Maternity Experience

Positive Maternity Experiences

Caesarean sections

On Monday, to begin #ExpOfCare week, we had an insightful blog from Dr Sarah Winfield reflecting on her experience of taking part in the ‘Lithotomy Challenge’. And today, to end #ExpOfCare week, another #FabObs, Dr Florence Wilcock – the originator of the #LithotomyChallenge and co-founder of #MatExp – tells us all about Caesarean sections and what really happens…

Dr Florence Wilcock

As we come to the end of #ExpOfCare week, I would like to share a blog about Caesarean sections, to demystify the birth that mothers and partners may unexpectedly experience. I originally wrote this blog at the request of Milli Hill & the positive birth movement in October 2016 , subsequently this has been included as a contribution to Milli’s book ‘The Positive Birth Book’ published 16th March 2016.

Why do we need to talk about Caesarean sections?

Unfortunately, sometimes people can be prone to making value judgements about different types of birth. One of the most common examples is vaginal birth = good and Caesarean section = bad. The truth is that in the UK current statistics show 25% of women will give birth by Caesarean section, 10% planned so called ‘elective’ and 15% unplanned ‘emergency’. We can argue these rates back and forth; we can aspire to improve care and change these facts, but for the moment given that 1in 4 women will meet their baby in the operating theatre it is vital that we talk openly about this experience and how it can be a positive, emotional & fulfilling birth for each new family.

Even in an unexpected ‘emergency’ there are still choices to be made. Nice guidance on Caesarean section CG132 section 1.4.3.4 recommends 4 categories of urgency; only category 1, the most urgent suggests delivery within 30mins. Far more common is the ‘emergency’ caesarean category 2, delivery within 75mins of decision making. This gives a woman time to express contingency birth preferences and ensure that even if she did not plan a caesarean birth it remains a calm and positive start for her and her baby. Skin to skin in theatre, optimal cord clamping, birth partner announcing the sex of the baby, choice of music are all possible. I would love to say these are all standard in every hospital but unfortunately that wouldn’t yet be true, however the more women know and ask, the more these will become universally accepted. As I often say ‘Wrong is wrong even if everybody is doing it and right is right even if nobody is doing it’. I wish you all an interesting and positive month discussing Caesarean birth and would like thank Milli for inviting me to contribute & become part of it. If you want to know more about how I am working to try and improve maternity services do check out matexp.org.uk

Caesarean Section a theatre experience & Who is who in the operating theatre? 

The majority of caesarean sections in the UK will be done under a spinal anaesthetic, that is numb from the nipples downwards. It’s a peculiar feeling as one can feel touch but not pain. It means that women will be awake and aware of people milling around them which can be daunting but it also means they are awake and ready to meet their new baby. Lying on the operating table we tilt women slightly to their left to keep the bump of the baby off the major blood vessels, this prevents dizziness from low blood pressure. If you lie on the operating table in the maternity theatres at my Trust you will look up and find butterflies & cherry blossom on the ceiling, something nice to focus on while you wait for your baby to arrive. I know this is unusual & we are lucky but there is nothing to stop you tucking your favourite picture or photo in your birthing bag so that you have something familiar and relaxing to look at.

It might seem odd that at the start everyone in the theatre will introduce themselves to one another. It isn’t that we have never met but its start of the World Health Organisation (WHO) safety checklist. There is a special checklist just for maternity theatres and it is routine to start by checking simple information such as the woman’s name and date of birth and move onto clinical issues and equipment and it is all aimed at making the experience as safe as possible. So, who are all these people around you and what are their roles, why are there so many people there?

Anaesthetist: At least one sometime two; these are doctors who will administer the anaesthetic ad monitor you closely during the surgery. They will be standing just by your head and often chat to you and reassure you as the operation progresses. 

Operating Department Practitioner (ODP): at least one; their role is to assist the anaesthetist, getting & checking the required drugs, drips or equipment, the anaesthetist cannot work without one being present.

Obstetricians: at least two; one will be performing the Caesarean section (the surgeon) the other will be assisting (the assistant) e.g. cutting stiches, holding instruments.

Midwife: At least one; to support the woman and help her with her newborn baby when it arrives

Scrub nurse or midwife: At least one; To check, count all needles, stiches and instruments and to hand them to the surgeon when needed.

Midwifery assistant or runner: This person double checks the swab and instrument count with the scrub midwife or nurse and ‘runs’ to get any additional equipment required as they are not ‘scrubbed up’ so can go in & out of theatre to fetch things.

Paediatrician: asked to attend any ‘emergency’ situation or if there are known concerns about the baby.

So, you see in theatre there is a minimum of seven people caring for any woman all with specific tasks to perform, any complication may result in us calling in extra members of the team.

So back to the woman, she will be on the operating table with her birth partner by her side and the anaesthetist and ODP close at hand. She can often choose the music she would like her baby to be born to. The anaesthetist needs to monitor her heart with sticky labels but these can be put on her back and her gown left loose leaving her chest free and ready for skin to skin with her baby. A sterile drape will be placed over her bump and this is usually used to make a ‘screen’ so that the woman doesn’t see and surgery she doesn’t wish to see however usually we drop this when the baby is ready to be born.

Many hospitals are starting to explore options of optimal cord clamping (waiting to clamp the cord) and passing the baby straight to the mother if the baby is in good condition. These can be done but need to be thought through so as not to contaminate the sterile surgical area, and the surgeon needs to be confident no harm such as excessive bleeding from the womb is happening whilst these things occur. Surgical lights need to be on so the surgeon can see clearly and operate safely but I know one anaesthetist who works in a hospital where the rest of the theatre lights can be dimmed. The mum and new baby can be enjoying skin to skin whilst the rest of the operation proceeds. Weighing and checking babies can be also done at this time but also can be done later on.

Traditionally if we operate with women under a general anaesthetic (asleep) her birth partner has not been in in theatre as their role is to support the woman. Recently on several occasions I have challenged this so that a baby is welcomed to the world with at least one of its family present and awake rather than by a group of strangers caring for the unconscious mother. There are safety considerations to be talked through for this to be successful but it is possible. However, kind and caring staff are, they are no replacement for a birth partner whom the mother has chosen to support her in the intimacy of birth.  

I hope I have given you a brief glimpse in to life in a maternity theatre. As an obstetrician, I am privileged to help bring many women and babies together for those special first moments. The emotions are always different for me: sometimes it is a couple I know very well and have bonded with over months or years, sometimes a woman I have only just met who has had to put her absolute trust in me immediately. The theatre atmosphere can range from almost party like jollity to quiet intimacy. Every birth is different; each birth is extremely special just as much as the births that happen in a less clinical environment and each birth will stay with that woman forever. 

Useful CS references

Ref NICE CG132 https://www.nice.org.uk/guidance/cg132/chapter/1-Guidance#procedural-aspects-of-cs https://www.nice.org.uk/guidance/cg132/ifp/chapter/About-this-information

RCOG Consent advice No 7

https://www.rcog.org.uk/globalassets/documents/guidelines/consent-advice/ca7-15072010.pdf

 

 

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#MatExp Whose Shoes? update

Some really exciting developments with #MatExp Whose Shoes? at the moment.

Bromley MSLC produced a ‘one year on’ report following up on their Whose Shoes? workshop at King’s College hospital using “I said, I did” as a framework to list all the fantastic outcomes that had come from pledges made on the day.

Language continues to be a big issue for women and families, but some great initiatives are now happening. Building on the Whose Shoes? workshops, Leeds and Colchester in particular are working on specific language challenges. I came up with a ‘Negativity Bingo’ and had great fun with my team at the NHS Fab Change Day #DoAthOn event launching #DumptheDaftWords.

I have been getting some exciting invitations to speak about building social movements and of course gave #MatExp a big shout out in my talk at the launch of #AHPsIntoAction, they have invited me back for a longer keynote session at their annual conference in June.

More hospitals are coming on board with the Whose Shoes? approach – the energy is particularly strong in London, the West Midlands and the South West regions. It has been great to present on several occasions now with Catherine MacLennan and Emma Jane Sasaru and to see people learning so much from their courageous sharing of their lived experience.

Last Friday, 3 Feb 2017, we were invited to present a #MatExp Whose Shoes? session to get some good discussions going as part of a packed event launching #PanStaffsMTP in Stafford. We concentrated specifically on continuity and perinatal mental health. This is the county-wide transformation programme to improve maternity experience in Staffordshire to implement the national ‘Better Births’ vision. This informal film gives you a flavour.

We are proud of the crowdsourced ‘Nobody’s Patient’ project and thank everyone for your fantastic contributions. We now have over 120 new Whose Shoes? scenarios and poems and the new resources will be made available shortly to all the hospitals who were existing customers. Florence Wilcock, Sam Frewin and I are finalising the supporting toolkit and collating the case studies, ahead of our ‘wrap up’ event in March. We are trying to pull together lots of ideas for positive change, with or without a workshop. I hope you are enjoying the regular Steller stories, including Florence’s monthly reports.

Wonderful to see everyone doing such amazing work, speaking all over the place, building networks, spreading the word and generally making great things happen.

Keep up the good work!

Gill Phillips @Whose Shoes

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BECAUSE OF YOU I DIDN’T GIVE UP: +ve #MatExp

Welcome to the start of ‘A Catalogue of Maternity Experiences’. Rachel @enduringdelight from This Woman’s Work Blog gets us started with her positive maternity experiences and how they inspired her. We hope this motivates you to share your story too.

Read “An Important Catalogue of Your Maternity Experiences” to find out more about this #MatExp action, and submit your story.

Rachel's Positve MatExp story

I am by no means as eloquent when writing as some of the other members of the #MatExp community, but after seeing this tweet from the inspirational Sheena Byrom and following a suggestion from the lovely Helen Calvert I felt it really important to write this post.  As Fab Obs Flo once told me, outside of my comfort zone is where the magic happens (thanks Flo!).

“I’ve learned that people will forget what you said, forget what you did, but people will never forget how you made them feel.” – Maya Angelou

This quote pretty much sums up the story of our children’s births.  I will never forget how the people who cared for us made me feel and how they changed my life.

Rachel at teaI’m Rachel, mama to (almost) 7 year old boy/girl twins and our youngest little boy who is 3½ years old.  I’m also now an NHS Breastfeeding Peer Supporter, MSLC Vice Chair and birth junkie with a particular interest in improving birth experiences for families and the relationship between attachment and neuroscience.

I can’t even remember how I stumbled across #MatExp , but it is an amazing movement; it excites me to know that there are many other people out there as passionate as I am about supporting families to have the maternity experience they crave.  For a long time I thought that my passion for positive birth and all of the issues surrounding it might just be a bit odd!! I don’t contribute to #MatExp as much as many or as much as I would like, but it is a privilege to be part of that community and so I am very grateful to some of #MatExp’s lovely ladies for encouraging me to persevere with writing this when I was struggling.

If you follow #MatExp you will know that, sadly, for a lot of the amazing people contributing to this grass roots movement inadequate care or a negative experience was their catalyst for getting involved.  For me the complete opposite is true, but sometimes that makes things difficult for me because in certain circumstances it’s really hard to talk about having had positive birth experiences as I feel like somehow people may interpret that as me being critical of theirs.

A positive birth experience for me was always going to be a physiological one, but I am not militant about it and I don’t believe that’s what everybody should have.  Moreover I believe that a birth that deviates from a woman’s ideal can still be positive if that woman is consulted, supported and given options rather than dictated to.

Having beautiful birth experiences and successful breastfeeding journeys are what drove me to become involved in movements like #MatExp and peer support.  I’m all too aware that sadly not everybody is as blessed as I am to have had experiences like mine, but I really feel like they should be.  It shouldn’t be a lottery that thankfully I won.  Every woman should be listened to, respected and involved every step of the way in her own and her baby’s care.

“Do the best you can until you know better and when you know better, do better.” –Maya Angelou

My maternity experiences were very different, but positive in their own right.  In hindsight there are things I would change if I could go back and there are things that weren’t ideal and that health care professionals should and could have dealt with differently, but that doesn’t make them a negative experience.  In fact the only reason I know that there are some things I would change and things that could have been done better is because of all of the things I have learned since, but if my birth experiences hadn’t been positive to begin with I wouldn’t have been propelled into the world of positive birth and maternity experience and so would have been none the wiser.  

The birth of our twins involved an induction at 38 weeks and 4 days gestation.   I see so many negative things written about induction that it is important to me to write about this.  I’m not writing about the process of induction and how good/bad this is for women and their babies.  What I want to write about is the fact that, if you have knowledgeable and respectful people caring for you it can be a positive birth experience even if it is not your ideal.  I am so grateful to the midwife who cared for us when our twins were born.  To be honest I think she was the catalyst for my passion for birth and the person who gave me the confidence to decide on a home birth for our youngest son.

Rachel Twins Positive Maternity Experience

I’d had a very straightforward multiple pregnancy and so despite being classed as “high risk” (a label I despise) I hadn’t needed much care at the hospital other than routine appointments and so was quite nervous about how I would gel with midwives caring for me when the time came for our babies to be born in hospital.  I need not have worried; as soon as Carmen walked in the room she came across as so knowledgeable and this gave me complete faith in her from the outset.  It was clear that she had every confidence in my body’s ability to do its job which in turn gave me that very same confidence.  After all, if she thought I could do it then why wouldn’t I?  

Something that particularly stays in my mind is her supporting my decision to not have an epidural. I had never wanted one, but the anaesthetist was fairly insistent on me having one almost as soon as the drip was in my arm and I think I would have given in were it not for Carmen; instead when she could see the conversation was becoming too much for me she delicately stepped in and dealt with it whilst remaining respectful and professional towards her colleague. I remember feeling so grateful to her for that and so relieved to not have to fight for what I wanted.  

“Drinking tea intelligently.” –Tricia Anderson

Our twins were born about 8½ hours after my syntocinon drip was started.  I remember Carmen talking me through each stage of the induction; she read my birth plan and made sure that I didn’t remain on the bed and that I got breaks from the CTG trace, she got a rocking chair to allow me to be more upright and off the bed, dimmed the lights and left us to it as much as possible, but without ever being more than a stone’s throw away.  She really did drink tea intelligently!!  Even when she was drinking tea for real on her break I was her priority and she came back when I begged for her to.

Three years later I found myself excitedly planning a homebirth for our third child in our teeny terrace house. There were a couple of little administrative hiccups, but each midwife I came into contact with was positive and enthusiastic about our plans which made me feel really confident about our decision.  

Rachel with newborn Positive MatExp

When the day came for our little boy’s birth I was blessed to have the support of another intelligent tea drinker; familiarizing herself with my birth preferences and facilitating them; Lorraine was a quiet, reassuring and confident companion and exactly what I needed.  Although she hadn’t been my named midwife I had met her at a routine appointment and as soon as she arrived at our home on my son’s birthday I remembered how enthusiastic she had been about my plans for a homebirth when I had seen her all of those weeks before so I immediately felt calmed by her presence.

It was a very straightforward, if a little speedy, birth and with the aid of a tens machine, some hypnotherapy and a little gas and air our son was born in water less then two hours after Lorraine arrived and probably only about 20 minutes after the arrival of the second midwife. They stayed with us for a couple of hours or so after the birth; helping my husband to tidy up and ensuring we got breastfeeding off to a good start, being attentive, but respectful of what was an important time for us.

Rachel with family

The midwifery team’s apparent confidence from the outset in the decision we had made to have our son at home as well as Lorraine’s confidence in her own ability as a midwife and my body’s ability to deliver our baby served to make me more determined to support other women and help them to achieve a birth experience that they were happy with.  This is how I came to become involved in our local MSLC just a few months later; I wanted so much to make a difference.

It goes without saying that when mistakes are made we need to learn from them and make sure that those mistakes never ever happen again; I’ve worked for solicitors on birth injury cases and am all too aware of the devastation that can result from human error.

In addition though it is vitally important that we learn from the positive.

There are many midwives (and other healthcare professionals) who are wonderful at their jobs and passionate about the care they provide.  These people have life changing positive impacts on families every single day and I feel so strongly about the fact that best practice should be shared and celebrated so that it can be replicated by others and that’s what I wanted to do today and to achieve in writing this. I wanted to share my positive experiences and celebrate the midwives who made a difference to me and to my family; I will forever be eternally grateful to you.

“We are like a snowflake; all different in our own beautiful way.” – Unknown

Most of the world faith traditions have stories of the birth of special people. There are signs accompanying the birth. Stars, wise men and phenomena announcing the arrival on earth of someone wonderful. Perhaps these stories are signs of what we should celebrate with each birth. The birth of every single child and every new parent is special.

As we welcome these little ones into our world let us think deeply. What physical environment is most fitting? What psychological and emotional factors should be named and made present? What people and attitudes will build that loving cradle of experience to welcome the newest member of the human race – our race? Every child and every mother are unique – like every snowflake.

Maternity experience is about creating the best for the newest.

I am fortunate that my experiences have been positive. Let’s always put women, children, families at the centre of our care and create experiences that reflect how special birth is.  

Rachel xx

(The content of this post is my story, but a special thank you to John Walsh not only for taking the time to proof read and make some suggestions as to the finer detail, but also for his encouragement. You can read more of John’s wonderful musings here.)

~ How has your maternity experience influenced you? ~

Look out for @HeartMummy Helen’s story next month.

You can submit your story too; see the second paragraph for more information.

Like what you’ve read? Share far and wide 🙂

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