Maternity Experience

The #MatExp Journey

#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!

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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.

GPIFN Logo 400x400

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

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

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.

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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.

Cynergy_Carolyn_Johnston_643

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.

scrubs

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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Women’s Voices in #MatExp – your Obstetrician

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

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the fifth of those. This is Ruth-Anna Macqueen’s experience as an obstetrician in training, and it includes an introduction and follow up comments from #MatExp founder Florence Wilcock.  Thank you so much to Ruth-Anna for agreeing to write for us.  You can read the other blogs in the series here:

Your Midwife

Your Doula

Your Breastfeeding Supporter

Your Sonographer

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

Helen.x

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

Florence Wilcock writes:

Flo

“One of the strengths of #MatExp is to try and hear all voices with respect and understand different perspectives so that we can work together to improve maternity experience.

Obstetricians have been an especially hard group to involve , I have written before about the traditional ‘bad press’ we seem to receive. I included it as a topic in the #matexpadvent Steller series you can read it here  https://steller.co/s/5AduBaxWL6v

I am therefore especially delighted to introduce a brave #FabObs blog, one of a couple that are hopefully coming our way. Some of this may be distressing, some of it may be unpalatable but I ask you to take a deep breath challenge your assumptions & read!  Don’t ‘bash’ the author she is giving you a peek into her world, a world fairly typical of many obstetricians in todays’ NHS . Take this unique opportunity to have sight of what it is like to be in ‘our shoes’ that way we can have the difficult conversations that move us forward.”

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

My name is Ruth-Anna, I’m 32 and a Mum of two busy, lively and opinionated little people aged 2.5 and 5. I’m also privileged to work as a doctor in obstetrics and gynaecology. My official title is ST5 doctor, which means I’ve been specialising in obstetrics and gynaecology for 5 ‘years’ (after 6 years at medical school and 2 years of moving around specialities). However it’s actually nearer 6.5 years since I started specialising, because of having time out for having babies, and working part time (I work 35 hours a week and spend two days at home with the kids). At the end of my ST7 ‘year’ of training, all being well, I’ll be able to apply for jobs as a Consultant but right now that feels a long way off!

This is a day in my life… (all events and women are fictionalised, of course)

Ruth-Anna

My alarm is set for 6.45 but the kids usually wake me up first. I get up & dressed, grab some breakfast (if I’m organised enough!) wave goodbye to the kids & husband and jump on my bike. It’s a Saturday so the cycle into work is pleasantly peaceful and I enjoy a bit of headspace. My job is incredibly varied and over the course of a week I could be seeing women in antenatal clinic, gynaecology clinic, on our day assessment unit (walk in for pregnant women with concerns about themselves or their baby), operating in gynaecology theatres, scanning women, looking after women who are inpatients for any gynaecological or pregnancy-related problems, seeing women in A&E with acute gynaecological problems, or covering the Early Pregnancy Assessment Unit.

Today, however, I’m working as the Labour Ward ‘registrar’. I’ll be working with an ‘SHO’ (in newer terminology, this could be an FY2, an ST1 or ST2 doctor), who may or may not be specialising in obstetrics and gynaecology, as well as my Consultant.

I’m in work by 7.45 and change into my scrubs, to head into our handover meeting for a prompt start at 8am. All the midwives, obstetricians and anaethetists for that day on Labour Ward are there. Our night team counterparts inevitably look pretty knackered and relieved to see us.

Some days we take over and there are only one or two women on the Labour Ward but today it’s a busy one. As we talk through the women, one by one, I’m thinking what the risks might be for that woman and baby, predicting and preventing any problems and pre-empting potential issues. Hopefully none of those will happen but our job is largely about predicting problems that never happen, so that we can be prepared for when they do. Even so, a day on Labour Ward is unpredictable and filled with surprises. My current hospital saw around 6000 babies delivered here last year and it serves a fairly ‘high-risk’ population, with above average numbers of women with a high BMI, older mothers, women who may have come into the UK recently, women with multiple pregnancies or concurrent medical problems. We also have women who are transferred in to us from other places where the NICU or SCBU don’t have the facilities to look after the smallest or sickest babies.

Women expected to have totally uneventful labours are normally on our Birth Centre and I won’t generally be involved in their care unless there’s an issue that the midwives ask me to help with. Myself, the Consultant, SHO, the Anaesthetist and the Labour Ward Co-ordinator (Midwife in charge) do a ‘ward round’ of all the other women – to introduce ourselves, find out more about her and how things are progressing, and make a plan, if anything else needs to be done. This morning there are 12 women on Labour Ward. The first woman we see had a Caesarean section overnight and lost a lot of blood. She’s having ‘high dependency unit’ care and is currently having her third unit of blood transfused as she had a very low haemoglobin level due to the blood loss. We assess whether she has had enough blood replaced, whether there are any signs of further bleeding, and whether she needs any further treatment. She’s understandably shell-shocked and we go through the events of the night with her and her husband. Her baby was taken to the NICU and her priority is getting well enough to get into a wheelchair so she can go and see him there.

Next we see a woman who’s tragically had a stillbirth. She attended the day unit at 38 weeks into a normal pregnancy with reduced fetal movements, and it was confirmed the baby had died. Her labour was induced yesterday and she’s spent the night trying to come to terms with what has happened. Understandably she has lots of questions for us, which we do our best to answer. I offer her some medication to suppress her breastmilk production and give her some information to consider about a possible post mortem examination for the baby. We offer her the choice of going home today or staying another day and she will think about it and let her midwife know.

We complete the ward round, seeing a woman with a straightforward labour who is on the Labour Ward only because she has an epidural, a woman who previously had a Caesarean but is in spontaneous labour and all is well, a woman who is being induced for a post-dates pregnancy and a woman who has been admitted in possible preterm labour at 28 weeks.

The next few hours is a whirlwind of emergency buzzers and bleeps. Another woman has been admitted from the day unit – she’s had an uneventful pregnancy so far but at her midwife appointment today at 32 weeks her blood pressure was found to be dangerously high, with protein in her urine. Her midwife suspects she has pre-eclampsia and has sent her in to us. She needs urgent assessment my myself and my anaesthetic colleague, a cannula (drip), bloods taken, and medication to lower her blood pressure. She starts complaining of a headache and when we test her reflexes they are abnormal so we also recommend that she starts another medication (magnesium sulphate) to reduce the risk of having seizures. We need to see how she responds to the treatment but it’s likely we will need to deliver her baby imminently to treat the pre-eclampsia, so we also recommend the first of two doses of steroid to help mature the baby’s lungs. Her midwife calls the Neonatal team to check that our NICU have a cot available for this premature baby. She also asks them to come and speak to the woman to explain what to expect if her baby needs to be born prematurely. I perform a scan under the supervision of my Consultant which shows the baby is small and its fluid is reduced – this is a common effect of pre-eclampsia. We ask her not to eat and drink in case the baby needs delivering imminently (if she needed a general anaesthetic it’s important to have an empty stomach).

I leave my SHO administering the first dose of the magnesium sulphate as the Co-ordinator calls me to see a woman who is in the second stage of labour (fully dilated and pushing) whose baby is showing signs of significant distress. I assess the woman, and the fetal monitoring, and explain that I would recommend an instrumental delivery, to which she agrees. As the baby is already quite low in the birth canal I decide this can be safely achieved in her delivery room, so after giving an injection of local anaesthetic to block the my SHO and I perform a ventouse delivery and her baby is delivered with no complications.

I finally see a woman who has been waiting several hours to progress to the next stage of her induction of labour. We haven’t been able to proceed with things as we would have hoped due to the other situations that have arisen and the effect on available staffing levels. I explain this to her but she’s understandably upset and frustrated, as well as exhausted, and I leave the room feeling pretty downheartened.

It’s 3pm and I suddenly realise I haven’t eaten anything so grab a sandwich and a drink before heading back to see the unwell woman with pre-eclampsia. Her blood pressure still isn’t under control despite high doses of medication and my Consultant decides that we can’t wait any longer and that she will need to have her baby delivered today. At 30 weeks in her first pregnancy, with a growth restricted baby, the team decide that Caesarean will be the quickest and safest way of delivering her baby. She’s shocked – it certainly wasn’t what she was expecting when she headed to her midwife appointment that morning, but her partner has now arrived and she is willing for us to proceed. I talk her through the operation and explain the risks and benefits, before she signs a consent form. The Co-ordinator speaks to the theatre team to prepare everything, as I call my anaesthetic colleagues. Her midwife gives her ‘pre medications’, tight stockings to wear and gets scrubs for her partner to wear.

While with my sick woman I was asked to attend the Birth Centre to check whether a woman who has just delivered has a ‘second degree’ tear (that can be sutured by the midwife in her room) or a ‘third degree’ tear that would need to be sutured in theatre by me. As the anaesthetists perform their anaesthetic for the woman in theatre, I finally make it across to the Birth Centre and thankfully for the woman it’s a second degree tear. I apologise she’s been waiting so long for me – she’s lovely about it but I still feel bad.

I’m bleeped from theatre to say the spinal anaesthetic is working and they are ready for us to start the operation. I do her Caesarean, with my Consultant supervising in view of how sick she is and the fact the baby is premature. Thankfully it is an uneventful procedure and the baby is born in reasonable condition, although he still needs to go to the NICU. His mum comes back to the Labour Ward as she is still unwell and the next 24-48 hours can actually see a deterioration in her condition.

tea phone

We sit down for a quick cup of tea and I feel guilty I haven’t tackled any of the computer-based tasks I have piling up, and the audit I’m trying to finish before my appraisal next month. Still, they’ll have to wait for another day. I check my phone and see 15 messages from home – thankfully it’s nothing urgent; they are just photos from my husband of the family party he and the kids are at today.

The night team start to arrive and I feel relieved. Today I’ll manage to get away pretty much on time, once we’ve finished handover. I need to send some electronic tickets to my Consultant so she can sign to say what she’s witnessed me doing today, for my appraisal. I know that if I don’t do it now I’ll forget. I’m out of the building by 20.45 and head home to wolf down the dinner leftovers. I spend the cycle home thinking about the women and babies I’ve looked after today, hoping all will be well, and wondering what I could have done differently. After 8.5 years as a doctor I’m pretty good at trying to leave all those thoughts behind – at least temporarily – when I put my key in the lock, although I do drop my night colleagues a quick text before bed to ask how the woman with pre-eclampsia is doing. She’s stable and I finally let myself switch off. Tomorrow is one of my days at home with the kids and I’m looking forward to taking my 5 year old to school and my 2 year old to toddler group.

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

Florence Wilcock writes:

“When I first read the blog I felt it pretty accurately captured a fairly ‘standard’ day on labour ward for an obstetrician. I recognized it absolutely & have spent many days similar to this over the years. The multitasking, prioirtising, constant juggling of clinical situations is quite typical. Some of it may feel dispassionate and lacking emotion, that doesn’t mean that the author doesn’t feel anything or that she doesn’t treat the women she sees with compassion and care it just means there is an element of self-preservation to enable one to take split second clinical decisions we need maintain an exterior calm. It is also essential so that we are not sobbing halfway through the shift or at the end of the day it enables us to be resilient and get up and do it all again the next day or to care for our own family. Imagine what it would be like if you were trying to do this job pulled from pillar to post how would you feel? This is where working as part of a fantastic multidisciplinary team becomes important, those of us that are lucky have wonderful midwives, nurses, midwifery assistants alongside us. If we are less lucky or those relationships are adversarial that can be very difficult as the support isn’t there. No obstetrician sets out to hurt or upset women or become a barrier they may be under huge pressure, having a bad day, feeling scared of that responsibility, worrying about an exam or appraisal. We are human too.

There is no fluff here , this is obstetrics in reality. There are one or two particular clinical situations that may distress you: such separation of mother and babies is never ideal & making the focus getting a mum to see her baby in NNU sounds so simple but can be harder than it sounds if people don’t work together & make it happen, A bereaved mum seemingly given cursory information and a very short hospital stay after such a life changing event is hard to read but sadly is the current reality , we know this needs improving hugely with better support during and after and a birth environment separate from the main maternity wards. A shocking sudden decision to deliver a baby preterm at 30 weeks. It is hard to write and hard to read and some elements can’t be changed they are clinical reality but amongst that the words we use, the understanding we have of how it might feel both for families and those caring for them there are plenty of things that can be done to improve care.

A mile in my shoes

A few ideas:

Look at #Hugoslegacy #Saytheirname & cards for bereaved parents.

Watch Abigail’s Footsteps’ video ‘The deafening Silence’.

Look at the campaign to have a bereavement suite in every maternity unit started by Ben Gummer MP.

Think about what language you are using in that short time you have to see someone.

Think about the importance of the team to the obstetrician often junior on whose shoulders there is massive responsibility; if you are a midwife or other healthcare professional support them and work with them.

Think about self-care.  What is available to you as a healthcare professional at your Trust, have you had a break, did you eat or drink today?  Looking after yourself is the first step to being able to look after others.”

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Women’s Voices in #MatExp – your Sonographer

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

So I decided to start a series of blog posts on “Women’s Voices in #MatExp” from the point of view of those working in maternity, and this is the fourth of those.  Unlike the others, this one is anonymous.  You can read the other blogs in the series here:

Your Midwife

Your Doula

Your Breastfeeding Supporter

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

Helen.x

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

Ultrasound

I have been a sonographer for 13 years, and I’ve asked to be anonymous because I want to be honest, and I don’t think my managers would appreciate every aspect of this.

I’ve worked in a few different NHS trusts over the years, and now work in a small, rural hospital.

I do both pregnancy and non-pregnancy scans, and enjoy the variety in my work. There are more complaints around pregnancy scans, but my overwhelming impression of pregnancy scans is that it can be very hard to meet parents expectations in the NHS.

For routine, screening scans parents generally expect the reassurance that all is well, without necessarily fully considering that the scan findings may be devastating. I have a moment with the notes (hopefully, if the mum remembered them) to quickly obtain a bit of history which may give me an indication that the parents may actually be extremely anxious- but some things aren’t written down, and I struggle to determine the body language differences between anxiety, or that I’m interrupting an argument between the parents, or there is worry about something unrelated to the scan, all while the mum may have a desperately full bladder.

Once the parents are in the room, its usually only a minute or so before the lights are dimmed, if they were ever turned up in the beginning. Myself, and older colleagues have noted how our eyes adjust more slowly to sudden darkness- I used to have no trouble going from bright light to darkness in a scan room, but now I’m older I can’t see very well when the lights go off- not very helpful for the scan, but keeping the room dim all the time adds more barriers to communication.

I have been scanning a number of years, but I only learned a couple of years ago the importance of eye contact in those first seconds of the scan. I think if I’d learned that sooner, I could have easily made more clients feel more welcome. Right at the beginning is when I’m usually checking I’ve got the right patient on the computer screen or paper details, probably staring at a screen, and I expect I really came across rushed or off-hand, before I knew better. I have asked for customer skills training, but the training I have had has been more about dealing with challenging behaviour, and when I asked for training around breaking bad news I ended up on a course which was more about end of life conversations, which was interesting, but geared to spending a lot more time setting the scene for breaking end of life news without interruptions, rather than sonographers specific task of breaking bad news very quickly, with little warning.

Something that comes up time and again, is how rude sonographers are, prodding bellies and saying how fat our clients are. I’m sure a lot of us could gain from some training in customer service, but there is a reason behind the hurtful words. A scan can be uncomfortable- pressing on a full bladder isn’t great at the best of times, but sonographers end up pressing harder on larger tummies trying to see the detail that is required for that scan. We try not to, not only because we don’t intend to hurt our clients, but most sonographers are in physical pain scanning and pressing harder makes it worse. We are our own worst enemies at times though, because we concentrate so hard on what we are looking at on the ultrasound screen. So, brains may not be fully engaged on saying tactful comments, we may not realise how hard we are pressing (I rarely notice the pain I am in until I finish up the scan, and realise I shouldn’t have pressed so hard).

At the end of the scan, the other vital part of our job is communicating the findings, which usually involves giving a copy of the report to the parents in their notes.

We have to explain what limitations there are on the scan- have I seen everything perfectly like the text books? Usually not, and then we have to explain why. I’m not aware of too many people feeling insulted when its baby’s position that is a limitation, but the various ways we say we lost detail because the sound waves were travelling further (which happens if there is a layer of fat in the way) can be perceived as insulting. I know in my trust the midwives try to mention this to larger ladies before they come for any scans, and I feel that being forwarned helps when the sonographers then are repeating something already said. It doesn’t seem too shocking if I’m trying to explain the extra layers around where I’ve been scanning have limited what I can see, if its already been mentioned, hopefully by someone they trust. Sometimes that hasn’t happened, or the parents haven’t taken it on board, and some of us sonographers manage to say things quite badly. Probably in fear of saying it badly, some of us don’t mention it all, and leave it to the midwife to explain the terms on the report, which can be just as upsetting.

Sonographers sometimes across as grumpy, and one possible reason is that we are usually rushed. My day in obstetrics is divided into 15 minute slots- with double slot for first trimester screening and the 20 week anatomy / anomaly scan (different places give it slightly different names), and a bit extra for twins. In that time we really need to allow about 5-7 minutes for trying to document the findings accurately, and producing a copy for the parents to keep in the notes (IT technical issues can easily double this, and are a regular problem where I work now).

Some scans take longer than the allotted time, and sometimes in that short time interval I have to give devastating news, try to be supportive but also find another health care professional to handle the initial grief and arrange what happens next. With no time to reflect I must carry on and scan a lady who might have been kept waiting longer, with a desperately full bladder. I try hard, but part of me is probably still processing the blow I dealt the previous lady, and hoping that while distracted/upset I am doing my job well enough for both clients, and I really hope the lady who has been kept waiting is kind, because I can’t tell her any of this.

The 15 minute break slot I get each list is rarely a break, but just a little leeway so I can try to take a minute or two extra with with each lady I meet without running too late by the end. My lunch break is officially 30 minutes, where I’d love to step outside and enjoy the beautiful grounds my hospital is in, but many days in obstetrics I barely have time to eat in the scan room, before washing my hands and continuing to run late.

I’d love to spend longer, explaining each part of the report, going into the parents particular concerns and signposting them to the appropriate person if I am not the one who can help.

Officially I need to work on my time management. I take too long, I must scan too slow or talk too much. My rescan rate is too high (at the 20 week scan, if we can’t see everything in one visit we are allowed to offer one rescan, which where I worked previously wasn’t ever counted or limited, but now I use that option too freely apparently and I must have less than 10% rescan rate), but that means I must scan for longer to see everything- it is unthinkable that I would say I had seen something when I hadn’t, but I do wonder what will happen when sonographers who aren’t as honest as I am, or feel more pressured than I do, get to this point.

I have been specifically told to talk less to parents before the first trimester screening test, because after a conversation, some mums decided against it. In my old trust we were told, as Band 7 staff in the process and the person about to do the test, that we had to be sure the ladies really wanted it- and check they have heard the potential outcomes including that the diagnostic test, with a risk of miscarriage, may be offered. Where I work now I may ask if they’ve discussed the test with their midwives, have they seen the booklet, but I must not ask enough for me to be confident about the information they have, because their community midwife takes responsibility for this.

Screening tests are an option, not compulsory part of pregnancy. Many women I meet wouldn’t dream of having a pregnancy without a scan, but its not an informed choice if the mum gets in the scan room before she realises the scan is optional-this is something that happened last week.

My personal choices around scans have changed over the years, going from wanting everything going first time around, to having none with my third. I found the anatomy scan with my second child a hugely anxious time, knowing the potential conditions that could be diagnosed, and the huge number of abnormal but unexplained things that might be seen, and of course the range of conditions that a scan would never detect.

A dear friend had a devastating diagnosis at a 20 week scan before my third pregnancy, which meant baby needed delivering at a specialist centre for the best chance of survival, and I was hugely affected by how the family were affected by the diagnosis and the stress throughout the final 20 weeks of pregnancy. Their experience and my attempts to support them made me evaluate exactly what I would gain or lose from scans in my third pregnancy, and, for me, at that time, the decision was not to have scans. The same events affected other people differently, and they tell me they wouldn’t dream of not having a scan after being involved with such a tough experience, which I can completely understand, appreciate and support. I’m not planning more children, but if I did I would have to consider it all very carefully- I don’t know if I would opt for scans or not.

In the first trimester screening scan, sometimes called the NT scan, sonographers are audited in a few different ways. Where I work we have one 30 minute appointment, and if we can’t obtain measurements that meet the national screening committees criteria, then we must offer the quad test. So, we get audited on how many ladies end up being offered the quad. We are audited that our images meet standard criteria. We are audited that our measurements fit a national expected scale- and steps are taken if we don’t meet all these criteria. It isn’t too hard to meet these criteria in a baby that is lying in the perfect position, but the position of baby is one thing outside of our control.

I imagine this scan will be around for a while yet, though I am glad to know non-invasive prenatal screening has been around in private practices a while and hopefully will become more widespread in the NHS in years to come – this blood test is a much more sensitive and specific screening tool, but it is currently quite expensive.

Something else sonographers do that causes conflict is limit the number of people in the scan room, and warn that noisy or disruptive children may need to leave. If there is an accompanying adult then they miss the scan by having to leave with the child, or the scan may be abandoned if the mum is the only adult with unsettled children. I have tried to continue to scan while a child was working very hard to stick their fingers in the fan, run around, screamed constantly, but these are situations where I have to stop before I make a mistake.

It is also very difficult to concentrate when an excited parent/grandparent has someone extra to talk to. The rare time I break the rules and allow someone extra in, I have usually regretted it. I must need further training in being politely assertive to obtain the quite atmosphere I absolutely need to concentrate on seeing all the structures I need – in the given time.

If I scan in silence, I am complained about for being too serious- so I try to keep a light hearted, pleasant line of conversation going while I stare at the screen intently concentrating, looking for potentially life threatening problems with baby. Its a situation perfect for misunderstandings.

Keeping the chatting going is much harder on those days I have a bit of a headache, or my 3 year old has had a bad night, or my 7 year old had a nightmare. I suppose I might call in sick for not being on top form, but the team I work with is so small so I know parents may turn up for long-awaited appointments and be forced to rebook, or my colleagues might try to squash extra scans in an already full list- with all the usual pressures still standing for making it a pleasant scan, not rebooking, etc. And of course, like any business, sickness records are kept and if you take sick time too often, then steps are taken.

I’m struggling at the moment. Concentrating non-stop, knowing mistakes mean huge potential consequences for families, doing it all against the clock and targets is draining me. By the end of my working week I usually feel too exhausted to cuddle my kids before I crawl into bed, unable to cook or eat tea, straight from work, hoping I can take time out of family life to recover from my week. My head hurts, I keep going faint, but the GP says there’s nothing to worry about. My sickness record is something else to worry about. I can’t cut my hours- I think I could probably cope if I were doing it less. If I could have some time for catching up at the end of my lists, I think I could do a better job.I work with a good team, but the managers don’t seem to get the pressure they are putting on us. But then, I don’t know what pressure they are under. I suspect my manager is struggling, but trying to keep it private. She is taking unpaid leave to try to keep going, but scheduling it has been almost impossible. The needs of the service come first.

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Why Your MSLC Matters

Maternity Service Liaison Committees (MSLCs) provide a means of ensuring the needs of women and professionals are listened to and we saw how effective they could be when properly supported and led.”

National Maternity Review February 2016

“I urge you to play your part in creating the maternity services you want for your family and your community. Voice your opinions, just as you have during this review, and challenge those providing the services to meet your expectations.” (Julia Cumberlege, Chair of the Review Team, 2016)

These quotes really illustrate why MSLCs matter. They sum up why I am so passionate about maintaining and sustaining our wonderful Maternity Services Liaison Committee and helping others maintain theirs.

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Because I have seen the difference a dynamic, properly supported, MSLC can make to a hospital Trust. Bromley MSLC, like its counterparts throughout the country, is a mix of individuals including commissioners, service users, midwives, doctors and other professionals coming together to monitor and improve local maternity services. The respect that everyone has for each other is evident in our meetings and some of the lightbulb ideas that arise are extraordinarily exciting. I tend to come away from meetings with my head reeling, but also tremendously grateful that we have this group of extraordinary passionate, dedicated people working and living in our area.

MSLCs were first established in 1984, enabling women to be involved in shaping the maternity care provided for them. The Department of Health suggests there should be an MSLC for each Trust in England and Wales. The Health and Social Care Act of 2012 states that health services at every level need to actively engage with service users:

  • Participating in planning and making decisions about their care
  • Enabling effective participation of the public in the commissioning process itself
  • So that services reflect the needs of local people.

Recommendation 13 from the 2015 Kirkup report into the Morecombe Bay Investigation also highlighted the importance of MSLCs.

MSLCs matter because…..

  • They are the only multi-disciplinary committee of its kind in maternity, bringing together commissioners, NHS Trust staff AND the women for whom the service is designed. One third of the committee is made up of service users, including a service user rep chair and vice chair.
  • They are independent NHS working groups that advise on commissioning and service development
  • They should include service users from all parts of the community, ensuring that all women’s voices are heard.
  • They promote collaboration and involvement
  • They plan, oversee and monitor maternity services in a local area and make recommendations for improvements where necessary.

They are one of the few examples in maternity where there is true collaboration between healthcare professionals and service users on equal terms at a local level. This leads to a much greater understanding between both parties of the challenges that are faced and the issues that really matter to local women.

The National Maternity Review also highlights the consensus among health professionals to change things for the better. Nowhere is this more evident than on an MSLC!

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MSLCs can achieve amazing things:

They plan…..together with the commissioners, service users have the unique opportunity to help shape the future of the maternity services in the local area. For example, because of user testimonials provided by our MSLC to the clinical executive, a new perinatal mental pathway is being developed in our local area by the CCG, which will greatly benefit thousands of women.

They oversee……our MSLC is involved in one off projects designed to improve maternity experiences for local women. We have designed information posters, are having an input into a “Welcome to the Ward” postnatal pack and have helped improve the birth environment on the Labour Ward. We also make tours of the wards, bringing a service user perspective and a fresh pair of eyes to the environment.

They monitor……our MSLC gains feedback from women through surveys, questionnaires and Walk the Patch both in the hospital and more recently in children centre health clinics in the community. That feedback is given directly to the lead health professionals of the Trust as well as the commissioners, who listen and act on our recommendations. Those improvements are then fed back to the service users, via social media and other means, so that we close the loop.

This type of work is not just being done by our MSLC. I know of countless other committees which are tirelessly working to improve services in their local area too. Our brilliant vice chair Michelle Quashie is planning a Women’s Voices conference in October and has asked me to present the achievements of our MSLC and others around the country, demonstrating how effective collaborative working can be. I am looking forward to showcasing just what has been and can be achieved then.

At our recent Whose Shoes event pledges were made at the end of the workshop about something that the delegates would do differently as a result of that day. These pledges have formed the workplan for our MSLC for 2016 and we will check to ensure that they have been carried out. MSLCs are true examples of #MatExp in action at a local level.

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We were also really pleased to see the importance of MSLCs highlighted on our beautiful graphic courtesy of New Possibilities.

For this blog I asked members of other MSLCs for their thoughts on why MSLCs matter. Responses included:

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Catherine Williams has written a lot about the importance of MSLCs in her blog https://birthandbiology.wordpress.com/

And from our MSLC Leaders Facebook group:

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And this from our vice-chair Michelle Quashie:

“MSLCs matter because it is gives all that are passionate about a Women’s Maternity experience a chance to join forces and make their hopes for better birthing world a reality.  It enables all members to be involved in ensuring this happens. It allows true collaborative working and keeps service users involved in decisions made about women’s maternity care and that of their family. It’s a safe place where women’s voices are heard, valued and respected. A Women’s experience is its driving force for that reason I am proud to be part of such a dynamic committee.

Initiatives like ‘Walk the Patch’ enable all women’s voices to be heard regarding the maternity care they are receiving. These voices from the community can then be filtered back to senior levels and actions are derived to improve the service as a result. WTP also gives the chance for those HCP that are providing truly women entered care the recognition they deserve.

I joined the MSLC after feeling very let down buy my personal maternity care. I knew I had to help change things for other women. Being part of the MSLC has enabled me to do that from the inside out. The work we have done and the wonderful HPs I have worked with has helped to restore my faith and feel empowered by being part of making change happen for others.

I hope that MSLCs get the recognition and support for the amazing work we are doing across the country. All that give up their time, do so because they are passionate and dedicated. MSLC’s should be mediatory for all trusts. How else can you ensure a woman centred service is given without women voices being heard in order to influence that service?”

Refreshed guidelines from NHS England, due for imminent publication, call for MSLCs to be run, maintained and funded by the CCGs. This is much needed, because in the current economic climate many MSLCs are fighting for modest but essential funding to continue the collaborative work they are doing. In addition, due to the unique nature of these committees it can be difficult for the commissioners to work out a mechanism for funding.

It is against this background, while MSLCs are struggling, that Julia Cumberlege, chair of the National Maternity Review, urges women in her introduction, “play your part…for your family and community … voice your opinions” as quoted at the top of this blog. MSLCs provide an ideal forum for service users to do just that. They are the ‘best practice model’ for shaping the future of our maternity services.

A petition has been started to emphasise the need for MSLCs in all areas. Please consider signing and sharing this petition so that MSLCs can continue the vital collaborative work they are doing at a local level, with volunteers’ expenses paid and commissioners everywhere listening and learning. https://petition.parliament.uk/petitions/121772

If you are not already involved with a local maternity group that feeds into an MSLC – or the MSLC itself, search online to see what you can find out about local provision. Contact your local CCG, your head of midwifery, local Healthwatch, or any pregnancy and parenting groups, such as the NCT and find out what’s happening. You can find out more about MSLCs at https://www.nct.org.uk/professional/mslcs

Laura James

Chair, Bromley MSLC

2016

Facebook: http://www.facebook.com/bromleymslc

Twitter: @BromleyMSLC

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Musings on the 2015 CQC Maternity Survey

Flo

I have been mulling over a few thoughts about the CQC Maternity Services Survey 2015.

With the launch this week of #YourMaternityCare campaign by the Care Quality Commission (CQC) encouraging women to share their maternity experiences now seems as good a time as any to share some of my thinking and importantly ask some questions.

To be clear I am not going to talk scientific methodology, survey design or validity, I am simply going to share some personal ideas as an obstetrician and a member of the #MatExp gang and question if we could use the survey to challenge ourselves in a more creative way.

What sort of impact does this sort of survey have on the care women receive?

The answer to this may depend on how you view the results. It can be examined at a national level looking at care across the country and comparing with previous years to look at trends and themes.

Undoubtedly this survey showed better experiences overall than in previous years and this is good news. An excellent example is the increase in the number of women receiving care before 10 weeks of pregnancy, with a big potential impact on eventual outcome. It is important to take time to give ourselves a collective pat on the back and celebrate those improvements as it can be so easy to focus only on the negatives.

For a great visual overview, take a look at the infographic produced by Picker.

On a regional level the 2013 Maternity survey and the negative results of some London Trusts was actually one of the sparks that led to the London Maternity Strategic Clinical network focusing on ‘Patient experience’. Therefore it directly led to the ‘birth’ of #MatExp and our collaboration with Gill Phillips to produce a maternity version of her Whose Shoes game and development of a workshop toolkit & examples of best practice.

So that’s another positive: the resulting #MatExp change platform and community of people interested in improving maternity experience therefore could be said to be a direct result of the 2013 survey.

We can examine hospital level data and see how a maternity service changes over time, and how women respond on specific questions. This can help us identify a particular area that needs improvement, such as continuity or postnatal care, as well as giving positive feedback about what is working well. It can help us benchmark our services against others locally or nationally. It is undoubtedly a valuable data point even if it has limitations and exclusions however it is only one of many ways we should be looking at feedback.

Most Trusts will have an effective governance system meaning that the results will be reviewed and circulated, an action plan devised and those actions systematically ticked off when completed.

We need to be cautious as it can become all about process and tick boxes if we are not careful, held at management level and a little detached from both those in daily practice and our service users.

I wonder how many Trusts have worked proactively with their Maternity Service Liaison Committee (MSLC), staff and service users since they received their individual 2015 reports to identify what improvements would have the biggest impact for their women and to look at how their survey results correlate with other methods of feedback they use?

Moving on to some specifics now, the very first sentence in the recently published CQC response to the survey results is a shock There are almost 700,000 live births each year in England. Having a baby is the most common reason for a hospital admission.’  

Why is this?

According to the National Tariff benchmark data 65% of women are ‘standard’ i.e. do not have a complicated antenatal period and therefore are ‘healthy’ pregnant women.

Therefore, the first challenge from the results is why are so many of these births happening in hospital. It probably has something to do with the fact that the survey showed 63% of women who have given birth previously were definitely given enough information about where to have their baby, falling to 53% of women giving birth for the first time. This presumably means large numbers of women are not getting adequate information.

I’m not going to recap NICE Intrapartum care 190, but we know it provides evidence that for healthy pregnant women who have had a baby before we should be explaining birth at home or in a midwifery led unit is likely to have less intervention and the same outcome as delivery in a hospital.

Across the survey results first time mothers seem to be getting a worse experience with consistently lower results than women who have given birth previously. Is this because we are doing something different for first time mothers, is this because we should be doing something different or is it simply that the different groups of women have different expectations? Do first time mothers have higher expectations and are then disappointed whereas mothers who have given birth previously have lower expectations as they know what it was like last time?

In amongst some good improvement scores remain worrying minorities. 89% of women said that during their antenatal care they were “always” spoken to in a way they could understand – up by 7 percentage points since 2007 (82%). However, this means that 11% were not “always” spoken in this way.  87% of women reported that they were always treated with dignity and respect during labour and birth compared to 85% in 2013, but what about the 13% that were not? Surely these are the fundamental basics of care and should be true for every single woman. What are we doing about these women? Can we identify who they are, are there specific groups we are not catering for or not understanding what they need?

Don’t even get me started on lithotomy: ‘The proportion of women being in a position of lying with legs in stirrups whilst having a normal vaginal delivery has seen a steady increase over the past few years going from 17% in 2010, to 19% in 2013 and 22% in 2015’. What on earth is this all about? In 2015 I undertook a lithotomy challenge on NHS Change day and you can read about my experience in the blog I subsequently wrote.

Postnatal experience is clearly lagging behind antenatal and labour care with much lower figures sitting in the approx. 50% region on all aspects of care including physical and emotional wellbeing. Collectively we need urgent action to address this? But the need for collective action raises a problem. Within the NHS we now have this terrible dilemma collaboration versus competition.

The CQC Response to the survey results clearly highlights Trust who have performed better or worse than expected in the last two surveys. If we accept that these results are valid and not a difference in expectations or different for other reasons, then as a simple solution we could potentially buddy up good performing Trusts with poor performers.

However, Trusts are individual organisations. The strategic clinical networks and NHS England can influence, but there is no obligation for Trusts to help others. If we work at a good Trust what is the incentive to share what works? Pure altruism goes some way, but when you face difficult budget choices and competing demands collaboration can be an easy casualty, and as health care professionals what responsibility do we have to try and improve quality outside our own immediate practice?

I certainly don’t have all the answers. For me #MatExp is some attempt at trying to improve and discuss many of these issues on a broader scale, ignite a lively conversation about maternity care and to encourage others to think that they can influence positive change however big or small.

Florence Wilcock

2016

If you are interested in joining the conversation or taking action on improving maternity experience in anyway jump in and join us on Twitter (find tweets tagged #MatExp), join our group on Facebook, or send us a message.

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