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:
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And yes, I will be doing a “Men’s Voices in #MatExp” series too. Because this campaign is about all voices.
Florence Wilcock writes:
“One of the strengths of #MatExp is to try and hear all voices with respect and understand different perspectives so that we can work together to improve maternity experience.
Obstetricians have been an especially hard group to involve , I have written before about the traditional ‘bad press’ we seem to receive. I included it as a topic in the #matexpadvent Steller series you can read it here https://steller.co/s/5AduBaxWL6v
I am therefore especially delighted to introduce a brave #FabObs blog, one of a couple that are hopefully coming our way. Some of this may be distressing, some of it may be unpalatable but I ask you to take a deep breath challenge your assumptions & read! Don’t ‘bash’ the author she is giving you a peek into her world, a world fairly typical of many obstetricians in todays’ NHS . Take this unique opportunity to have sight of what it is like to be in ‘our shoes’ that way we can have the difficult conversations that move us forward.”
My name is Ruth-Anna, I’m 32 and a Mum of two busy, lively and opinionated little people aged 2.5 and 5. I’m also privileged to work as a doctor in obstetrics and gynaecology. My official title is ST5 doctor, which means I’ve been specialising in obstetrics and gynaecology for 5 ‘years’ (after 6 years at medical school and 2 years of moving around specialities). However it’s actually nearer 6.5 years since I started specialising, because of having time out for having babies, and working part time (I work 35 hours a week and spend two days at home with the kids). At the end of my ST7 ‘year’ of training, all being well, I’ll be able to apply for jobs as a Consultant but right now that feels a long way off!
This is a day in my life… (all events and women are fictionalised, of course)
My alarm is set for 6.45 but the kids usually wake me up first. I get up & dressed, grab some breakfast (if I’m organised enough!) wave goodbye to the kids & husband and jump on my bike. It’s a Saturday so the cycle into work is pleasantly peaceful and I enjoy a bit of headspace. My job is incredibly varied and over the course of a week I could be seeing women in antenatal clinic, gynaecology clinic, on our day assessment unit (walk in for pregnant women with concerns about themselves or their baby), operating in gynaecology theatres, scanning women, looking after women who are inpatients for any gynaecological or pregnancy-related problems, seeing women in A&E with acute gynaecological problems, or covering the Early Pregnancy Assessment Unit.
Today, however, I’m working as the Labour Ward ‘registrar’. I’ll be working with an ‘SHO’ (in newer terminology, this could be an FY2, an ST1 or ST2 doctor), who may or may not be specialising in obstetrics and gynaecology, as well as my Consultant.
I’m in work by 7.45 and change into my scrubs, to head into our handover meeting for a prompt start at 8am. All the midwives, obstetricians and anaethetists for that day on Labour Ward are there. Our night team counterparts inevitably look pretty knackered and relieved to see us.
Some days we take over and there are only one or two women on the Labour Ward but today it’s a busy one. As we talk through the women, one by one, I’m thinking what the risks might be for that woman and baby, predicting and preventing any problems and pre-empting potential issues. Hopefully none of those will happen but our job is largely about predicting problems that never happen, so that we can be prepared for when they do. Even so, a day on Labour Ward is unpredictable and filled with surprises. My current hospital saw around 6000 babies delivered here last year and it serves a fairly ‘high-risk’ population, with above average numbers of women with a high BMI, older mothers, women who may have come into the UK recently, women with multiple pregnancies or concurrent medical problems. We also have women who are transferred in to us from other places where the NICU or SCBU don’t have the facilities to look after the smallest or sickest babies.
Women expected to have totally uneventful labours are normally on our Birth Centre and I won’t generally be involved in their care unless there’s an issue that the midwives ask me to help with. Myself, the Consultant, SHO, the Anaesthetist and the Labour Ward Co-ordinator (Midwife in charge) do a ‘ward round’ of all the other women – to introduce ourselves, find out more about her and how things are progressing, and make a plan, if anything else needs to be done. This morning there are 12 women on Labour Ward. The first woman we see had a Caesarean section overnight and lost a lot of blood. She’s having ‘high dependency unit’ care and is currently having her third unit of blood transfused as she had a very low haemoglobin level due to the blood loss. We assess whether she has had enough blood replaced, whether there are any signs of further bleeding, and whether she needs any further treatment. She’s understandably shell-shocked and we go through the events of the night with her and her husband. Her baby was taken to the NICU and her priority is getting well enough to get into a wheelchair so she can go and see him there.
Next we see a woman who’s tragically had a stillbirth. She attended the day unit at 38 weeks into a normal pregnancy with reduced fetal movements, and it was confirmed the baby had died. Her labour was induced yesterday and she’s spent the night trying to come to terms with what has happened. Understandably she has lots of questions for us, which we do our best to answer. I offer her some medication to suppress her breastmilk production and give her some information to consider about a possible post mortem examination for the baby. We offer her the choice of going home today or staying another day and she will think about it and let her midwife know.
We complete the ward round, seeing a woman with a straightforward labour who is on the Labour Ward only because she has an epidural, a woman who previously had a Caesarean but is in spontaneous labour and all is well, a woman who is being induced for a post-dates pregnancy and a woman who has been admitted in possible preterm labour at 28 weeks.
The next few hours is a whirlwind of emergency buzzers and bleeps. Another woman has been admitted from the day unit – she’s had an uneventful pregnancy so far but at her midwife appointment today at 32 weeks her blood pressure was found to be dangerously high, with protein in her urine. Her midwife suspects she has pre-eclampsia and has sent her in to us. She needs urgent assessment my myself and my anaesthetic colleague, a cannula (drip), bloods taken, and medication to lower her blood pressure. She starts complaining of a headache and when we test her reflexes they are abnormal so we also recommend that she starts another medication (magnesium sulphate) to reduce the risk of having seizures. We need to see how she responds to the treatment but it’s likely we will need to deliver her baby imminently to treat the pre-eclampsia, so we also recommend the first of two doses of steroid to help mature the baby’s lungs. Her midwife calls the Neonatal team to check that our NICU have a cot available for this premature baby. She also asks them to come and speak to the woman to explain what to expect if her baby needs to be born prematurely. I perform a scan under the supervision of my Consultant which shows the baby is small and its fluid is reduced – this is a common effect of pre-eclampsia. We ask her not to eat and drink in case the baby needs delivering imminently (if she needed a general anaesthetic it’s important to have an empty stomach).
I leave my SHO administering the first dose of the magnesium sulphate as the Co-ordinator calls me to see a woman who is in the second stage of labour (fully dilated and pushing) whose baby is showing signs of significant distress. I assess the woman, and the fetal monitoring, and explain that I would recommend an instrumental delivery, to which she agrees. As the baby is already quite low in the birth canal I decide this can be safely achieved in her delivery room, so after giving an injection of local anaesthetic to block the my SHO and I perform a ventouse delivery and her baby is delivered with no complications.
I finally see a woman who has been waiting several hours to progress to the next stage of her induction of labour. We haven’t been able to proceed with things as we would have hoped due to the other situations that have arisen and the effect on available staffing levels. I explain this to her but she’s understandably upset and frustrated, as well as exhausted, and I leave the room feeling pretty downheartened.
It’s 3pm and I suddenly realise I haven’t eaten anything so grab a sandwich and a drink before heading back to see the unwell woman with pre-eclampsia. Her blood pressure still isn’t under control despite high doses of medication and my Consultant decides that we can’t wait any longer and that she will need to have her baby delivered today. At 30 weeks in her first pregnancy, with a growth restricted baby, the team decide that Caesarean will be the quickest and safest way of delivering her baby. She’s shocked – it certainly wasn’t what she was expecting when she headed to her midwife appointment that morning, but her partner has now arrived and she is willing for us to proceed. I talk her through the operation and explain the risks and benefits, before she signs a consent form. The Co-ordinator speaks to the theatre team to prepare everything, as I call my anaesthetic colleagues. Her midwife gives her ‘pre medications’, tight stockings to wear and gets scrubs for her partner to wear.
While with my sick woman I was asked to attend the Birth Centre to check whether a woman who has just delivered has a ‘second degree’ tear (that can be sutured by the midwife in her room) or a ‘third degree’ tear that would need to be sutured in theatre by me. As the anaesthetists perform their anaesthetic for the woman in theatre, I finally make it across to the Birth Centre and thankfully for the woman it’s a second degree tear. I apologise she’s been waiting so long for me – she’s lovely about it but I still feel bad.
I’m bleeped from theatre to say the spinal anaesthetic is working and they are ready for us to start the operation. I do her Caesarean, with my Consultant supervising in view of how sick she is and the fact the baby is premature. Thankfully it is an uneventful procedure and the baby is born in reasonable condition, although he still needs to go to the NICU. His mum comes back to the Labour Ward as she is still unwell and the next 24-48 hours can actually see a deterioration in her condition.
We sit down for a quick cup of tea and I feel guilty I haven’t tackled any of the computer-based tasks I have piling up, and the audit I’m trying to finish before my appraisal next month. Still, they’ll have to wait for another day. I check my phone and see 15 messages from home – thankfully it’s nothing urgent; they are just photos from my husband of the family party he and the kids are at today.
The night team start to arrive and I feel relieved. Today I’ll manage to get away pretty much on time, once we’ve finished handover. I need to send some electronic tickets to my Consultant so she can sign to say what she’s witnessed me doing today, for my appraisal. I know that if I don’t do it now I’ll forget. I’m out of the building by 20.45 and head home to wolf down the dinner leftovers. I spend the cycle home thinking about the women and babies I’ve looked after today, hoping all will be well, and wondering what I could have done differently. After 8.5 years as a doctor I’m pretty good at trying to leave all those thoughts behind – at least temporarily – when I put my key in the lock, although I do drop my night colleagues a quick text before bed to ask how the woman with pre-eclampsia is doing. She’s stable and I finally let myself switch off. Tomorrow is one of my days at home with the kids and I’m looking forward to taking my 5 year old to school and my 2 year old to toddler group.
Florence Wilcock writes:
“When I first read the blog I felt it pretty accurately captured a fairly ‘standard’ day on labour ward for an obstetrician. I recognized it absolutely & have spent many days similar to this over the years. The multitasking, prioirtising, constant juggling of clinical situations is quite typical. Some of it may feel dispassionate and lacking emotion, that doesn’t mean that the author doesn’t feel anything or that she doesn’t treat the women she sees with compassion and care it just means there is an element of self-preservation to enable one to take split second clinical decisions we need maintain an exterior calm. It is also essential so that we are not sobbing halfway through the shift or at the end of the day it enables us to be resilient and get up and do it all again the next day or to care for our own family. Imagine what it would be like if you were trying to do this job pulled from pillar to post how would you feel? This is where working as part of a fantastic multidisciplinary team becomes important, those of us that are lucky have wonderful midwives, nurses, midwifery assistants alongside us. If we are less lucky or those relationships are adversarial that can be very difficult as the support isn’t there. No obstetrician sets out to hurt or upset women or become a barrier they may be under huge pressure, having a bad day, feeling scared of that responsibility, worrying about an exam or appraisal. We are human too.
There is no fluff here , this is obstetrics in reality. There are one or two particular clinical situations that may distress you: such separation of mother and babies is never ideal & making the focus getting a mum to see her baby in NNU sounds so simple but can be harder than it sounds if people don’t work together & make it happen, A bereaved mum seemingly given cursory information and a very short hospital stay after such a life changing event is hard to read but sadly is the current reality , we know this needs improving hugely with better support during and after and a birth environment separate from the main maternity wards. A shocking sudden decision to deliver a baby preterm at 30 weeks. It is hard to write and hard to read and some elements can’t be changed they are clinical reality but amongst that the words we use, the understanding we have of how it might feel both for families and those caring for them there are plenty of things that can be done to improve care.
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.”