Hi Caroline, thank you for agreeing to talk to me. Could you tell me who you are, and what you do?

 

I’m Caroline Wright, a Consultant Obstetrician and Gynaecologist in North London. 

 

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Can I ask you first of all a general question about birth? There can sometimes appear to be some animosity towards medics when birth is discussed, particularly if there has been a difficult birth. I wondered if there is anything you’d like people to know about your role?

 

I think I want mothers, partners and families want to know that obstetricians and midwives are working towards the same goal as mums – which is always getting mum and baby safely through labour and delivery, but also respecting birth plans/wishes. We are often mothers ourselves, and we are on your side! Our perspective can be different, as we see all there is to see, all the wonderfully good but also the occasionally terribly sad. I think obstetricians are often sold as the bad guys, but all they want is good outcomes for mums and babies. I hope that we are able to put our experience and knowledge across to mums in the right way to help them when decisions feel difficult. 

 

Being an obstetrician can be really tough. We throw ourselves into this profession. After medical school I worked in the field for 12 years before my first consultant post. A long training period, with long often antisocial hours and plenty of work outside our paid hours. Shift work can gruelling. We often haven’t sat down, had a drink or had a wee for 12 hours! We do this because you, our patients, are incredibly important to us. And we know these are special moments in your life and we strive to get it right! And I really hope that for the most part, we do. We all know the pressures on the NHS and staffing problems can make our job more difficult, but we are constantly trying to improve and deliver first class maternity care, because that is what women and families deserve. This is what we would want for ourselves, our families, our friends and our colleagues. We will keep listening, keep working, keep changing until we get it right. 

 

Thank you. I’ve been thinking about the maternity ‘journey’ women and their partners take, from pregnancy through to the early weeks of parenthood. Is there anything that you wish women and their partners knew before labour?

 

I think more information is needed in antenatal classes. For example, on complicated birth including C section, forceps, ventouse and other medical complications. Antenatal care is mainly delivered by midwives or external organisations who provide excellent information on ‘normal’ birth, but might not have as much first hand knowledge of these kind of procedures as an obstetrician. That’s something I’d like to change. Empowering mums means preparing for all kinds of outcomes, so that if the unexpected happens, mums still feel in control and understand the options available to them.

 

And during birth itself, many women spoke about procedures happening without feeling fully informed, or being spoken to in a disrespectful way. What are your thoughts on this? 

 

It’s very sad to hear that but I’m sure it does happen sometimes and that’s something we must very much work against. Complaints or comments about a doctors conduct are taken very seriously so we hope that women do feedback to us when things haven’t gone well, although in many trusts there is limited funds/capacity for formal postnatal debrief appointments which is such a shame and hopefully will change as postnatal care is becoming more and more recognised as a priority.

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Communication skills are a big part of being a doctor and we are trained in communication skills at medical school, and as part of our continuing professional development - but more can be done. We are starting to collect more direct real time individual feedback from patients for example.

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Procedures or decisions should be fully explained to mums and their birth partners and disrespectful approaches should simply not be tolerated.  I think in reality sometimes time constraints get in the way as labour wards can be very busy, or there are real concerns that a baby may deteriorate without very quick action, or there may be language barriers to work through- all of which impair the conversation - no of which are excuses, but I think play a role when less than ideal care is given. Often an individual is working under extreme pressure as there may be a training/staffing/workload issue at play, something that gets fed back to NHS bodies constantly through incident or near miss reviews, but obviously can take years to get perfect.

 

Many women were also left confused about why an intervention had happened, so I’d like to ask you about those particular circumstances. Firstly, can a baby get stuck? 

 

Yes, babies do get stuck. They get stuck because of the powers, the passenger and the passages – either the contractions are not strong enough or the baby is in a more complicated  position or the pelvis shape is stopping the baby or the baby is too big for the persons pelvis. Good labour management can help with several aspects of this, but not all births will be vaginal.

 

And in what situations would you use a forceps or a ventouse? How do you feel about using them?

 

Forceps and ventouse are a last resort when a baby cannot be delivered without them or needs a quick delivery to avoid hypoxic damage (brain injury due to oxygen deprivation). I am extremely confident using them and delivered hundreds of babies safely in this way and prevented hypoxic injury if left undelivered. A C-section when fully dilated – (although we do have to do these when baby is not safely deliverable with forceps or ventouse), carries much higher risks for mum including bleeding, visceral injury, infection and can result in hysterectomy in extreme cases. There have also been reports of babies being injured as they are retrieved from the vagina and delivered through the abdomen, so it may not be a safer option. Every scenario is different and obstetricians must use all their experience and training when deciding with mum what the best course of action should be. When used correctly injuries from forceps/ ventouse are extremely rare and trainees receive much higher levels of training in their use than they did a decade ago. These instruments are safe and their use is completely supported by the Royal College of Obstetricians. Hopefully as obstetricians we can make mums feel comfortable with a decision to use them and there’s no reason why it shouldn’t be a completely positive birth experience where mum stays in control.

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And why are mums sometimes discouraged from eating or drinking during labour? Some women find this really affected their birth due to lack of energy.

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It’s not ideal, but there is a risk of aspiration (inhaling the stomach contents) if a general anaesthetic is needed as an emergency. The risk of this is much higher for pregnant women than your average Joe unfortunately.  Aspiration pneumonia is very serious and could lead to admission to intensive care or even cause maternal death. You never know which women might require a general anaesthetic until they do so anyone who we think might be at risk of needing a C-section or might need to go to theatre for other reasons would be advised not to eat. Speak to your obstetrician if you need energy! Sometimes you can eat at certain time points, or you can have something sugary like jelly, energy gels or isotonic drinks - as they are made of clear fluids.

 

What happens if a mum disagrees with your view? How is that managed?

 

You can’t do anything to a mum without her consent. If you feel her choices are medically unsafe you have a duty to express your concerns and try and reach a consensus. Most of the time you come to the same decision when all the ideas/ concerns /expectations are properly listened to and discussed!! But ultimately, if the mum is of sound mind and says no, then you must respect that. An example would be a deeply held religious belief not to accept blood or not to accept induction of labour. It can be hard to accept someone’s decision when it could lead to their harm or babies harm, but if they feel strongly that is right for them, you must respect it. 

 

Finally, what services are available to support women and their partners if they have had a difficult birth? 

 

There is variation between trusts/ areas in the pathways in place for supporting women after a difficult delivery. All women should be are able to come back for a debrief appointment if they wish, but sadly there isn’t enough information on how to access this and some units will see women as hoc, whilst other units will offer follow up to larger groups, for example all C sections. Certainly those who have been bereaved will be followed up. It’s a funding/ capacity issues, but there are more initiatives happening all over to improve postnatal care pathways. For example, there is a huge drive in maternity at the moment to improve perinatal mental health so hopefully we will see more support for traumatic birth becoming available.

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Thank you for your time Caroline

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