups and downs in life and at times that can be overwhelming. My personal belief is that our Primary Care service in the UK is a ‘national treasure’ and is something that we should not take for granted. Everything a GP provides is covered by just £136 pounds per year per patient on their list (1). This does not excuse the occasions when care can and should be better, but just gives you an idea of the pressures on General Practice at the moment.

I have a personal interest in women’s and children’s health as I believe investment of time, money and effort in looking after a pregnant mother and a new family is the foundation for a healthy society. I am currently taking a career break, in order to look after my own family and restructure my working life. While I have been out of the Surgery I have been working for the Royal College of General Practitioners to raise the profile of Perinatal Mental Health issues and provide GPs with good educational resources to improve their care of mothers who are suffering mental health difficulties. It is really important that women and GPs appreciate that perinatal mental health problems are common. Between 10-20% of women will experience mental health difficulties during pregnancy or in the year after birth, and suicide is one of the major causes of maternal death (2). Once diagnosed perinatal mental health problems can be effectively treated so engaging in discussion about mood and feelings in the perinatal period can potentially be life-saving.

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I am also passionate about supporting mothers to breastfeed, something that is undervalued in the UK at present and reflected by low levels of prolonged breastfeeding in society. I see the provision of accurate advice to families on infant feeding and good Breastfeeding Support services as a duty for General Practice and the Community, not least because of the health benefits of Breastfeeding, but also because the early infant feeding journey can be emotional and challenging. With encouragement from members of #MatExp I recently set up an online Health Professional Facebook group called the GP Infant Feeding Network (UK). Through the positive power of social media myself and members are sharing good quality resources and educational materials on the issue of Infant Feeding and forging links with trained individuals in the field (Midwives, Health Visitors, International Board Certified Lactation Consultants (IBCLCs), Breastfeeding Peer Supporters and others). I personally believe it is so important that women are given reliable information about why breastfeeding is a healthy choice for themselves and baby and that if they want to choose to breastfeed, that they should be well supported to achieve their goals. Support from their GP can be very significant. I was amazed to rapidly make contact with many colleagues nation-wide who share my interest in this issue and have also made local connections, with the aim of increasing awareness of breastfeeding issues within my local GP community. Ultimately, GPs can have a role in all sorts of areas in maternity care and with public health initiatives, we don’t just work consulting at our desks!

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Despite all the recent negative media stories, financial difficulties for the health service and workload pressures in Primary Care, it is exciting to think that collaboration with colleagues can improve patient care and the experience of working in healthcare. Reassuringly, a recent survey demonstrated that patient satisfaction with their GP was 86% on average (3). When work in the GP Surgery was tough it was usually guaranteed that a consultation with an expectant Mum, or a 6-8 week baby check appointment could cheer me up and remind me that good things do happen in the world! One of the tasks that I always looked forward to was visiting a new baby at home following a homebirth. Entering the home on Day 1 of life to conduct the new-born examination in this situation is almost always an experience of tangible, joyful calm. Life is going on and the family is growing, and I was there to witness it happening. As GPs we need to be able to enjoy our work and look after ourselves so that we can continue to truly care for our community, from the maternity journey onwards.

Dr L Santhanam

General Practitioner

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If you are interested in joining the GP Infant Feeding Network (UK) please visit http://www.facebook.com/groups/gpifn/ or follow @GP_IFN on Twitter

Ref:

(1) http://www.hscic.gov.uk/article/6037/New-report-looks-at-the-NHS-payments-to-General-Practice

(2) http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/Perinatal-Mental-Health/RCGP-Ten-Top-Tips-Nice-Guidance-June-2015.ashx

(3) GP Patient Survey- National Summary Report July 2014, NHS England http://gp-survey-production.s3.amazonaws.com/archive/2014/July/1301375001_Y8W2%20National%20Summary%20Report_FINAL%20v1.pdf

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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

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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.

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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.

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Women’s Voices in #MatExp – your Anaesthetist

I was asked to do a talk to student midwives at Salford University in January on the topic of “Women’s Voices” in maternity care.  As part of my presentation I included the voices of the midwives who work in maternity care, and a reminder that there are many other women for whom maternity care is their professional, as well as perhaps their personal, experience.  “Women’s Voices” in maternity care should cover the midwives, obstetricians, health visitors, doulas who care for us, as well as the women giving birth.

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the sixth of those. This is Carolyn Johnston’s experience as an anaesthetist – thank you so much to Carolyn for agreeing to write for us.  You can read the other blogs in the series here:

Your Midwife

Your Doula

Your Breastfeeding Supporter

Your Sonographer

Your Obstetrician

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

Helen.x

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

Carolyn is a consultant anaesthetist in St George’s hospital in London.

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Anaesthetics is usually the biggest department of doctors in most hospitals. We cover services including intensive care, operating theatres for all specialties and patient groups, resuscitation teams, pain management, and many other areas as well as maternity care. For those of us with a special interest and training in obstetrics are usually on the maternity unit for the day, but on other days we may be working on general (abdominal) surgery, transplant or any other kind of surgery, intensive care or whatever our other specialty interests may be.

In our unit, my day starts with a handover from the night team. The registrar (senior doctor in training) who has been on the maternity unit overnight tells us who has had anaesthetic input with pain relief (usually epidurals), any women who have been to the operating theatre and require ongoing care and highlighting anyone who may require extra vigilance during the coming day. This might be because of a pre-existing medical issue or developments in labour that may make care more complex. Because all anaesthetists have training that includes caring for people who are critically unwell and are part of resuscitation teams, we have the skills to help the maternity team care for lots of conditions that maternity teams may see very rarely (like heart disease) or those that are more common but might be serious if not treated early (like infection/ sepsis or heavy bleeding).

We also start the day by checking our equipment in the operating theatre and emergency medications. We must be ready to move at a moments notice if the situation arises, for urgent surgery or some other intervention, as we all know, maternity situations can change rapidly! These are scenarios we practice and refine until we can do them as safely as possible. Safety is a key part of anaesthetic practice, in our training we learn a lot about teamwork, safety theories such as ‘human factors’ and communication, and we check and practice a lot, so when we need to act quickly we can do so safely.

We will be involved in any planned (elective) caesarian sections during that day, in my hospital there are usually 2 or 3 cases planned per day. It must be so intimidating for a woman to come to the operating theatre; such a foreign environment and the idea of surgery whilst you are still awake must be so daunting. And then of course the nerves and excitement about finally meeting your baby! I see it as a big part of my job to help make that experience as positive as it can be, and help make women and their partners feel welcome, secure and hopefully even relax. Maybe even some skin-to-skin contact in the theatre.

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Maternity work is very different from all other anaesthetic practice because unlike most of our other work, our patients are (usually) awake. This adds to the challenge: undertaking potentially difficult anaesthetic procedures, communicating with the theatre team, maintaining safety by monitoring and reacting to any changes in your patient’s condition but all whilst being mindful that the patient and her partner have holistic needs. Reacting to these needs and helping them to feel safe and secure is very important. There is always a balance to be struck with maintaining our best and usual practice for safety, and providing individualized holistic care. I think this is best achieved by talking and understanding each other’s perspectives. Perhaps we don’t do this enough.

We will, of course, respond to any requests for pain relief for epidurals, which is what most people think of when they think of anaesthetic involvement on delivery suite. It can sometimes be the case that women is distressed, distracted or even scared; so there is a real need for thoughtful communication and co-operation to help her and undertake the epidural safely. This balance of technical and people working skills is a common theme for us in obstetric anaesthetics.

I am lucky that our maternity team values co-operation and team working, and anaesthetists are an important part of that. It isn’t always the case that we are fully included in the team, and this can be a real source of frustration, because so many patients tell us our involvement is very helpful. We have a reputation (unfairly?) of being the epitome of intervention, so I guess we aren’t welcomed by some who hold strong views that birth should be natural. I have no desire to force my interventions on anyone- I would much rather put my feet up! Ultimately, I think the woman can make up her own mind, and as we pride ourselves on knowing the evidence, she should always get impartial advice about risks and benefits from an anaesthetist.

I’ve been trying to avoid the word ‘risk’- I know it’s becoming unpopular in maternity discussions. There is no avoiding it: anaesthetists deal in risk. We train and work in very high-risk areas including emergency surgery, trauma teams, heart surgery, intensive care and in those roles we’ve all seen someone die in front of us as we care for them. Anyone we look after is a patient, and rarely a client- it’s hard to switch this off when we come to maternity and so we often use terminology and even a more risk-based attitude that can clash with the modern ethos of maternity care.

I guess the solution to improving this is to talk more- to all our colleagues in maternity care and to our patients- we all have the same aims and aspirations to provide the best care for healthy happy mums, dads and babies. We also have a reputation for loving coffee, so my suggestion is to grab an anaesthetist on your precious coffee break and ask each other: “why are we all here and what skills do we bring to make that happen?”

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