Maternity Experience

Music While You Wait

3 February 2017 by Helen Calvert / #MatExp Actions, #MindNBody - holistic care, Environment and Facilities, The #MatExp Journey / 5 Comments

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

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

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

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

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

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

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

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

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

On the same morning….

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Claire Flower
February 2017

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Bedsharing, Breastfeeding and Family Centred Care

20 November 2016 by Helen Calvert / Environment and Facilities, Feeding, Informed Choice, Postnatal Care / Comments Off

It started with a thread about infant feeding that the lovely Lucy began on the #MatExp Facebook group. It was a fantastic discussion with a realistic and compassionate look at all kinds of barriers and problems, but one comment from student midwife Amy Prodgers stood out for me the most:

“Have found this discussion really fascinating as have been reflecting on similar issues after my first week on postnatal ward as a student midwife. I could go on about loads of things but a key point for me is the conflict between safe sleeping advice and facilitating breastfeeding. Women are exhausted from their birth experiences and their babies just want to feed but can’t sleep together. Women then end up feeling a failure for not being able to settle their babies in the cot, whilst also feeling guilty for wanting to sleep. This is when women start asking for formula and when midwives begin to doubt their intentions. Totally undermines confidence.”

I started a new thread with this comment at the top, and tagged in Gill Phillips as I felt it would make an excellent scenario for the WhoseShoes game that is used in #MatExp workshops around the country. We then had a discussion about bedsharing that raised some important points, and I felt it important to capture that discussion and share with you here.

sidecar-cot — *Via https://www.facebook.com/BellyBellyBaby*

What was quickly brought up was the co-sleeper cots that used to be available to women on some postnatal wards. This article was linked to: http://www.scarymommy.com/hospitals-everywhere-should-have-this-amazing-co-sleeping-bed-for-new-moms/ and I remembered that midwife Jenny Clarke had been tweeting about them this year.

An IBCLC on the group explained that “The old co-sleeper cots don’t fit the new beds (which were needed to reduce back strain on staff). However there are several new designs that fit the new bed, and research starting up too. Helen Ball’s research and videos of mothers clearly showed that the co sleeper cots made things *much* easier for mothers, much happier for babies, and didn’t add to staff’s workload.”

But would co-sleeper cots solve the problem? A paediatric consultant commented “I had co-sleeper cots after both my deliveries but actually my babies just wanted skin-to-skin for the whole first night. I think we really need better hospital beds in maternity and children’s wards to facilitate bedsharing.”

The important thing to bear in mind here is that these babies are displaying completely normal behaviours. It is our maternity wards that need to be “fixed”, not the babies. For a lot more discussion about expectations and reality when it comes to infant sleep, please see this blog by Alice Amber-Keegan of the Infant Sleep Information Source: https://growingfamilies.co.uk/2016/09/04/infant-sleep-expectations-and-reality/

Founder of the Positive Birth Movement, Milli Hill, agreed that “co-sleeper cots imply that at some point your baby will not mind being put down separately from you, and that you won’t mind putting them down separately either! Not always what mum or baby wants or needs.”

And of course, not having baby on the same surface as you can make life very difficult for post-birth mothers, as Polly Rogerson pointed out: “I was in hospital for a week after birth [due to post-partum haemorrhage], I was so weak that I couldn’t even lift my baby out of the cot – even with it right next to the bed. Yet somehow I was expected to do exactly that to try to feed him.”

Bedsharing when Baby is Unwell

The conversation then went in a couple of different directions – one discussion of bedsharing on children’s wards when a baby is ill, and one discussion of the guidelines that trust’s expect health visitors to follow when discussing bedsharing with the families they support.

Anyone who follows my hospital breastfeeding campaign will know how excited I was to have a paediatric consultant say that it would be good to have bedsharing facilitated on children’s wards! The consultant in question went on to say:

“Because in real life, I’d say close to 100% of families bedshare when children are ill. Banning it on hospital wards is just stupid. Having informed discussion about it is sensible.”

She clarified that her reservation for bedsharing with unwell children “is smoking parents and small babies and children with respiratory illness, as it is unrealistic to expect parents to stop smoking at such a stressful time, but the smoke clinging to clothes and hair definitely seems to exacerbate the children’s respiratory problems.” However this doctor confirmed:

“I spend a lot of time at work putting babies and children back into parents’ arms. That’s where they are usually happiest, but most importantly for me, most physiologically stable!”

This issue came up on my own private Facebook group today, as a member explained that her niece was hospitalised (and will likely be so for some time) and is refusing to sleep anywhere but on mum. As mum is unable to bedshare in hospital due to lack of facilities, mum is getting very little sleep.

A paediatric nurse on my group explained that from her professional perspective “we never advocate or advise co sleeping in our hospital as the babies are with us due to illness & therefore it can increase the chances of problems. However it is a parent’s choice and some still do, but we are bound by our duty of care to highlight the implications.”

She went on to say though:

“I’m a big believer in family centred care (which all children’s wards/nurses/professionals should be) so if a parent still wants to co sleep (and they would do so at home) I feel it’s my duty to help that parent as best I can so their wishes are upheld, but in a way that I feel most comfortable with in my work setting. As a children’s nurse you’re not only nursing the child but the whole family too, so to keep things as they would do at home or in regular life is important; the change of circumstance by being in hospital is bad enough for the child and family never mind then saying ‘well sorry you can’t keep your normal routine whilst here’. I think sometimes as a health professional we’re so focused on making that child better medically it can be forgotten how big a change being in hospital can be on them emotionally; even though they may not outwardly show signs of distress it is definitely affecting them psychologically, and therefore keeping things as much to their norm as possible is very important.”

Bedsharing when Baby is at Home

latter-beverley — *Image courtsey of Beverley Latter and the Infant Sleep Information Source*

The discussion about what health visitors can and can’t say to new parents was prompted by one mother explaining “my health visitor at 6 weeks (1st baby) gave me info about safe co-sleeping and it was the reason I continued to breastfeed.”

I then shared the discussions that mothers from my group have had with health visitors online, including a discussion specifically about bedsharing: HVe-COP newsletter The two quotes from that discussion that summarise the issues for me are:

“We are very constrained sometimes. We have to follow Trust policy…..even if we believe that bed sharing can be very beneficial and are up to date (with evidence)” (health visitor participator)

“Just to put this out there…….we have a responsibility to our NMC Code of Practice and the clients…after that Trust policy is important. The day health visitors do not provide evidence based information to their clients because of Trust policy is a grave one indeed” (health visitor participator)

On this thread in the #MatExp group, one health visitor explained: “Trust guidance is the Lullaby Trust safe sleep recommendations, and signposting to NICE for bed sharing…..personally I don’t advocate it but I talk about if [you are] bedsharing [how to] minimise risks.”

This conversation took place before the launch of the new Baby Friendly “Co-sleeping and SIDS” guidance for healthcare professionals, which has been developed in conjunction with the Infant Sleep Information Source and the Lullaby Trust. This guidance focuses on helping healthcare professionals “to take a sensible, proportionate parent-centred approach in order to find practical solutions to this complex issue”.

We can hope that this guidance and the continued expansion of Baby Friendly training for UK health visitors will put an end to less nuanced campaigns such as this one from Bolton, Wigan and Salford that Amy Prodgers highlighted:

As you can imagine, this heavy handed campaign elicited a strong response from those on the thread! Amy herself commented that “reducing SIDS by telling people not to bed share is a bit like reducing road traffic accidents by telling people not to use cars! And of course we’ll also avoid the issue of how much more dangerous it is to fall asleep on the sofa (whilst presumably trying your best to follow this advice and stay awake).”

One mother’s experience explains the reality of what happens when health visitors advise against bedsharing: “When I told my HV I was co-sleeping, on purpose and in accordance with safety instructions, she gave me leaflets on ‘cot death’ and strongly discouraged me from doing it. She then arranged another visit for a few weeks later, after advising me to ‘keep trying with the moses basket’. When she returned I just lied and said that my baby was now sleeping in the basket as I couldn’t be arsed with having to defend my conscientious parenting decisions.”

For information on the practicalities of sharing a bed with your baby, please see this detailed post by Elena Abell: https://growingfamilies.co.uk/2016/06/15/the-practicalities-of-sharing-a-bed-with-your-baby/

Or see the “Safe Sleep Seven” from La Leche League:

And for the latest research on bedsharing, infant sleep and SIDS please see the Baby Friendly website: https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-bed-sharing-infant-sleep-and-sids/

Midwife Sally Goodwin said at the end of the thread that she was “grateful to all for highlighting this issue. I think this subject comes up erm…… every day for me as a midwife.”

Certainly a topic we need to continue to discuss then.

Helen Calvert
November 2016

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

6 September 2016 by Gill Phillips / #MatExp Actions, About MatExp, The #MatExp Journey, Whose Shoes / 1 Comment

Launched today by Sarah-Jane Marsh

at NHS Expo…

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

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

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

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

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

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

Entry form – Nobody’s Patient competition

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

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Optimal Cord Clamping

15 August 2016 by Helen Calvert / The #MatExp Journey / Comments Off

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

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

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

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

Placental delivery.

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

Active management.

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

Physiological third stage of labour.

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

Lotus birth.

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

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

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

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

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

Amanda Burleigh. Aug 2016.

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

22 June 2016 by Gill Phillips / The #MatExp Journey / Comments Off

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

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

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

Link to evaluation report: Whose Shoes report Maternity SCN

MatExp RCOG Poster

Other key quotes and testimonials:

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

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

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

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

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

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

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#MatExp poster!

20 June 2016 by Gill Phillips / The #MatExp Journey / Comments Off

Launched today. ‘#FabObs Flo’ Florence Wilcock a.k.a @fwmaternitykhft is at the World RCOG Congress in Birmingham, proudly launching our collaborative poster. Follow #RCOG2016 on Twitter. The poster tells the #MatExp story!

Download it here: MatExp RCOG Poster

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The Flaming June of the future

1 June 2016 by Helen Calvert / The #MatExp Journey / Comments Off

A blog post from #MatExp founder Florence Wilcock.

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!

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.

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.

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Excessive Crying – What’s The Right Response?

5 May 2016 by Helen Calvert / Feeding, Language, Postnatal Care / Comments Off

Our thanks to Sally Hogg for this blog post. Sally is a mother who works in children’s policy, research and practice, and has done extensive work on the subject of excessive crying in infants.

All babies cry and some babies cry a lot; between 10 and 20 per cent of babies will cry excessively during the first three months of life. As professionals, we know that this crying is normal and will pass. But for parents it is tough. Really tough.

“There were times when I resented him for screaming, and then hated myself for feeling like that, and also for not being able to make it better. I just felt a huge sense of failure.”

While most families survive a period of excessive crying relatively unscathed, it does increase the risk of a range of poor outcomes including maternal mental illness, relationship breakdown, child abuse and childhood behavioural problems.

Parents of babies who cry a lot will often try to identify a cause of this crying, and, with it, a solution. This isn’t helped by the fact that excessive crying is generally known as ‘colic’, leading to the common misconception that it is caused by stomach problems. In fact, excessive crying has been shown to be associated with digestive problems in only a small subgroup (around 5-10 per cent) of babies who cry excessively. For other babies, the causes of excessive crying might include temperament, early sensitivity, feeding problems, or a poor fit between parenting expectations and behaviours and babies’ needs. For many babies, we will never really know why they cry a lot.

Crying is one of the most common reasons that parents seek support in the postnatal period. In these situations, it can be tempting to suggest a ‘cure’ for the crying, or to reassure the parent that crying is normal. Both the academic evidence, and the experience of parents, tell us that neither response is appropriate.

It is not appropriate to simply suggest a cure for the crying – whether that be winding, infancol, changes to feeding, or actions like walking the baby in a pram or carrying him. These actions might work for some babies, but not for all. There is no ‘one size fits all’ solution to crying – all babies are different and can cry for a huge number of different reasons, requiring different responses.

It is also not appropriate simply to reassure parents that crying will pass. Even if the crying is normal and the baby fine, excessive crying is hugely difficult for parents and can damage their self-esteem, self-efficacy, mental health and wider wellbeing. So some form of response is required.

So what might an appropriate response to excessive crying be?

Based on a review of the evidence, and in particular a useful article by Ian St James Roberts I would suggest that a good response to excessive crying has six parts. These are set out below. I’ve also highlighted where we might take action in the antenatal period to prepare parents to cope with a crying baby.

Building awareness of babies’ development.

The first three months of a child’s life (sometimes called the ‘fourth trimester) is a distinct phase of babies’ development, in which they are not yet able to regulate themselves, and in which their crying has particular characteristics. Ronald Barr refers to the ‘period of purple crying’, where the acronym ‘purple’ describes different features of babies’ early crying.

Supporting all parents – both antenatally and postnatally – to understand this developmental stage, and to know that it will pass, can be really helpful. (Although there isn’t a magic transition point at three months and each stage of children’s development brings new and different challenges, so it’s important to manage parent’s expectations!)

Help parents to understand the stress that they feel and how to cope with this.

It is normal for parents to find their baby’s crying stressful, but hard to admit this. We can help parents by normalising this experience, making it acceptable to talk about how one feels when a baby cries, and helping parents to think about ways to deal with this. Evidence shows that giving parents coping strategies to deal with the stress they feel when their baby cries, together with educating them about the importance of not shaking baby, can help parents and reduce the risk of abuse to babies. The NSPCC’s Coping with Crying Programme has shown the value of sharing these messages with parents in the antenatal and postnatal period.

Provide a menu of options

There are many reasons why a baby might cry and many ways to help babies to keep calm, or to soothe them when they cry. These could be shared with parents antenatally, to help provide them with a ‘toolkit’ to draw from when their baby cries.

When a baby is crying excessively, it is useful to help parents to consider their own baby’s experiences and needs, and to identify what actions might help them. Evidence from successful interventions suggests that the most effective responses to excessive crying involve reassuring and supporting parents, and helping them to formulate hypotheses about why the baby is crying and identify and test actions to reduce their babies’ crying or to make it feel more manageable. One intervention, Possums, uses five domains – infant health, mother health, feeding, sensations and sleep – to consider the families’ needs and identify actions.

Help parents to enjoy their baby.

When a baby cries excessively, this understandably becomes the focus of parents’ attention. But the perinatal period is a formative time when parents develop beliefs about their child’s personality which can influence how they interpret and respond to the child’s behaviour and the quality of their interactions. It is therefore important to highlight a babies’ wider characteristics, and help parents to enjoy the positive interactions that they have with their baby so that they don’t develop too negative an image of their child based on their crying.

Frame crying as an experience and not a symptom.

It is helpful to address the idea that crying is a sign that there is something ‘wrong’ with the baby, either physiologically or emotionally. Helping parents to see excessive crying as a part of their baby’s experience of early life, rather than a symptom of a medical problem or a sign of poor behaviour, can help them to focus on how best to soothe their baby and cope with crying during this stage.

Be Kind.

Finally, let’s not forget that excessive crying is really hard, and parents can feel feelings of isolation, helplessness and failure. These mums and dads need a kind, compassionate response and ongoing support.

“More helpful still were the very few people at health clinics who bothered to learn my or my babies’ name, who offered to hold him for a little bit, and who were interested in how I was doing. These people were few and far between.”

Sally Hogg

2016

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A Shift in Gear

3 May 2016 by Florence Wilcock / The #MatExp Journey / Comments Off

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

29 March 2016 by Helen Calvert / Feeding, MatExp and Me, Postnatal Care, The #MatExp Journey / Comments Off

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

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

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!

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!

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.

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!

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

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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