ARK VOL.2
In this issue
The Voice of Healthcare
WHY CONTROL THE UNCONTROLLABLE? THE GIFT OF NEW LIFE THE CHOICES OF THE NEXT GENERATION CHOICES START WITH WHICH ADVICE YOU TAKE THE DE-MEDICALISATION OF MIDWIFERY
Caring for people is at the heart of everything we do POWERED BY
WHY TRY TO CONTROL THE UNCONTROLLABLE? By Geraldine Bedell
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n our first issue of Ark we dealt with the difficult but important topic of palliative care. In this, our second issue, we move our focus away from the end and back to the beginning – childbirth.
While new life brings great cause to celebrate, pregnancy, labour and birth are not without their risks. And their tragedies. All those working in obstetrics and midwifery are dedicated to protecting women, giving them options based on what is right for them and their babies while continuously finding ways to reduce the risks associated with childbirth. Our conversations with women about their experiences of childbirth, as well as with those whose work focuses on labour and delivery, have proved this. From Nicola who achieved a ‘perfect birth’ for her daughter with the help of an independent midwife and doula, to Dr Roshan Fernando who is spearheading research into PIEB pumps to care for women using epidurals.
Geraldine Bedell has four children, and four very different birth stories. My first child was born in a hospital for expatriates in the Middle East that makes Call The Midwife look like the leading edge of 21st century obstetrics. There were enemas, shaving, your feet up in stirrups and an episiotomy so dramatic that the baby shot out across the table and had to be caught like a rugby ball. When the congratulatory cards arrived, with their soft-focus images of new motherhood, I laughed bleakly: I had survived the equivalent of a medieval torture chamber. After that I moved back to Britain, where the birth plan had become commonplace. Women were turning up for labour with sheets of instructions dictating that they were only to deliver their babies to the strains of Brahms, by vanilla-scented
candlelight. Not me, though: I was so traumatised by the first birth that I was in denial. Not altogether surprisingly, I ended up having a caesarean. If anyone still thinks that there is such a thing as ‘too posh to push,’ think again: it’s major abdominal surgery. You can’t stand up straight for days. This turns out to be a real drawback when looking after a new baby. By the time I had my third child, I was taking a much more militant, feminist earth mother line. I did pregnancy yoga and arranged a birthing pool. I drank herb teas and employed a doula, a kind of wise woman, who was going to rub my back sympathetically whenever I got out of the water.
As you will see from the articles that follow, they have also uncovered an opportunity for more communication between the professions. That way women may be able to feel more in control of their choices for bringing their child into the world. Ali El Moghraby, Editor. Rachel McClelland, Editor in Chief.
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There are about five hundred different ways of giving birth, and rarely are you in much control
Everything was planned. Unfortunately, my husband got lost on the way to the hospital. The maze of a one-way system he chose to take was littered with speed bumps. Every time we went over one, I was in agony. I travelled with my head out of the sun roof, groaning. It would be a better story if I had given birth in the back of the car but we made it eventually, and claimed our pool. I hated it. I endured three contractions, and climbed out. The doula helped, though, so I
decided to keep her for the fourth birth – and she did the best thing anyone has ever done for me in labour, and suggested to the midwife that she might hold off an internal examination for half an hour. Ten minutes later, I was pushing. Birth plans are useful for concentrating the mind beforehand. But the annoying thing about birth is that it happens when it happens, takes as long as it takes, and the pain….
There are about five hundred different ways of giving birth, and rarely are you in much control. The bad thing about birth plans is that they are typical of over-achieving modern life: the only thing you can truly be sure of is that in some respect, they’ll set you up for failure. Of course, in that sense, they’re excellent training for parenthood. Even if you do stay in control of the birth, it’s the last thing you’re going to be fully in control of for a long while.
THE GIFT OF NEW LIFE It is 86 years since the foundation of the Royal College of Obstetricians and Gynaecologists (RCOG). Here, current President Dr David Richmond describes how, despite its many achievements over the years in shaping women’s healthcare, the specialty still faces some difficult challenges ahead. by Pat Hagan
THE ROLE OF THE RCOG So much of medicine is about trying to avoid loss of life, that the chance to help bring new life into the world is something all healthcare professionals cherish. That’s how it is with obstetrics and gynaecology, where the overriding objective of all involved is to ensure the safety and survival of a mother and her newborn child. This was one of the driving forces behind Dr David Richmond’s decision to pursue it as a clinical specialty when he was starting out as a hospital doctor back in the late seventies. Several decades later, it led to him becoming elected President of the RCOG, a role which has given him the chance to steer women’s healthcare in new directions. “I think this organisation’s greatest achievement has been becoming a Royal College in its own right,” says Dr Richmond.
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“In 1929, a group of obstetricians and gynaecologists decided they weren’t getting a satisfactory deal through the Royal College of Physicians and Royal College of Surgeons. Women’s health was probably falling between the gaps and there was a specific opportunity to focus particularly on that aspect of healthcare. “The RCOG’s royal charter talks about the remit to enhance and promote the standards of women’s healthcare. And that remit extends way beyond Britains shores - the College has a global influence, particularly when it comes to raising the bar in standards and education.”
A GLOBAL REMIT Over the last 15 to 20 years, the RCOG has been spearheading education and training packages designed to standardise the quality of new doctors across large parts of the world. Today, the RCOG exam is sat by over
5,000 hopefuls, not just in the UK but in 22 different countries. “It has become a global passport in obstetrics and gynaecology,” says Dr Richmond. But testing new recruits is one thing. A bigger challenge is to uphold the standards of care amongst all qualified obstetricians and gynaecologists. This is where RCOG guidelines come into play. Dr Richmond says: “At any one time, there will probably be 60 to 70 guidelines available. They can be plucked from the shelf whether you are in Kathmandu, Kuala Lumpur, Beijing or London. They are universally acclaimed and respected and are completely patient focussed.”
Over the last 15 to 20 years, it has been spearheading education and training packages designed to standardise the quality of new doctors across large parts of the world
REDUCING MATERNAL AND INFANT DEATHS Universal improvements in care take time, however. And there are still some frightening statistics around the world on the numbers of women losing their lives during childbirth. Dr Richmond says: “It’s roughly 800 women a day globally – or the equivalent of two jumbo jets crashing every single day of the year.” As far back as 1952, the College led the way on tackling maternal mortality. Dr Richmond says a report led by MMBRACE-UK is highly regarded around the world as a means of reducing future risks. But he adds: “If you are in deepest, darkest Africa or other parts of the world where you haven’t got access to anaesthetists or surgeons or even blood, you haven’t a chance.” Maternal deaths are not the only issue. The RCOG has recently initiated a project called ‘Each Baby Counts’, which is a national quality improvement programme which aims to reduce by 50% the number of stillbirths, early neonatal deaths and brain injuries occurring in the UK as a result of incidents during term labour by 2020. A crucial part of the project involves bringing together the lessons learned from local investigations in order to improve the quality of care in labour at a national level.
“Around £500m to £600m a year is spent on obstetric litigation,” he says, “of which 85 per cent will be cerebral palsy.” If we could reduce that by just ten per cent, then much of the savings could go on more midwives, more doctors and better equipment. “It’s only been running a few months but already we’ve seen phenomenal enthusiasm from midwives and doctors around the country.“ We hope that all maternity providers will continue to show their support for this project and engage in reporting and learning from these tragic incidents, so that in time we can make it as safe for a baby to be born as it is for a mother to deliver.”
THE CHALLENGES TO IMPROVING CARE Driving up care standards is laudable but largely futile without adequate staffing. Dr Richmond says around 3,000 more midwives are needed in the UK to properly staff NHS units. And limits on use of overseas doctors means finding locums is harder than ever. As well as top-down management, this clinical specialty faces other challenges more to do with the changing nature of motherhood. Obesity is emerging as a major factor because it means consultants must now deal with a whole range of health issues, such as diabetes and high blood pressure and the consequences for the baby and delivery process.
“Obesity is a serious public health problem and it is our role as healthcare professionals to inform and encourage women to adopt healthier lifestyles, and this approach should be taken throughout a woman’s life. We must focus on early intervention, rather than just preventing disease,” says Dr Richmond. Among obese women, newborn deaths are higher, Caesarean sections are more difficult, anaesthetics are harder to manage, sepsis is more likely and there is an increased risk of clots. Rising maternal age is the other major current issue, as professional women postpone motherhood. “By your early forties, the physical function of having a baby is not as good as in your twenties and so we have to take account of that,” Dr Richmond says. The challenges may change as the years pass. But the role of the RCOG is clear, he says. “I would like to see this College as the voice of women for women, promoting their rights across the spectrum and promoting outcomes to improve the health of women in this country.”
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THE CHOICES OF THE NEXT GENERATION OF MIDWIVES WILL IMPACT THOSE AVAILABLE TO THE NEXT GENERATION OF MOTHERS By Ali El Moghraby
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ndrea Robertson has just qualified as a midwife. She sites her journey from being a staff nurse to becoming an NHS midwife as ‘a calling’. She continues to be in awe of the profession she has spent the last two years studying towards. “Every day I admire and respect the experienced midwives when they are at work,” she says. “Midwives care so much for the women and families who come into their labour wards. They work really hard to give those women the birth that they want.”
“In Africa, it is accepted that women and babies can die in childbirth,” says Andrea. “While no-one should die in labour, our culture of needing to blame someone if the worst does happen means that midwives are questioning themselves rather than having faith in their own judgement. So midwives are more likely to focus on what could go wrong and send a woman for a procedure than trust their decisions and give the woman time to birth her baby herself,” she says.
As Andrea embarks on what she sees as her destiny, the future of the profession lies in her and her peers’ hands. How many choose to turn their back on the NHS and become independent midwives remains to be seen.
Give the woman time to birth her baby herself
Andrea is excited about the support she is going to give to women and she has a plan for how she wants to achieve that. “I am looking forward to gaining experience in the NHS,” she says, “but I think I will become an independent midwife in the future.” Her reason for this is that the NHS is not able to give women one to one care. “For example, when a woman has queued behind 40 others to have her baby weighed and her blood pressure checked, she’s not likely to be comfortable talking about her feelings to a stranger,” explains Andrea. “But if she knows her midwife, it’s easier to say ‘I’m feeling strange today’ or ‘can I just sit down and have a chat with you’ if that’s what she needs.” For Andrea, the increasingly litigious nature of midwifery makes her uncomfortable when she thinks about the effect it has on the level of medical intervention seen in labour wards. Having spent six weeks in Africa where mother and infant mortality rates are higher than in the UK, she is able to put the impact of litigation on the medicalisation of midwifery here into a bit of perspective.
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CHOICES START WITH WHICH ADVICE TO TAKE Nicola Nicholson went against her consultant’s advice and chose an independent midwife for her second child. by Nicola Nicholson
‘I see no reason for you not to have a successful natural birth after a caesarean section, but as you are high risk, you will need to be on the labour ward for continuous monitoring.’ These were the words of my consultant, which felt strangely contradictory. I was in early pregnancy with my second child, following a pretty harrowing experience with my first baby, which ended in an emergency caesarean section. A heated exchange of words followed, as I explained that being forced to lie back strapped to machines would in no way allow me to birth my baby naturally. I was told in no uncertain terms that to do anything other than this would put my life and that of my baby at risk. The thought of this filled me with dread, so I began to do my own research. The more I thought about it the more I knew that hospital was the last place in the world I wanted to be. So I asked a good friend who is a midwife, whether she thought I would be crazy to have my baby at home. She explained the risks to me in terms of probabilities and this enabled my husband Charlie and I to make what we felt was quite an easy decision. We felt the benefits of being at home far outweighed any undue risks. We decided to pay an independent midwife to look after us during the remainder of my pregnancy and the birth. We wanted to know that the person present on the day would be experienced in home birth and would not rush us into hospital unless there really was a genuine need. This turned out to be the best investment we could have made.
Professor Lakhani
Our midwife, Meg, had decades of experience in natural births, understood all the risks and totally trusted in her own abilities and those of the birthing mother to be able to do it just as nature intended. She was an incredible support, especially when I had the hospital pressuring me to go in for induction because my baby was ‘overdue’. Meg kept saying if I wanted to birth my baby naturally, I needed to leave it alone. Do nothing, but chill out, it will come when it is ready. I spent a lot of my pregnancy visualising what my perfect birth would be, and in the end, it was exactly that! My waters broke around 11.30pm so Charlie called the midwife and our doula and began filling the birthing pool. We had decided to have a doula for our homebirth to provide extra support to him and Meg, and this also proved to be a very worthwhile investment. Meg arrived soon after, and observed me quietly and un-intrusively. There were no internal examinations, just a few whispered questions and then she quietly told me that I could get into the pool.
What a wonderful relief warm water is! I was in my kitchen, with a few candles and some soft music playing, with Meg, Charlie and Louise working in whispers around me. I didn’t hear all the exchanges that occurred, I was in my own zone, completely surrendered to the moment. Not once did I ever allow myself to think anything other than ‘I can do this’ and I never felt out of control or overwhelmed. Our beautiful baby girl, Isabelle Rose, was born just after 4.30am, peacefully in the pool. An hour later, her older brother Ben trotted downstairs, immediately noticed some chocolate biscuits by the fireplace and didn’t even realise that he had a new sister! What a stark contrast to our first birth experience, which ended up being filled with bright lights, pain and fear. Hindsight is a wonderful thing, but so is the power of a woman’s body. Given the right circumstances and being allowed to do what we all instinctively know, we can all birth like goddesses. Trust your instincts, we’ve been doing this for millennia.
THE DE-MEDICALISATION OF MIDWIFERY The midwife profession is currently in a state of flux according to Susan Baines, Expert Midwifery Advisor for the Care Quality Commission and lecturer of midwifery at The University of Salford. “It’s a wonderful profession to be in”, she says, “but professional confidence and resource and time restrictions within the NHS are severely impacting on the true By Ali El Moghraby business of midwifery.”
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aving spent 40 years as a nurse, 29 of which as a practising midwife, Susan is concerned about the future of the profession. For example, she welcomes the new NICE guidance (2014) regarding second time mothers having a choice of home birth if they are deemed low risk. But she also believes that this choice is suitable for most other mothers as well, as long as they have the right midwifery support and a joined up team approach to managing any issues. “If women are to regain control of their choices for childbirth then the midwifery profession needs to return to a degree to its pre-medicalised form,” says Susan.
PAPER OR PERSON? Labour and delivery has been getting more medicalised for a long time now. The profession is well aware of it, as are most women planning for the birth of their child. But as they research their options and make choices for how they want to bring their baby into the world, Susan believes that too often the midwife pigeon-holes them into being ‘high risk’ just because of the forms she has to fill in. “For example, as soon as a woman turns 40 she is deemed high risk,” says Susan. “She could be fitter and healthier than the average 20 year old, but as soon as her midwife ticks the box that says she’s over 40, she’s flagged up by the computer as high risk.” This immediately impacts on her pregnancy and birthing choices. “Her midwifery care
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now takes her down a path that is not supporting what we know about the woman and her capabilities,” says Susan. The woman may be denied the option of a homebirth or of giving birth in a midwifeled birthing centre. Straight away, the chances of medical intervention in her labour are significantly increased. “We have to get away from this business of going to see a woman straight away with a form,” says Susan. Susan supports the mindfulness approach as one of the ways to achieve this, including when caring for women shortly after the birth of their baby. “Midwives visiting a woman in her first days as a mother should put their notes away, sit and simply watch and listen to her,” she says. “That way the woman can better articulate what she is really feeling and is more likely to benefit from the interaction. This gives the midwife a better opportunity to support her more effectively. The notes can be filled in afterwards in the car.”
DOUBT HAS CREPT IN It is Susan’s view that midwives are too busy filling in paperwork and not listening to what women, their bodies and their babies are saying. As a result, some midwives have lost their confidence in being able to support choice and actually see the woman’s body as being able to perform naturally. “We now practice such defensive midwifery and are so fearful of litigation that we are doing things for all the wrong reasons,” explains Susan. “We are taking a woman down a path and taking away her choices at each step.”
Susan highlights the rise in the rate of free birthing as a symptom of women’s lack of confidence in their midwives. “The women who are free birthing don’t want any medical people around them at all,” explains Susan. “What does it say about us as a profession when women are actually moving away from us as midwives? In my view, they don’t trust us because we are so medicalised, we are so rigid in our views, and we are so frightened,” Susan explains. “That’s a real issue.” “You cannot give women the choices that they want in a system that simply doesn’t allow it,” says Susan. “There needs to be more awareness of independent practitioners if only because they offer women a choice other than hospital. There are many excellent independent midwives out there who actively support choice safely.”
TIME FOR ONE TO ONE CARE Many midwife degree courses are oversubscribed, yet there is a severe shortage of midwives in the UK (the Royal College of Midwives says that the NHS needs 4,800 more). This has two implications in the context of trying to make midwifery less medicalised. The higher volumes of women that have been labelled as ‘high risk’ go into hospital as prescribed by their risk assessment. But as Susan explains, the number of hospital midwives just doesn’t allow them to always receive the one-to-one care that they have apparently gone into hospital for. “More often than not, the delivery suites are really busy, the midwives on shift are stretched and then all of a sudden, it can become worse when several other women in labour are admitted,” she says. “They have all been deemed high risk and so should be monitored closely by their own midwife, but it can be impossible – the midwives may be required to help out in other delivery rooms thus taking them away from their woman in labour”. The midwives are trying their best but there simply isn’t the time to always provide one to one care. This is not only unsafe but demoralising and stressful for all concerned.
While encouraging more home births should provide the level of one-to-one care that hospitals struggle to deliver, too often women who have booked a homebirth are left severely disappointed when there isn’t a midwife available when they need them. “We hear it all the time,” says Susan. “The woman is in labour but we have no one to send out because we are really short staffed and have a full delivery unit. She ends up in hospital, anxious and fearful with her choice having been removed. The bottom line is that for some women, technology and medicalised care can be a life saver, however for most women they need to regain trust in their natural physiological ability to birth their baby,” she says.
THE FUTURE The good news is that the profession is changing. In March 2015, the Nursing and Midwife Council launched its new code of practice for nursing and midwives. “The new code has been amended to better support individualised care and promote professional accountability regarding choice. It is aimed at placing the women at the centre of everything we do,” says Susan. “It is about trying to keep birth normal, trying to listen to the mother and allow her to make choices.”
What does it say about us as a profession when women are actually moving away from us as midwives?
For Susan, the real future of the midwife profession lies with midwives themselves and their ability to work closely with women. Additionally, she sees the importance of doulas. “Half the time we midwives are not with the women anymore, we are with technology,” she says. “We are often not even in the same room as the woman when they are in hospital. So how can we call ourselves midwives when the term itself means ‘with woman’? Doulas are normal women who get to know their mothers well and who offer continuity and practical and emotional support.” “There is evidence to support the fact that women do better in labour if they have the continued support of a doula,” concludes Susan. “At the end of the day, all women want is a friendly caring person to help them believe in themselves.”
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THE OBSTETRIC ANAESTHETIST With 20 years’ experience in obstetric anaesthesia behind him, consultant anaesthetist Dr Roshan Fernando from University College Hospital London (UCLH) has seen many changes – mostly for the better. Here, he talks about progress in pain relief for mothers, on-going staffing challenges and the fact that he’s busier than ever. by Pat Hagan
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uring Dr Fernando’s training days at Queen Charlotte’s Hospital in London, specialising as a consultant in obstetric anaesthesia was not as popular as specialties such as cardiac and paediatric anaesthesia, even though it is such an important field. Things have since improved and many delivery suites within hospitals are better staffed and equipped than ever before. But the rising workload means there are often resource issues, he says.
UNDER-AVAILABILITY OF ANAESTHETISTS “I regard our delivery suite at UCLH as one of the best. We have very motivated staff and good resources for certain things. But we are still under resourced in terms of obstetric anaesthetists who need to cover both the emergency and elective workload. I used to work at the Royal Free Hospital in London, where annual deliveries are about 3,000 a year. “Here at UCLH we deliver 6,500 mothers each year, so double the workload. We often have three anaesthetists working extremely hard, sometimes from 8am to 5pm without a break. The challenge is obviously obtaining funding to provide a safe and high quality service to our mothers.” However, as every politician, health professional and member of the public knows, the NHS does not have enough funding to deliver the service most patients expect these days. But in a perfect world, he says, he would staff all delivery suites with a consultant obstetric anaesthetist present 24/7. Many years ago, it was rare to see any type of consultant outside of normal daily working hours. Things have changed and now some of the busy
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obstetric hospitals have consultant obstetricians available up to 10pm and during weekends or even 24 hours a day. But anaesthetists are lagging behind in terms of providing consultant cover, says Dr Fernando. “We are usually present from 8am to 6pm, but rarely beyond that and certainly not at weekends. The ideal model in my opinion would be to have a consultant obstetrician and consultant obstetric anaesthetist working together on the delivery suite throughout the day and night.”
CUTTING-EDGE EPIDURAL RESEARCH But while the ideal staffing formula has yet to be perfected, technological innovation marches on. Dr Fernando is currently at the forefront of new research on the use of epidural pain relief pumps that provide a programmed intermittent epidural bolus, or PIEB function, which first came into use at UCLH a few years ago.
hopefully, shed more light on best practice for using the PIEB technology. “At the last UK meeting on obstetric anaesthesia there were quite a lot of research abstracts on PIEB. It’s early days to see if it’s going to reduce motor block in the mothers legs (a well known side effect of epidural analgesia) and improve instrumental delivery rates but it’s an interesting development.” In the long-run, says Dr Fernando, these ground-breaking pumps may all be linked to Wi-Fi so that consultants can remotely check how much epidural drug each patient is receiving. In Singapore this type of technology has already been in use for several years. Naturally, these pumps can’t be seen as a substitute for qualified staff – especially not in areas such as the delivery suite or in the high dependency care area.
A clinical research trial is planned for this summer where women opting for an epidural will be randomised to various PIEB protocols involving different bolus volumes and intervals. Dr Fernando says: “I think the PIEB pumps could be one of the most important things to have been developed recently to provide epidural pain relief to mothers. There are many hospitals in the UK which are now starting to look at these new PIEB pumps.” UCLH has already run a pilot study involving epidural PCA pumps with a PIEB protocol capacity. “About a year or so ago we had a short trial of the PIEB and it worked quite well,” he adds. The upcoming trial will be bigger and more in-depth and,
Dr Roshan Fernando
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HOME BIRTH RISKS FROM THE ANAESTHETIST’S PERSPECTIVE Against the backdrop of hospital-based treatments, in Dr Fernando’s view, is the on-going controversy over the safety of home births. In December, the National Institute for Health and Care Excellence (NICE) issued new guidelines stating births at home or in midwife-led units were better for certain mothers and often just as safe for babies as being born in hospital. But Dr Fernando believes many women are not currently properly informed about the likely risks of home births. “It’s very difficult to quantify the absolute risks. “Let’s imagine you live in central London and your hospital is UCLH. If things do not go according to plan and you have to get to the hospital urgently, how quickly can you get there and how? Patients need to understand all the potential risks involved.” Obstetrics and obstetric anaesthesia has significantly advanced over the course of Dr Fernando’s career, with major improvements in caring for mothers, however perhaps the best is yet to come.
The Voice of Healthcare
Our next issue of Ark will focus on Nutrition. If you would like to contribute please email Rachel at rmcclelland@cmemedical.co.uk If you would like to request hard copies or if you would like to receive future issues of Ark please email arkmagazine@cmemedical.co.uk
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