When you have to visit the same department of a hospital several times, you memorise the signs. I now know that domestic violence spikes during sports events, and what different nursing uniforms mean. I know that if you dare try and get NHS treatment fraudulently, Teresa May herself is coming round with the boys. I know that, despite brexit, we can still get EHIC cards. And I know whether or not I would recommend the department to my nearest and dearest.
Wait, what?
We have spent a lot of time in ambulatory care at Peterborough hospital of late. It's a strange, useful department, designed for people who are too poorly to be seen in outpatients but who don't require an inpatient bed. A lot of people in there are being followed up from A+E, or having transfusions. Almost everyone in there feels like shit and a lot of them look it too. It's not the sort of place you go for a picnic, or the stunning view of the car park and Macmillan unit next door. The water's cold, the outside benches were designed for people with waves for arses, and they really need more reading material, but I'm not about to go on Tripadvisor and leave an excoriating review of the amenities. It's not somewhere you go for a jolly - we are there because Mum has to be there.
And yet, would I recommend this department to my friends and relatives? What a bizarre thing to ask people in an acute care centre. A few years back, I had a brain injury and about two weeks later, someone rang me up and asked me how I would rate the A+E dept. I can barely remember being in A+E, so how I was expected to rate it, I do not know.
The NHS likes to bang on about choice, namely choice of provider. Sometimes this can be really useful - I was able to get my son re-referred to his old hospital for an operation despite being out of area - but mostly it is meaningless, particularly in terms of acute care. When dripping blood everywhere, who has time to ponder to which A+E they are going to drag their detaching limb? Who has that level of local choice outside big cities? Where I live, there is Peterborough, which is five minutes away, but the next nearest large hospital is Hinchingbrooke, which is half an hour in good traffic. In an emergency, there's no question of where I'm going to go. Offering choice in acute care is illusory. Being asked to rate it is meaningless.
Treating patients as customers within the NHS is a real bugbear of mine. A good patient experience is very difficult to quantify. For example, excellently executed palliative care still results in a dead patient. Conversely, a live mother and baby is considered the best outcome in maternity care (as well it should be) regardless of trauma suffered. Patients experience the same illness in very different ways, every clinician has a slightly different approach to treatment, illness progression and injury healing can be very difficult to predict. How high patients are likely to rate departments surely depends on their mood, their particular problems and their experience on that day.
To give an example, when my mum was in Scarborough hospital (rated as requiring improvement by the CQC), some of her care on the ward and in transit was substandard from a professional point of view, but we are all so grateful that they saved her life that we wouldn't consider complaint. If asked whether I would recommend their emergency care team, I would give them a very high rating despite seeing some negligent care later on, because of that gratitude. However, when we have been sitting in ACU at Peterborough for six hours, waiting for medication that seems to take days to dispense, while Mum cries and dozes on a bed, I am disinclined to rate them highly. It's not their fault, their care is always excellent, but my mood is never good there.
To rate patient experience requires more detail and nuance than a simple "How likely are you to recommend us to friends or relatives? 1-5" rating, like you get in bloody Argos. If my curtains take thirty minutes to come down the chute in Argos, perhaps I have cause for complaint. Perhaps my giving them a 2 rating is justified. But giving a hospital a low rating because I had bad news that day? Because a poorly toddler was screaming and it made my migraine worse? Because some drunk vomited all over the waiting room and it took a while to clean up? Because I was scared? Because I was in pain? No. That's not a fair way to rate a department.
When I worked in general practice, we had to do patient surveys. For a month a year, everyone on reception would sick of the sight of this stack of questionnaires, ignored upon the desk because nobody coming to an urgent GP appointments wants to rate the surgery - they want to get their medication and go home. So what ended up happening was that all the regular patients would fill them in, rating us generally highly because they absolutely loved the GP or rating all the reception staff poorly because everyone hates GP receptionists. It never felt like a particularly fair way to assess patient opinion, least of all with all the staff fearful of what they might write (I believe now the CCG sends questionnaires direct to patients).
The NHS is not a shop. It is not Argos. It's not even Amazon. It's a public service. Hospitals are not theme parks, or holiday homes, or somewhere you can reasonably expect to enjoy yourself (unless you're some sort of fetishist). Rating your care is so subjective as to be almost meaningless outside of detailed debriefs after the event. Complaining is one thing: I am a seasoned complainer, usually because of instances of negligence or misconduct rather than bitching about a receptionist's tone, and the NHS needs to be open to justified complaint, but giving a flash rating subject to emotion at the point of care is ridiculous. Make it stop.
Showing posts with label hospital. Show all posts
Showing posts with label hospital. Show all posts
2 Sept 2016
6 Jul 2015
Birth Story - Alex, 2015
IN BRIEF:
Gestation:39w 5d
Site: Hospital
First Stage: 1hr 35min active labour
Transition: One contraction's worth
Second Stage: 10 minutes
Third Stage: 20 minutes
Tearing: Mainly external second degree tear
Weight: 8lb 10oz
Details:
As some of you know, I had been quite terrified of going into labour with this baby. My history of short labours and PPH (post-partum haemorrhage) plus generalised anxiety genuinely made me fear we would both die if I went into labour with nobody around to help. I think my body knew that, because despite two weeks of prelabour, nothing kicked off properly until the older boys had gone to their dad's and Tom was home from work.
Early on Friday evening, I started to get a burning cervical pain. I'd been getting a lot of pressure for a few days, but this was really uncomfortable and specific, so I could barely sit. I rang the hospital and they said it was more likely to be thrush or a UTI than imminent or silent labour, but considering my history, to come in to be checked. I didn't really think it could be labour because he wasn't due til the 6th, and other people have their babies early, not me!
Off we went, and had to wait for HOURS to be seen because they had several emergencies - Friday night is party night in delivery. I had a normal CTG. The obstetrician thought it was probably a UTI as I had a lot of leuks and protein in my wee, but my cervix was still thick, and 2-3cm dilated, as it had been for the previous two weeks. I got some antibiotics and left, starving and tired at 11pm. When we left, I didn't want to get out of the car. I had a strong urge to be safe at home, so Tom took me back and went into town to try and find some food. When he rang to tell me he couldn't get anything, I started to cry, which is rather unlike me. He went to McDs and then came home, knocked on the door for me to let him in and as I stood, my waters went CATASTROPHICALLY. It was a veritable DELUGE. I must have lost two pints in the first gush. I managed to get the door open, and then started giggling for joy. I rang the hospital who were sceptical about my need to be admitted immediately until I told them that my consultant had told me to insist on it. I couldn't eat because I knew I was likely to be sick in labour, and leaked about the house while Tom ate his burger.
My waters broke (the first time) at 12:10am.We got to hospital around 1, were seen around 1:30am in triage. I had some fierce backache, but no real contractions. I'd wodged a huge towel between my legs to try and catch the river, and the midwife asked if I hadn't got any pads. My waters had already soaked through two pairs of trousers and pads, I thought a towel might be more dignified...
I went on the monitor, and had a couple of painful contractions. On VE, I was 2cm stretching to 5, and admitted on the basis of previous precipitate labours. I wasn't in much pain, and was still quite joyful at the prospect of incoming child.
I was moved into a delivery suite around 2am, and nothing much was happening aside from the BIBLICAL STORM outside. If you missed it, shame on you - chain lightning, forked lightning, drunks outside A+E stumbling around in the rain. Gorgeous. Ahem. I was cannulated in case of PPH, and had some bloods done. I was then monitored for bloody ages. Alex's heart rate was ALL OVER the place. He was decelerating and accelerating and generally being very worrying, but because I wasn't technically in established labour, they were happy to wait and see if he settled down when labour settled in. I spent most of the next three hours alternating between being monitored and jigging about the room in soggy trousers, trying to get labour going. My waters didn't stop breaking until around 6am, and there were pints and pints of it. I can't believe how much there was. Me and Tom both kept nodding off, although I was getting one contraction every 15 minutes. They prepped my syntocin drip ready for afterwards. I explained that my cervix did not dilate as they're supposed to, but I only actually had two VEs from when my waters broke, which was great.
At 5:15am, I had another VE which was 4cm, stretching to 7 or 8cm, but this still didn't put me in officially established territory. Nonetheless, the VE got me going, to about one every four minutes. Annoyingly, I had to stay on the CTG throughout because he was still decelerating. I had the same midwife with me (Nina) throughout, and she only left for breaks (in which case someone else came in) or to get someone else to check his trace. This surprised me - I thought I'd be left to get on with it, and I did find it a bit inhibiting to begin with. Once I got going, there could have been a circus in there and I wouldn't have noticed.
The contractions lengthened and got a lot more painful. I was starting to get quite vocal during them, and hallucinating between them as I did in strong labour before, and my official labour start time was 5:55am. However, Nina kept telling other midwives I wasn't established, presumably so they didn't panic about the CTG. It didn't feel like my other labours because I had to be lying down - it made me feel rather detached, and although they were more widely spaced than if I'd been mobile, they were also more difficult to cope with because I couldn't use my body position to cope. Also, the CTG was registering my thunderously vicious contractions as 30-40, instead of 100, which made me wonder if I was actually progressing at all.
The next hour or so is a total blur. I had to stay on the bed. Tom was there the whole time, but I had my eyes shut through most of it. I got onto all fours, so I could let gravity do its thing, while staying on the CTG. Then I asked to go to the toilet, for a wee, because I was feeling pushy and I badly wanted to stand up for a minute. Going for a wee was an agony of blood and pain. Nina gave me some dextrose tablets (I hadn't eaten since Friday lunch) and I got back onto all fours, leaning into the back of the bed. She rubbed my back, while Tom held my hands. I remember telling Tom it was nearly time. A midwife came in to review the trace and organise shift handover, and said I was going to be referred to the coordinator for a caesarean, because of his heartrate (this wasn't actually discussed with me or stated explicitly, but I know the drill). I hit transition around then, and my legs started shaking uncontrollably, I felt sick and I told Tom he wasn't allowed to go and I wanted to go home and I couldn't do it anymore.
Then I began to push, so Nina got between my legs to monitor him, and just let me get on with it. I tell you now, giving birth without people telling you if you're allowed, or what to do is the best bloody way! Two other midwives came in then to take over the shift from Nina (who had already told me she wanted to stay until he was born) and were quite surprised to find me pushing since they'd been told I was 4cm and not established. I felt like it was very much my party - nobody told me what to do. It didn't take long at all, only ten minutes. I started screaming that it burned when he crowned, but otherwise I tried to be quiet and just pushed. I managed to mostly pant his head out and his shoulders took a bit longer to be born than I was expecting, but then out he came! He was a bit wrapped in cord, but I had my back to them so I'm not sure how bad it was.
I had him at 7:41am, four minutes before Nina's shift finished! I went a bit "Oooh, I had a baby", because it didn't really feel real. They helped me get onto my back and I started to haemorrhage immediately. They gave him to me and I haemorrhaged some more, so they plugged my syntocin in quickly. I lost about 500ml, so not as bad as last time. Alex was quite bluey purple and still properly covered in vernix. He took a while to go pink, but his Apgars were fine.
Then came the placenta. Even with the syntocin and syntometrine injection, it took a while. It was a bit tangled up in membranes and my body did not want to push it out. They got it out in one piece after about twenty minutes, while I was feeding the baby.
Then, bloody horrible stitching. I didn't tear too badly this time (2nd degree, mostly exterior) but being examined by a student with shaky hands was deeply unpleasant. However, when they'd finished and gave me the best tea and toast in the world, I was much improved.
They weighed and checked Alex. He is 8lb 10oz, so a little smaller than we expected but not much. His head circ is only 36cm, which is MUCH smaller than I expected, and quite a relief.
We sat around waiting to go. My drip took 3.5 hours to get through and they wouldn't uncannulate me until it was time to go in case I suddenly had a haemorrhage again. He passed his hearing test first time, which surprised me because he had such a soggy labour. The paediatrician (who I'm sure I went to school with) didn't come round til gone 2pm. Alex is all normal. Then my midwives started to discharge me, got halfway through and called to an emergency, and then we sat for an hour waiting for someone to finish it off. He pooed all over the discharging midwife. We finally left around 5pm, by which time I was heartily sick of hospital having been there (with a break) for almost 24hrs.
I think this was probably my easiest birth. It was frustrating being hooked up and immobile for hours, particularly as I'm sure he would have been born sooner if I'd been allowed up and I couldn't really tell how I was progressing because it feels so different from being active in labour. BUT his actual delivery was really good and felt much more natural and easy than the other two and I didn't have quite as bad atony in the third stage as before. I didn't want or need any painkillers, which totally shocked all the midwives, but what's the point for two unbearably hard contractions? That's all it was as well - and they didn't seem to get to the point where they rolled into each other, so I was still getting breaks right up to transition. I was worried before that having him on the consultant led unit would mean a lot of intervention and trying to make my body go by the book, but despite being monitored, the midwife was quite happy for me to get on with it on my own terms.
Alex is beautiful and looks just like his brothers.
I never want to do it again, but I'm so glad it went well.
Gestation:39w 5d
Site: Hospital
First Stage: 1hr 35min active labour
Transition: One contraction's worth
Second Stage: 10 minutes
Third Stage: 20 minutes
Tearing: Mainly external second degree tear
Weight: 8lb 10oz
Details:
As some of you know, I had been quite terrified of going into labour with this baby. My history of short labours and PPH (post-partum haemorrhage) plus generalised anxiety genuinely made me fear we would both die if I went into labour with nobody around to help. I think my body knew that, because despite two weeks of prelabour, nothing kicked off properly until the older boys had gone to their dad's and Tom was home from work.
Early on Friday evening, I started to get a burning cervical pain. I'd been getting a lot of pressure for a few days, but this was really uncomfortable and specific, so I could barely sit. I rang the hospital and they said it was more likely to be thrush or a UTI than imminent or silent labour, but considering my history, to come in to be checked. I didn't really think it could be labour because he wasn't due til the 6th, and other people have their babies early, not me!
Off we went, and had to wait for HOURS to be seen because they had several emergencies - Friday night is party night in delivery. I had a normal CTG. The obstetrician thought it was probably a UTI as I had a lot of leuks and protein in my wee, but my cervix was still thick, and 2-3cm dilated, as it had been for the previous two weeks. I got some antibiotics and left, starving and tired at 11pm. When we left, I didn't want to get out of the car. I had a strong urge to be safe at home, so Tom took me back and went into town to try and find some food. When he rang to tell me he couldn't get anything, I started to cry, which is rather unlike me. He went to McDs and then came home, knocked on the door for me to let him in and as I stood, my waters went CATASTROPHICALLY. It was a veritable DELUGE. I must have lost two pints in the first gush. I managed to get the door open, and then started giggling for joy. I rang the hospital who were sceptical about my need to be admitted immediately until I told them that my consultant had told me to insist on it. I couldn't eat because I knew I was likely to be sick in labour, and leaked about the house while Tom ate his burger.
My waters broke (the first time) at 12:10am.We got to hospital around 1, were seen around 1:30am in triage. I had some fierce backache, but no real contractions. I'd wodged a huge towel between my legs to try and catch the river, and the midwife asked if I hadn't got any pads. My waters had already soaked through two pairs of trousers and pads, I thought a towel might be more dignified...
I went on the monitor, and had a couple of painful contractions. On VE, I was 2cm stretching to 5, and admitted on the basis of previous precipitate labours. I wasn't in much pain, and was still quite joyful at the prospect of incoming child.
I was moved into a delivery suite around 2am, and nothing much was happening aside from the BIBLICAL STORM outside. If you missed it, shame on you - chain lightning, forked lightning, drunks outside A+E stumbling around in the rain. Gorgeous. Ahem. I was cannulated in case of PPH, and had some bloods done. I was then monitored for bloody ages. Alex's heart rate was ALL OVER the place. He was decelerating and accelerating and generally being very worrying, but because I wasn't technically in established labour, they were happy to wait and see if he settled down when labour settled in. I spent most of the next three hours alternating between being monitored and jigging about the room in soggy trousers, trying to get labour going. My waters didn't stop breaking until around 6am, and there were pints and pints of it. I can't believe how much there was. Me and Tom both kept nodding off, although I was getting one contraction every 15 minutes. They prepped my syntocin drip ready for afterwards. I explained that my cervix did not dilate as they're supposed to, but I only actually had two VEs from when my waters broke, which was great.
At 5:15am, I had another VE which was 4cm, stretching to 7 or 8cm, but this still didn't put me in officially established territory. Nonetheless, the VE got me going, to about one every four minutes. Annoyingly, I had to stay on the CTG throughout because he was still decelerating. I had the same midwife with me (Nina) throughout, and she only left for breaks (in which case someone else came in) or to get someone else to check his trace. This surprised me - I thought I'd be left to get on with it, and I did find it a bit inhibiting to begin with. Once I got going, there could have been a circus in there and I wouldn't have noticed.
The contractions lengthened and got a lot more painful. I was starting to get quite vocal during them, and hallucinating between them as I did in strong labour before, and my official labour start time was 5:55am. However, Nina kept telling other midwives I wasn't established, presumably so they didn't panic about the CTG. It didn't feel like my other labours because I had to be lying down - it made me feel rather detached, and although they were more widely spaced than if I'd been mobile, they were also more difficult to cope with because I couldn't use my body position to cope. Also, the CTG was registering my thunderously vicious contractions as 30-40, instead of 100, which made me wonder if I was actually progressing at all.
The next hour or so is a total blur. I had to stay on the bed. Tom was there the whole time, but I had my eyes shut through most of it. I got onto all fours, so I could let gravity do its thing, while staying on the CTG. Then I asked to go to the toilet, for a wee, because I was feeling pushy and I badly wanted to stand up for a minute. Going for a wee was an agony of blood and pain. Nina gave me some dextrose tablets (I hadn't eaten since Friday lunch) and I got back onto all fours, leaning into the back of the bed. She rubbed my back, while Tom held my hands. I remember telling Tom it was nearly time. A midwife came in to review the trace and organise shift handover, and said I was going to be referred to the coordinator for a caesarean, because of his heartrate (this wasn't actually discussed with me or stated explicitly, but I know the drill). I hit transition around then, and my legs started shaking uncontrollably, I felt sick and I told Tom he wasn't allowed to go and I wanted to go home and I couldn't do it anymore.
Then I began to push, so Nina got between my legs to monitor him, and just let me get on with it. I tell you now, giving birth without people telling you if you're allowed, or what to do is the best bloody way! Two other midwives came in then to take over the shift from Nina (who had already told me she wanted to stay until he was born) and were quite surprised to find me pushing since they'd been told I was 4cm and not established. I felt like it was very much my party - nobody told me what to do. It didn't take long at all, only ten minutes. I started screaming that it burned when he crowned, but otherwise I tried to be quiet and just pushed. I managed to mostly pant his head out and his shoulders took a bit longer to be born than I was expecting, but then out he came! He was a bit wrapped in cord, but I had my back to them so I'm not sure how bad it was.
I had him at 7:41am, four minutes before Nina's shift finished! I went a bit "Oooh, I had a baby", because it didn't really feel real. They helped me get onto my back and I started to haemorrhage immediately. They gave him to me and I haemorrhaged some more, so they plugged my syntocin in quickly. I lost about 500ml, so not as bad as last time. Alex was quite bluey purple and still properly covered in vernix. He took a while to go pink, but his Apgars were fine.
Then came the placenta. Even with the syntocin and syntometrine injection, it took a while. It was a bit tangled up in membranes and my body did not want to push it out. They got it out in one piece after about twenty minutes, while I was feeding the baby.
Then, bloody horrible stitching. I didn't tear too badly this time (2nd degree, mostly exterior) but being examined by a student with shaky hands was deeply unpleasant. However, when they'd finished and gave me the best tea and toast in the world, I was much improved.
They weighed and checked Alex. He is 8lb 10oz, so a little smaller than we expected but not much. His head circ is only 36cm, which is MUCH smaller than I expected, and quite a relief.
We sat around waiting to go. My drip took 3.5 hours to get through and they wouldn't uncannulate me until it was time to go in case I suddenly had a haemorrhage again. He passed his hearing test first time, which surprised me because he had such a soggy labour. The paediatrician (who I'm sure I went to school with) didn't come round til gone 2pm. Alex is all normal. Then my midwives started to discharge me, got halfway through and called to an emergency, and then we sat for an hour waiting for someone to finish it off. He pooed all over the discharging midwife. We finally left around 5pm, by which time I was heartily sick of hospital having been there (with a break) for almost 24hrs.
I think this was probably my easiest birth. It was frustrating being hooked up and immobile for hours, particularly as I'm sure he would have been born sooner if I'd been allowed up and I couldn't really tell how I was progressing because it feels so different from being active in labour. BUT his actual delivery was really good and felt much more natural and easy than the other two and I didn't have quite as bad atony in the third stage as before. I didn't want or need any painkillers, which totally shocked all the midwives, but what's the point for two unbearably hard contractions? That's all it was as well - and they didn't seem to get to the point where they rolled into each other, so I was still getting breaks right up to transition. I was worried before that having him on the consultant led unit would mean a lot of intervention and trying to make my body go by the book, but despite being monitored, the midwife was quite happy for me to get on with it on my own terms.
Alex is beautiful and looks just like his brothers.
I never want to do it again, but I'm so glad it went well.
21 May 2015
Planning A Birth
When you are pregnant the first time, all the baby magazines, books and websites talk about your Birth Plan, as though it is something enshrined in law. While your midwife concentrates on various medical choices, which either horrify you or go straight over your head, the baby media remind you that you should pack incense and candles and soothing music. The reality of a first birth is usually some miles away from the happy ideal of the joyous birth plan. In fact, the birth plan is usually ignored. No pain relief sounds a noble thing indeed until the 36th hour of labour. No amount of Enya is going to stop you screaming like a banshee at some point. And that's fine.
I would argue that giving birth for the first time is inherently traumatic, regardless of how natural and beautiful it's supposed to be. It would certainly explain the vast numbers of women who speak of their first delivery in terms of awestruck horror. I certainly found my first birth traumatic, although most other women regard it with a mix of disdain and envy. Only four hours of labour? Lucky bitch. Yeah, four hours of labour is fine until you're going down the A47 at 80mph in the middle of the night, trying not to give birth in the front seat. That is less relaxing.
I was strongly advised to have a homebirth with my second baby. This was no problem for me: not only was my first birth traumatically fast, I also had an absolute shit time on the postnatal ward and was left in a very fragile mental state for six months. I blamed my postnatal depression mainly on my poor postnatal experience, and was scared it would happen again.
So, when the time came, I popped my middle boy out at home. I was considered low risk in comparison to the high risk of precipitate labour. As far as the labour and delivery went, it was beautiful and just like birth is SUPPOSED to be. Then it all went to shit.
I thought I was OK with my second birth. My baby was alive, somehow. I was alive and safe if a bit fucked up for a week, and I'd done it at home all by myself. It was a lot more controlled and easier to cope with than the first. I drew a line under it.
Or I thought I did, until I got pregnant again.
Initially, I thought I would have a homebirth. As pregnancy progressed, I realised that I was actually quite terrified of having another homebirth. They're great. They're lovely. They're amazing. Until they go wrong, and then they are SHIT. You have to hang around waiting for an ambulance, get dislodged from your comfy house to go and lie on a horrible hospital bed. And that's if you manage to get your baby out first - the idea of doing the same IN LABOUR fills me with horror.
My consultant got my notes from my old hospital, and said it would be a lot better if I had the baby on the consultant led unit so they can treat me immediately if I haemorrhage again.
And what upset me was not that the decision to have a homebirth was taken away, but that I no longer felt able to trust my body how to have a baby. I no longer WANTED to have a homebirth, and that felt very strange to me.
I've got 46 days to brew, give or take a fortnight. And I am dreading birth. I don't want to go into labour - not enough to be induced, which has been offered, but enough to already be second guessing my body's various twinges. I am scared of haemorrhaging again, scared of tearing, scared of everything. It sucks. I have never feared birth before, trusting wholly in my uterus to do what is expected of it, but now I am full of doubt. I sincerely hope that I am so sick of pregnancy that I welcome it by the end, because this anxiety is all new. It may be because I *know* this baby is my last, and I feel pressure to get it right, to minimise the curious feeling afterwards that I need to do it again to make it right.
There is no such thing as a perfect birth. There are only births that are good for the individual, and being realistic in your aims and expectations is the first step. I expect to give birth without pain relief - I have twice before. I expect to refuse induction unless the baby's distressed - I'm like that. I expect to be allowed to labour without monitoring or VEs - I've always laboured at home, so this might be a bit more of a stretch. I expect labour to be fast - if it's not, I shall be surprised! I am prepared to labour too fast to get assistance, which is part of the fear. I expect to haemorrhage, but I hope I won't. I expect to need surgical repair, but really hope I won't. I expect a big baby.
But that's all I expect. Everything else is too unpredictable to even think about trying to plan for.
I would argue that giving birth for the first time is inherently traumatic, regardless of how natural and beautiful it's supposed to be. It would certainly explain the vast numbers of women who speak of their first delivery in terms of awestruck horror. I certainly found my first birth traumatic, although most other women regard it with a mix of disdain and envy. Only four hours of labour? Lucky bitch. Yeah, four hours of labour is fine until you're going down the A47 at 80mph in the middle of the night, trying not to give birth in the front seat. That is less relaxing.
I was strongly advised to have a homebirth with my second baby. This was no problem for me: not only was my first birth traumatically fast, I also had an absolute shit time on the postnatal ward and was left in a very fragile mental state for six months. I blamed my postnatal depression mainly on my poor postnatal experience, and was scared it would happen again.
So, when the time came, I popped my middle boy out at home. I was considered low risk in comparison to the high risk of precipitate labour. As far as the labour and delivery went, it was beautiful and just like birth is SUPPOSED to be. Then it all went to shit.
I thought I was OK with my second birth. My baby was alive, somehow. I was alive and safe if a bit fucked up for a week, and I'd done it at home all by myself. It was a lot more controlled and easier to cope with than the first. I drew a line under it.
Or I thought I did, until I got pregnant again.
Initially, I thought I would have a homebirth. As pregnancy progressed, I realised that I was actually quite terrified of having another homebirth. They're great. They're lovely. They're amazing. Until they go wrong, and then they are SHIT. You have to hang around waiting for an ambulance, get dislodged from your comfy house to go and lie on a horrible hospital bed. And that's if you manage to get your baby out first - the idea of doing the same IN LABOUR fills me with horror.
My consultant got my notes from my old hospital, and said it would be a lot better if I had the baby on the consultant led unit so they can treat me immediately if I haemorrhage again.
And what upset me was not that the decision to have a homebirth was taken away, but that I no longer felt able to trust my body how to have a baby. I no longer WANTED to have a homebirth, and that felt very strange to me.
I've got 46 days to brew, give or take a fortnight. And I am dreading birth. I don't want to go into labour - not enough to be induced, which has been offered, but enough to already be second guessing my body's various twinges. I am scared of haemorrhaging again, scared of tearing, scared of everything. It sucks. I have never feared birth before, trusting wholly in my uterus to do what is expected of it, but now I am full of doubt. I sincerely hope that I am so sick of pregnancy that I welcome it by the end, because this anxiety is all new. It may be because I *know* this baby is my last, and I feel pressure to get it right, to minimise the curious feeling afterwards that I need to do it again to make it right.
There is no such thing as a perfect birth. There are only births that are good for the individual, and being realistic in your aims and expectations is the first step. I expect to give birth without pain relief - I have twice before. I expect to refuse induction unless the baby's distressed - I'm like that. I expect to be allowed to labour without monitoring or VEs - I've always laboured at home, so this might be a bit more of a stretch. I expect labour to be fast - if it's not, I shall be surprised! I am prepared to labour too fast to get assistance, which is part of the fear. I expect to haemorrhage, but I hope I won't. I expect to need surgical repair, but really hope I won't. I expect a big baby.
But that's all I expect. Everything else is too unpredictable to even think about trying to plan for.
8 May 2015
The NHS Is Doomed
No election should be fought on a single issue. No party should stand on a single issue - one of my main problems with UKIP outside the rampant fascism is their focus on immigration at the cost of everything else. However, the NHS is a massive issue that should have totally dominated this election, far more than taxes, immigrants or the EU.
The NHS is a socialist ideal - free healthcare for all. It's a very simple, very expensive ideal. It was introduced as a post-war reform, to centralise, regulate and democratise healthcare. Prior to this, healthcare was paid for either as it was necessary, or by insurance. My granny and her sister were in hospital for weeks with diphtheria in the 1930s, and that was paid for by their father's work 'stamp'. There was a lot of self-medication then as well - this being in the days before antibiotics - mostly with unregulated supplies of opiate based medicine. Colicky baby? Opiates! It was to be paid for through work-related National Insurance, which was not dissimilar to what most people were used to paying anyway. It was an ideal system.
The NHS, since those days, has mutated into an enormous, bureaucratic beast. In attempts to save money, managers were brought in to regulate practice. They have ended up sucking more money out of the NHS in wages than they save in administration. I was an NHS administrator, I know we are very necessary people, but I was on minimum wage to begin with and some are on hundreds of thousands of pounds a year.
Labour had some interesting ideas on how to make the NHS more profitable - mainly by getting private firms to build hospitals on a sort of hire-purchase agreement. Then they started selling off the buildings and responsibility for hospitals and GP surgeries to private companies. That worked fine, until the private companies decided they couldn't afford to run them anymore, and withdrew. You see, that's the real problem with privatising aspects of healthcare, as it has been with privatising other public services. When it ceases to be profitable, the private sector simply run away. Free healthcare is not a very lucrative business, so this is likely to happen a lot more in future.
The coalition government also made a lot of cuts to the services offered on the NHS, as well as raising prescription costs enormously (£7.20 per item in 2010 to £8.20 in 2015). In a startling deviation from my usual lefty saucepan-banging, I believe prescription costs should be around £0.50 per item, but applicable to all but the critically ill and the extremely poor. I know how much medication costs wholesale: it shouldn't be free to as many people as it is, but neither should it be prohibitively expensive. The coalition government also cut staffing, particularly in nursing where I suppose they think people won't notice, and in A+E departments, where people certainly do.
The problem with the new Conservative government and the NHS is that the Conservatives are ideologically opposed to the NHS. This isn't me being a bleeding-heart liberal: they believe in telling us what to do to keep healthy, and that is as far as it goes. The Conservative viewpoint on health is that it is your responsibility, your fault and your problem if you're ill.
Thatcherism took this even further into the realms of market liberalism. Don't be fooled by the name, the liberalism refers to the freedom of the markets, not you. Market liberalism holds that the market should be free to set costs without government interference. So not only are you ill (which is your fault), your treatment price is inflated. Hurrah for Thatcher (said nobody, ever).
And the thing is, that would be FINE if health was merely down to a matter of personal responsibility. But we all know it's not, even if we try and convince ourselves ideologically that people give themselves cancer, or depression, or chronic disease. We all know someone healthy cut down in their prime by some apparent fluke illness or accident. We all know someone who's done every single recklessly unhealthy thing you can imagine and lived to a ripe old age.
One of the biggest factors in your lifespan and your years of freedom from disability is your wealth. The more money you have, the healthier you are likelier to be, and the longer your life. There is a nine year gap in average lifespan between the richest and poorest areas of the UK. NINE YEARS. Not only is there that lifespan gap, there's also a huge gap in experience of disability.
Now, there are loads of reasons poor people experience poor health, and very few of them are down to personal factors. One of the main reasons is infrastructure. When you live in a poor area, your access to doctors, hospitals, transport, nutrition, good housing, employment, and exercise is limited. Your exposure to pollution, cigarette smoke, accidents, antisocial behaviour, stress and housing-related issues like mould is increased. Education also has an important, if unexplained, effect on health - more educated people tend to be healthier, and schools in poor areas tend to have lower qualification rates.
All of this is exacerbated by work. If you are fairly well off and work in the private sector, it's likely that you have a sick pay scheme. You may even have health insurance. Even so, suddenly being unable to work for a long period of time can be a disconcerting, depressing and stressful experience. However, when you work in lower class employment, or in the lower sectors of the public sector, you are dependent on statutory sick pay. SSP is currently £88.45 a week. You cannot claim SSP if you are on a zero-hours contract, or a very low wage. It's eligible for six months, after which you either continue on nothing, be sacked for continual absence and thus ineligible for jobseekers allowance, or leave work and switch to a disability benefit. I know a lady who was sacked because she'd had too many periods of sickness in the last few years, and then had a bad chest infection. Her previous absences were due to having chemotherapy. This was perfectly legal. Naturally, switching to a disability benefit is universally considered a bad thing by the Conservatives. Far better to keep the working masses in work, surely?
Yet it is the working mass, the seething, swarming low-paid mass, that needs the NHS most, potentially costs the benefit system most, and is capable of paying back into the economy. These are the people the Conservative government would prefer did not exist. The people they wish would be as wealthy as they are, so they didn't have to worry about society. The people they continually push down the ladder through social and economic inequality, and then seem surprised when it costs the state money to do so. I'm sure there are plenty of individual Conservative MPs and voters that staunchly believe in the NHS, but that's not the party line, so they may as well piss in the wind.
Thatcher said there is no such thing as society. Unfortunately for her acolytes, there is, but don't expect the gentle dismantling of the NHS infrastructure to stop now the coalition has ended.
Expect it to get worse. Expect it to become more overt. Expect to become anaesthetised to the idea that the NHS is a salvageable , workable entity. Expect to be unsurprised when it's rebranded, or you are asked to put down a deposit when making a GP appointment 'to ensure your attendance'. Expect GPs to be blamed. Expect A+Es to be blamed. Expect managers to be blamed. Expect ill people to be blamed. Expect immigrants to be blamed. In fact, expect everyone else to be blamed for the sad, but necessary dissolution of the NHS except the government.
I love the NHS - I love it as staff, I love it as a patient, I even love it as a parent of a disabled child, where it's failed us most.
I hope I'm wrong about this. Ask me in five years.
The NHS is a socialist ideal - free healthcare for all. It's a very simple, very expensive ideal. It was introduced as a post-war reform, to centralise, regulate and democratise healthcare. Prior to this, healthcare was paid for either as it was necessary, or by insurance. My granny and her sister were in hospital for weeks with diphtheria in the 1930s, and that was paid for by their father's work 'stamp'. There was a lot of self-medication then as well - this being in the days before antibiotics - mostly with unregulated supplies of opiate based medicine. Colicky baby? Opiates! It was to be paid for through work-related National Insurance, which was not dissimilar to what most people were used to paying anyway. It was an ideal system.
The NHS, since those days, has mutated into an enormous, bureaucratic beast. In attempts to save money, managers were brought in to regulate practice. They have ended up sucking more money out of the NHS in wages than they save in administration. I was an NHS administrator, I know we are very necessary people, but I was on minimum wage to begin with and some are on hundreds of thousands of pounds a year.
Labour had some interesting ideas on how to make the NHS more profitable - mainly by getting private firms to build hospitals on a sort of hire-purchase agreement. Then they started selling off the buildings and responsibility for hospitals and GP surgeries to private companies. That worked fine, until the private companies decided they couldn't afford to run them anymore, and withdrew. You see, that's the real problem with privatising aspects of healthcare, as it has been with privatising other public services. When it ceases to be profitable, the private sector simply run away. Free healthcare is not a very lucrative business, so this is likely to happen a lot more in future.
The coalition government also made a lot of cuts to the services offered on the NHS, as well as raising prescription costs enormously (£7.20 per item in 2010 to £8.20 in 2015). In a startling deviation from my usual lefty saucepan-banging, I believe prescription costs should be around £0.50 per item, but applicable to all but the critically ill and the extremely poor. I know how much medication costs wholesale: it shouldn't be free to as many people as it is, but neither should it be prohibitively expensive. The coalition government also cut staffing, particularly in nursing where I suppose they think people won't notice, and in A+E departments, where people certainly do.
The problem with the new Conservative government and the NHS is that the Conservatives are ideologically opposed to the NHS. This isn't me being a bleeding-heart liberal: they believe in telling us what to do to keep healthy, and that is as far as it goes. The Conservative viewpoint on health is that it is your responsibility, your fault and your problem if you're ill.
Thatcherism took this even further into the realms of market liberalism. Don't be fooled by the name, the liberalism refers to the freedom of the markets, not you. Market liberalism holds that the market should be free to set costs without government interference. So not only are you ill (which is your fault), your treatment price is inflated. Hurrah for Thatcher (said nobody, ever).
And the thing is, that would be FINE if health was merely down to a matter of personal responsibility. But we all know it's not, even if we try and convince ourselves ideologically that people give themselves cancer, or depression, or chronic disease. We all know someone healthy cut down in their prime by some apparent fluke illness or accident. We all know someone who's done every single recklessly unhealthy thing you can imagine and lived to a ripe old age.
One of the biggest factors in your lifespan and your years of freedom from disability is your wealth. The more money you have, the healthier you are likelier to be, and the longer your life. There is a nine year gap in average lifespan between the richest and poorest areas of the UK. NINE YEARS. Not only is there that lifespan gap, there's also a huge gap in experience of disability.
Now, there are loads of reasons poor people experience poor health, and very few of them are down to personal factors. One of the main reasons is infrastructure. When you live in a poor area, your access to doctors, hospitals, transport, nutrition, good housing, employment, and exercise is limited. Your exposure to pollution, cigarette smoke, accidents, antisocial behaviour, stress and housing-related issues like mould is increased. Education also has an important, if unexplained, effect on health - more educated people tend to be healthier, and schools in poor areas tend to have lower qualification rates.
All of this is exacerbated by work. If you are fairly well off and work in the private sector, it's likely that you have a sick pay scheme. You may even have health insurance. Even so, suddenly being unable to work for a long period of time can be a disconcerting, depressing and stressful experience. However, when you work in lower class employment, or in the lower sectors of the public sector, you are dependent on statutory sick pay. SSP is currently £88.45 a week. You cannot claim SSP if you are on a zero-hours contract, or a very low wage. It's eligible for six months, after which you either continue on nothing, be sacked for continual absence and thus ineligible for jobseekers allowance, or leave work and switch to a disability benefit. I know a lady who was sacked because she'd had too many periods of sickness in the last few years, and then had a bad chest infection. Her previous absences were due to having chemotherapy. This was perfectly legal. Naturally, switching to a disability benefit is universally considered a bad thing by the Conservatives. Far better to keep the working masses in work, surely?
Yet it is the working mass, the seething, swarming low-paid mass, that needs the NHS most, potentially costs the benefit system most, and is capable of paying back into the economy. These are the people the Conservative government would prefer did not exist. The people they wish would be as wealthy as they are, so they didn't have to worry about society. The people they continually push down the ladder through social and economic inequality, and then seem surprised when it costs the state money to do so. I'm sure there are plenty of individual Conservative MPs and voters that staunchly believe in the NHS, but that's not the party line, so they may as well piss in the wind.
Thatcher said there is no such thing as society. Unfortunately for her acolytes, there is, but don't expect the gentle dismantling of the NHS infrastructure to stop now the coalition has ended.
Expect it to get worse. Expect it to become more overt. Expect to become anaesthetised to the idea that the NHS is a salvageable , workable entity. Expect to be unsurprised when it's rebranded, or you are asked to put down a deposit when making a GP appointment 'to ensure your attendance'. Expect GPs to be blamed. Expect A+Es to be blamed. Expect managers to be blamed. Expect ill people to be blamed. Expect immigrants to be blamed. In fact, expect everyone else to be blamed for the sad, but necessary dissolution of the NHS except the government.
I love the NHS - I love it as staff, I love it as a patient, I even love it as a parent of a disabled child, where it's failed us most.
I hope I'm wrong about this. Ask me in five years.
6 Mar 2013
Labour pains
Once upon a time, there was no such thing as pain relief in labour. It didn't matter if your labour lasted an hour or three days: there was nothing to offer for the pain. As well as this, if your baby got stuck, it died and most of the time, so did you. This used to be considered part of the curse of womanhood - to punish Eve for her fall, God stated that women must bear their children in blood and pain. In our time, it is difficult to understand how absolute the word of the Bible was historically. Childbirth was a pain women had to bear.
Times have changed and obstetric practice has gone through various fashions. For example, twilight birth was first offered as a treatment for pain of childbirth in the 1860s, via chloroform (praised magnificently by Queen Victoria, who didn't have easy births despite her grand multiparity), and evolved to being normal practice in the US until the 1940s. Women were injected with a morphine based mixture in the early phases of labour, and then remained barely conscious and unaware of pain until after the birth. The side effect was a drowsy baby with decreased respiratory function.
In the 1970s, pethidine was given to labouring women in hospital, usually without consent. Our notion of informed consent is surprisingly modern - until the mid 1980s, women were shaved and subjected to enemas in early labour, monitored and confined to bed throughout the labour and then given an episiotomy during the birth without much explanation, as a matter of course, to keep things tidy and easy for the delivering doctor.
Radical midwifery began the change in obstetric practice in the 1980s, as a response to this overmedicalisation of childbirth. The radical midwifery movement saw childbirth as a natural and normal act, whereas the medical fraternity of the time saw it as fraught with risk.
Nowadays, obstetrics falls somewhere between the two extremes. Women are considered low risk, unless they fit one of a number of criteria which escalates them to high risk. Women now have a right to choose where to deliver their child, and have a choice of pain relieving medications. Some women are able to have a vaginal delivery, with minimal interference, at home or hospital. Other women have more technical deliveries, overseen by several clinicians. However, the assessment of who needs what kind of birth is done on a case by case basis, and the woman's needs are acknowledged in the process - or at least, they should be. As I've alluded to before, this isn't yet internalised procedure for all clinicians.
The issue of pain relief in childbirth is one that comes up, most often when women are in their first pregnancy and their midwife, family and friends ask them what they are planning to use. Midwives generally advise women not to plan their pain control too much, as it doesn't allow for adaptation in labour. Friends who have already had children, will often fall into one of two camps based on their experience - 'have ALL the pain relief because it's the worst pain ever and you'll DIE' or 'pain relief is for wusses'.
The red camp are scaremongerers, the blue camp are not being realistic. Nobody knows what they are capable of withstanding physically until they do it. No woman can predict how the length or intensity of their labour, whether it's their first child or ninth. There are women who have their children with no pain relief at all, and ones who have an epidural at 4cm because the pain is so vicious. Neither are wrong, or right, they're just doing what they need to do to get through it.
There are side effects of using pain relief - pethidine, diamorphine and meptid can lead to a dopey baby, or worse a baby in respiratory distress. Having an epidural contributes to birth interventions, because the woman cannot coordinate her physical pushing with the uterine contractions, and being confined to bed protracts labour as gravity cannot work. Gas and air is the safest form of pain relief, though it can lose it's effectiveness in the later stages of labour.
However, an excessively painful labour may lead to psychological problems postnatally. I had no pain relief in my first labour because it progressed so quickly that there wasn't time. For some time afterwards, I had vivid flashbacks to being in agony and terrified - pain is very frightening if you don't feel in control of it. The pain, and speed of delivery, alienated me from my baby to begin with. I simply couldn't comprehend that this child had come from me. I had been expecting a long first labour, mostly in hospital. Instead, I got two hours of agony on my toilet at home, an hour of trying not to push while I got to hospital, and then an hour of pushing. I don't know if my trauma would have been lessened if I had pain relief, but I probably would have felt more in control. It has been almost four years, and I can still feel my body trying not to push if I think about the half an hour or so before I was 'allowed' to push by a midwife.
Equally, a labour without pain relief can be extremely cathartic. I had my second child without pain relief, by choice, expecting a fast labour. I got a fast labour - 1 hour 50 minutes - and felt wholly in control throughout. The pain was awful, as labour pain is, but it never felt unmanageable. His birth was healing, both to the trauma of my first birth, and the trauma of my second pregnancy.
A drug-free labour can be extremely empowering, but a planned drug-free labour that goes awry for whatever reason can lead to feelings of failure and inadequacy. Some women consider using pain relief to be cheating, or an easy way out, rather than an advantage of modern medicine. Other women consider using pain relief as a normal part of life - after all, you take medication for a headache, why not for the worst pain you'll ever bear?
Labour pain requires management. Some women can manage it on their own, through sheer force of will, through breathing techniques or hypnosis. Some women need drugs to manage the pain. Pain thresholds vary from person to person, and people's perception of pain also varies. Most women are capable of giving birth vaginally, without pain relief, but not doing so, through choice or necessity, does not make them less of a woman, or less of a mother.
Times have changed and obstetric practice has gone through various fashions. For example, twilight birth was first offered as a treatment for pain of childbirth in the 1860s, via chloroform (praised magnificently by Queen Victoria, who didn't have easy births despite her grand multiparity), and evolved to being normal practice in the US until the 1940s. Women were injected with a morphine based mixture in the early phases of labour, and then remained barely conscious and unaware of pain until after the birth. The side effect was a drowsy baby with decreased respiratory function.
In the 1970s, pethidine was given to labouring women in hospital, usually without consent. Our notion of informed consent is surprisingly modern - until the mid 1980s, women were shaved and subjected to enemas in early labour, monitored and confined to bed throughout the labour and then given an episiotomy during the birth without much explanation, as a matter of course, to keep things tidy and easy for the delivering doctor.
Radical midwifery began the change in obstetric practice in the 1980s, as a response to this overmedicalisation of childbirth. The radical midwifery movement saw childbirth as a natural and normal act, whereas the medical fraternity of the time saw it as fraught with risk.
Nowadays, obstetrics falls somewhere between the two extremes. Women are considered low risk, unless they fit one of a number of criteria which escalates them to high risk. Women now have a right to choose where to deliver their child, and have a choice of pain relieving medications. Some women are able to have a vaginal delivery, with minimal interference, at home or hospital. Other women have more technical deliveries, overseen by several clinicians. However, the assessment of who needs what kind of birth is done on a case by case basis, and the woman's needs are acknowledged in the process - or at least, they should be. As I've alluded to before, this isn't yet internalised procedure for all clinicians.
The issue of pain relief in childbirth is one that comes up, most often when women are in their first pregnancy and their midwife, family and friends ask them what they are planning to use. Midwives generally advise women not to plan their pain control too much, as it doesn't allow for adaptation in labour. Friends who have already had children, will often fall into one of two camps based on their experience - 'have ALL the pain relief because it's the worst pain ever and you'll DIE' or 'pain relief is for wusses'.
The red camp are scaremongerers, the blue camp are not being realistic. Nobody knows what they are capable of withstanding physically until they do it. No woman can predict how the length or intensity of their labour, whether it's their first child or ninth. There are women who have their children with no pain relief at all, and ones who have an epidural at 4cm because the pain is so vicious. Neither are wrong, or right, they're just doing what they need to do to get through it.
There are side effects of using pain relief - pethidine, diamorphine and meptid can lead to a dopey baby, or worse a baby in respiratory distress. Having an epidural contributes to birth interventions, because the woman cannot coordinate her physical pushing with the uterine contractions, and being confined to bed protracts labour as gravity cannot work. Gas and air is the safest form of pain relief, though it can lose it's effectiveness in the later stages of labour.
However, an excessively painful labour may lead to psychological problems postnatally. I had no pain relief in my first labour because it progressed so quickly that there wasn't time. For some time afterwards, I had vivid flashbacks to being in agony and terrified - pain is very frightening if you don't feel in control of it. The pain, and speed of delivery, alienated me from my baby to begin with. I simply couldn't comprehend that this child had come from me. I had been expecting a long first labour, mostly in hospital. Instead, I got two hours of agony on my toilet at home, an hour of trying not to push while I got to hospital, and then an hour of pushing. I don't know if my trauma would have been lessened if I had pain relief, but I probably would have felt more in control. It has been almost four years, and I can still feel my body trying not to push if I think about the half an hour or so before I was 'allowed' to push by a midwife.
Equally, a labour without pain relief can be extremely cathartic. I had my second child without pain relief, by choice, expecting a fast labour. I got a fast labour - 1 hour 50 minutes - and felt wholly in control throughout. The pain was awful, as labour pain is, but it never felt unmanageable. His birth was healing, both to the trauma of my first birth, and the trauma of my second pregnancy.
A drug-free labour can be extremely empowering, but a planned drug-free labour that goes awry for whatever reason can lead to feelings of failure and inadequacy. Some women consider using pain relief to be cheating, or an easy way out, rather than an advantage of modern medicine. Other women consider using pain relief as a normal part of life - after all, you take medication for a headache, why not for the worst pain you'll ever bear?
Labour pain requires management. Some women can manage it on their own, through sheer force of will, through breathing techniques or hypnosis. Some women need drugs to manage the pain. Pain thresholds vary from person to person, and people's perception of pain also varies. Most women are capable of giving birth vaginally, without pain relief, but not doing so, through choice or necessity, does not make them less of a woman, or less of a mother.
22 Oct 2012
Informed choice and dissent in post-term induction of labour
Recently my little sister gave birth to her second baby. She was 42 weeks pregnant exactly, and had a spontaneous natural labour, that she described as peaceful. Her little girl was a healthy weight, and is absolutely beautiful.
However, the day before her labour started naturally, she was admitted for a routine induction of labour, which she refused. Despite saying repeatedly to her own midwife, the midwife on the phone and the midwife on the assessment ward that she did not want to be induced, she had to see an obstetrician to make sure she understood the risks of refusal. And that obstetrician did what all obstetricians do when women refuse induction solely for being overdue: she pulled the "YOUR BABY WILL DIE" card. Luckily, my sister refused to be scared, had a normal placental flow scan and was discharged. Her labour began properly the following evening and she had a quick, painkiller free delivery. I am VERY proud of her.
I had my second child at 42 weeks gestation as well. I was due to be admitted for an induction (which I did not want) a few hours after he was born. I had an exceptionally fast labour and when he was born, he was shown to have two knots in his umbilical cord. Not only could this have killed him at any time from around 14 weeks of pregnancy, if my membranes had been ruptured, he would have become distressed and I would have had either a caesarean or stillbirth. Instead, I had a natural birth at home, exactly as I'd wanted, and he was born healthy.
My mother's sixth child (the sister mentioned above) was 19 days late before she was finally browbeaten into an induction, however she was already in early labour. Her EIGHTH child was twelve days late, when the obstetrician on call asked her if she wanted her baby to die, to try and force her into an induction. Considering my mother's seventh child was a premature stillbirth, this was incredibly cruel. My youngest sister was born safe and happy 12 hours later.
Are there risks associated with overdue babies? Yes, of course there are, or it wouldn't be an issue. One study shows that at your due date, in a normal pregnancy, your risk of stillbirth and neonatal death sits at 0.24%. By 43 weeks, it has increased to 0.58% (Hilder, 1998). A much larger, longer case study was done in Scotland, which put the mortality rate at 43 weeks at 1.15%, as opposed to 0.22% at term. The baby, being presumed more mature, may pass meconium in labour, which may poison them. However, this is not exclusive to overdue babies.There has been a Dutch report that suggests there is increased likelihood of ADHD in postterm babies. (NHS choices, 2012). Otherwise, aside from fears of large babies, postmaturity syndrome, and placental problems, there are few risks associated with prolonged pregnancy that do not exist in ALL pregnancy.
However, although the NICE guidelines are that pregnancy should not progress past 42 weeks, and suggests induction of labour in these circumstances it also states that "Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour." and "if a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman's care with her from then on." (NICE, 2012). It also advises that induction of labour should not be offered solely because of likely macrosomia (NICE, 2012), otherwise known as a big baby.
My sister had previously told her midwife that she was uninterested in an induction, and was told that the last patient who'd done that had died, along with the baby, in a teepee in the garden. She then asked my sister if she was also planning on giving birth in a teepee. When I told my midwife that I did not want to be induced, she shrugged, said she had to follow protocol (in booking it) and that it was up to the consultant. A friend (who delivered under the same midwifery team as me) tells me how her midwife was equally surprised at her induction refusal and implied it was the consultant's choice.
Another describes her delivery team as: "I was given the impression that they thought I was a silly little girl for wanting it my way and that I'd change my mind and do what they wanted me to do."
Another women said "It didn't feel like a choice at all, just something I was told was going to happen. The actual process of breaking my waters was done without my prior consent - I was led to believe they were simply examining me."
Informed, unpressured consent in the small pool of women I consulted happened in just under one third of the cases. All women described an amount of expectation, and pressure that they would conform to having an induction.Several described having to demand the information on the procedure and risks, rather than it being given as a matter of course.
What of the risk in being induced? Induced labours are markedly more painful than natural, as the body is being forced to do something it is not ready to do. Induced labours can also be much slower, which in natural labour is not much of a problem - you just carry on until you're fully dilated, unless you want to be augmented with hormones. However, once the induction process begins, you are on a timer, and if your body fails to do as it's told, more intervention is necessary to bring forth the baby.
Both of these factors can cause problems with the labour. Painful labour often means an epidural, an epidural means lying around in bed, and that slows labour down. The labour is then not progressing fast enough for doctor's, who start considering instrumental or caesarean delivery. One study quotes a threefold increase in risk for induced labours to end in caesarean, versus spontaneous delivery (Thorsell et al, 2011). There is not a lot of data available for perinatal mortality rates in induced vs natural post-term labour, however one study suggests that induction does not reduce the mortality rate (Wennerholm et al, 2009)
A due date is an estimation. Unless you have a patient who knows categorically when she concieved (for example, in an IVF pregnancy), it is difficult to know when a woman ovulated, when the sperm met the egg, when the egg implanted. Early gestational scans make the dating process much more precise, but the five days for error allowed in them means the difference between being considered 9 or 14 days overdue. Not all babies who are supposedly overdue are born with postmaturity syndome. My youngest certainly wasn't, and he could not have been less than 11 days overdue by my dates (14 days by scan), though he did have a most luxuriant mane of hair. Equally, my new niece does not display the features of postmaturity syndrome, and she was at least 14, if not 17 days late. Babies do not all 'cook' at exactly the same rate.
When the NICE guidelines advise that women are fully counselled in the risks associated with continuing the pregnancy, or inducing it, they do not also advise belittling, or ignoring the woman's preferences; or scaring her with statistics. Quite the opposite: the woman is supposed to be informed and supported in her choice between induction and natural labour.
We need to find out why this is overlooked so frequently. Do obstetricians genuinely believe that they will have a flood of stillbirths on their hands if they allow women to go more than ten, or twelve, or fourteen days overdue? Or are they trying to control an otherwise uncontrollable natural process? Are we going to end up like certain parts of the USA, where inductions are booked before the expected due date is even reached, to fully medicalise the process? Inductions are not cheap: they require drugs, monitoring, observation, and bedspace, and like any birth, can require surgical intervention at any time. However, with the increased likelihood of interventions, is it cost-effective to panic women into induction of labour before 42 weeks has even been reached?
Women deserve informed choice, especially when they are on the cusp of undergoing a physically and emotionally demanding delivery. They do not deserve to be frightened or coerced into any procedure, least of all one as life-changing as birth.
Hilder, (1998) 'Stillbirth and infant mortality births in term and post-term gestation' http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
Smith (2001), 'Perinatal death at term and post-term' in http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
NHS Choices (2012) http://www.nhs.uk/news/2012/05may/Pages/overdue-post-term-babies-adhd.aspx
National Institute for Clinical Excellence, 2012 http://publications.nice.org.uk/induction-of-labour-cg70/guidance
Thorsell, M,. Lyrenas, S. Andolf, E. and Kauser, M. (2011) 'Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women.' in Acta Obstetricia et Gynecologica Scandinavica; Oct2011, Vol. 90 Issue 10, p1094-1099
Wennerholm, U. Hagberg, H. Brorsson, B. Bergh, C. (2009) 'Induction of labour versus expectant management for post-date pregnancy. Is there sufficient evidence for a change in clinical practice?' in Atta Obstrecia et Gynecological Scandinavica; Jan2009, Vol 88 Issue 1, p.6-17
- Women's opinions and statistics gleaned by the author, from a brief online survey, comprising 13 participants between October 18th and 21st 2012.
However, the day before her labour started naturally, she was admitted for a routine induction of labour, which she refused. Despite saying repeatedly to her own midwife, the midwife on the phone and the midwife on the assessment ward that she did not want to be induced, she had to see an obstetrician to make sure she understood the risks of refusal. And that obstetrician did what all obstetricians do when women refuse induction solely for being overdue: she pulled the "YOUR BABY WILL DIE" card. Luckily, my sister refused to be scared, had a normal placental flow scan and was discharged. Her labour began properly the following evening and she had a quick, painkiller free delivery. I am VERY proud of her.
I had my second child at 42 weeks gestation as well. I was due to be admitted for an induction (which I did not want) a few hours after he was born. I had an exceptionally fast labour and when he was born, he was shown to have two knots in his umbilical cord. Not only could this have killed him at any time from around 14 weeks of pregnancy, if my membranes had been ruptured, he would have become distressed and I would have had either a caesarean or stillbirth. Instead, I had a natural birth at home, exactly as I'd wanted, and he was born healthy.
My mother's sixth child (the sister mentioned above) was 19 days late before she was finally browbeaten into an induction, however she was already in early labour. Her EIGHTH child was twelve days late, when the obstetrician on call asked her if she wanted her baby to die, to try and force her into an induction. Considering my mother's seventh child was a premature stillbirth, this was incredibly cruel. My youngest sister was born safe and happy 12 hours later.
Are there risks associated with overdue babies? Yes, of course there are, or it wouldn't be an issue. One study shows that at your due date, in a normal pregnancy, your risk of stillbirth and neonatal death sits at 0.24%. By 43 weeks, it has increased to 0.58% (Hilder, 1998). A much larger, longer case study was done in Scotland, which put the mortality rate at 43 weeks at 1.15%, as opposed to 0.22% at term. The baby, being presumed more mature, may pass meconium in labour, which may poison them. However, this is not exclusive to overdue babies.There has been a Dutch report that suggests there is increased likelihood of ADHD in postterm babies. (NHS choices, 2012). Otherwise, aside from fears of large babies, postmaturity syndrome, and placental problems, there are few risks associated with prolonged pregnancy that do not exist in ALL pregnancy.
However, although the NICE guidelines are that pregnancy should not progress past 42 weeks, and suggests induction of labour in these circumstances it also states that "Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour." and "if a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman's care with her from then on." (NICE, 2012). It also advises that induction of labour should not be offered solely because of likely macrosomia (NICE, 2012), otherwise known as a big baby.
My sister had previously told her midwife that she was uninterested in an induction, and was told that the last patient who'd done that had died, along with the baby, in a teepee in the garden. She then asked my sister if she was also planning on giving birth in a teepee. When I told my midwife that I did not want to be induced, she shrugged, said she had to follow protocol (in booking it) and that it was up to the consultant. A friend (who delivered under the same midwifery team as me) tells me how her midwife was equally surprised at her induction refusal and implied it was the consultant's choice.
Another describes her delivery team as: "I was given the impression that they thought I was a silly little girl for wanting it my way and that I'd change my mind and do what they wanted me to do."
Another women said "It didn't feel like a choice at all, just something I was told was going to happen. The actual process of breaking my waters was done without my prior consent - I was led to believe they were simply examining me."
Informed, unpressured consent in the small pool of women I consulted happened in just under one third of the cases. All women described an amount of expectation, and pressure that they would conform to having an induction.Several described having to demand the information on the procedure and risks, rather than it being given as a matter of course.
What of the risk in being induced? Induced labours are markedly more painful than natural, as the body is being forced to do something it is not ready to do. Induced labours can also be much slower, which in natural labour is not much of a problem - you just carry on until you're fully dilated, unless you want to be augmented with hormones. However, once the induction process begins, you are on a timer, and if your body fails to do as it's told, more intervention is necessary to bring forth the baby.
Both of these factors can cause problems with the labour. Painful labour often means an epidural, an epidural means lying around in bed, and that slows labour down. The labour is then not progressing fast enough for doctor's, who start considering instrumental or caesarean delivery. One study quotes a threefold increase in risk for induced labours to end in caesarean, versus spontaneous delivery (Thorsell et al, 2011). There is not a lot of data available for perinatal mortality rates in induced vs natural post-term labour, however one study suggests that induction does not reduce the mortality rate (Wennerholm et al, 2009)
A due date is an estimation. Unless you have a patient who knows categorically when she concieved (for example, in an IVF pregnancy), it is difficult to know when a woman ovulated, when the sperm met the egg, when the egg implanted. Early gestational scans make the dating process much more precise, but the five days for error allowed in them means the difference between being considered 9 or 14 days overdue. Not all babies who are supposedly overdue are born with postmaturity syndome. My youngest certainly wasn't, and he could not have been less than 11 days overdue by my dates (14 days by scan), though he did have a most luxuriant mane of hair. Equally, my new niece does not display the features of postmaturity syndrome, and she was at least 14, if not 17 days late. Babies do not all 'cook' at exactly the same rate.
When the NICE guidelines advise that women are fully counselled in the risks associated with continuing the pregnancy, or inducing it, they do not also advise belittling, or ignoring the woman's preferences; or scaring her with statistics. Quite the opposite: the woman is supposed to be informed and supported in her choice between induction and natural labour.
We need to find out why this is overlooked so frequently. Do obstetricians genuinely believe that they will have a flood of stillbirths on their hands if they allow women to go more than ten, or twelve, or fourteen days overdue? Or are they trying to control an otherwise uncontrollable natural process? Are we going to end up like certain parts of the USA, where inductions are booked before the expected due date is even reached, to fully medicalise the process? Inductions are not cheap: they require drugs, monitoring, observation, and bedspace, and like any birth, can require surgical intervention at any time. However, with the increased likelihood of interventions, is it cost-effective to panic women into induction of labour before 42 weeks has even been reached?
Women deserve informed choice, especially when they are on the cusp of undergoing a physically and emotionally demanding delivery. They do not deserve to be frightened or coerced into any procedure, least of all one as life-changing as birth.
Hilder, (1998) 'Stillbirth and infant mortality births in term and post-term gestation' http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
Smith (2001), 'Perinatal death at term and post-term' in http://www.nice.org.uk/nicemedia/live/12012/41260/41260.pdf
NHS Choices (2012) http://www.nhs.uk/news/2012/05may/Pages/overdue-post-term-babies-adhd.aspx
National Institute for Clinical Excellence, 2012 http://publications.nice.org.uk/induction-of-labour-cg70/guidance
Thorsell, M,. Lyrenas, S. Andolf, E. and Kauser, M. (2011) 'Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women.' in Acta Obstetricia et Gynecologica Scandinavica; Oct2011, Vol. 90 Issue 10, p1094-1099
Wennerholm, U. Hagberg, H. Brorsson, B. Bergh, C. (2009) 'Induction of labour versus expectant management for post-date pregnancy. Is there sufficient evidence for a change in clinical practice?' in Atta Obstrecia et Gynecological Scandinavica; Jan2009, Vol 88 Issue 1, p.6-17
- Women's opinions and statistics gleaned by the author, from a brief online survey, comprising 13 participants between October 18th and 21st 2012.
10 Jun 2012
Thoughts on hospital design
The worst stay in hospital I've ever had (and I've had eight, two of which were taking care of my poorly eldest) was immediately after the birth of my first child. I was an inpatient for just 16 hours, on the ward for 12 of those hours, and I loathed it.
The hospital was an old one, built in the 70s and never massively updated. The obstetric area was split into antenatal assessment, central delivery suite and antenatal longstay/postnatal. I had care on all three of these areas across my two pregnancies.
The antenatal assessment unit was shared with the abortion clinic and women's gynae/urodynamic department. I went there once for a scan with my eldest and twice for assessment with my youngest. He wasn't growing properly. They failed to identify a cause, and he was born with two true knots in his cord. This should have been seen on scan. He nearly died when he was being born. Thankfully he didn't, and I'm glad I was able to have him at home instead of by caesarean at 38 weeks.
Central Delivery Suite was amazing. I had multiple observations done there, and I delivered my eldest there, 90ish minutes after arriving. They kept me waiting 20 minutes when I got there, and I needed to push. Not the snappiest service, but once I was pushing, all was fine. They also stitched me up after the birth of my youngest. Ambulance transfer after you've managed to have a (miraculous) safe homebirth is a bit gutting, but they got me a comfortable bed to lie on and left me to it, discharging me after 6 hours.
However, the antenatal longstay/postnatal ward was dreadful. In modern hospitals, the two are kept broadly separate. If you're pregnant and in hospital for more than a day, there's probably something amiss and you don't want to be hearing newborns cry all day.
I was put in a four bed bay with two other women and newborns. One had been there a week while her baby was in SCBU and went home fairly early. The other was a spanish lady who was on her third baby and quite indignant about not being immediately discharged. I had asked for 6 hour discharge, but had torn quite badly after having a large baby. They wanted me to stay in overnight (he was born just after 4am) and I was vehemently against this. I went on the ward at 9am, and saw a midwife at 11am and 2pm. Then a paediatrician came and did newborn obs and declared that since my baby had been fast asleep for 5 hours and thus not fed (despite feeding 3 times in the first 5 hours), there was something wrong with him and we'd have to stay in.
We tried to wake him up to feed him, but he was having none of it. He'd had a fast, wet delivery and was snotty, sicky and tired.
No midwives came to see us. A snotty auxillary told us that we wouldn't be allowed home til feeding established. The window was wide open and it was freezing (he was born in March). I kept closing the curtains to try and sleep - they kept opening them. I had a fluorescent light over my head that I couldn't switch off. I couldn't sleep, and hadn't slept for over 36 hours by then (and had delivered a baby!). The food was dreadful - dried out pizza and chips, with no ketchup, and a tiny pot of jelly. Had I known I was allowed to bring my own food in, I would have sent my husband out for a McDonalds, but nobody told me that.
Eventually, they rang the 8pm gong to tell all the fathers to bugger off and I burst into tears. My husband went and found a midwife and bellowed at her. She was head of delivery, and tried to persuade me to stay in overnight, so I said I would self discharge. Finally, a midwife came round and checked me over (for the first time in over 6 hours) and said that it was totally normal for newborns to sleep after birth, and the paediatrician was wrong. We got home at 10pm and lo! The baby woke up and fed every half hour for the whole night.
Newborns are not easy, but if I'd been allowed home, or to stay on CDS, I would've slept and I would have coped and maybe I wouldn't have had postnatal depression.
The postnatal stay was the reason I had a planned homebirth second time round, and when I had to go into hospital afterwards, I asked to remain on CDS.
My best hospital stay wasn't for me, I was in with my eldest, who was having a tonsillectomy. He had them out in a brand new hospital, with a very well designed children's ward. He was in a four bed bay, designed in a cross shape, rather than 2 facing 2. There was loads of room and toys for him to play with and the whole bay was closed off with a nursing bay and locked door. When he went to theatre, he walked down, rather than go on a huge scary bed. He sat on my knee while they cannulated him and sat and watched when they anaesthetised him. It was nothing like the various general anaesthetics I had as a child, where I was gassed twice because I was hysterical and terrified. I was older than him, and more aware, but being stuck on a huge bed while men fiddle about round your hands and arms and everyone's dressed in scrubs is SCARY. However, he took it like a pro.
My current OU unit is on hospital design, and deisgn really makes a difference. Being treated (or ignored) in an overbright, cold, friendless room when you're feeling weak, battered and emotional is horrible. It's not really treatment at all - any medicinal benefit I was supposed to get from the 'rest' was lost. I don't class uncomplicated childbirth as something to be overmedicalised: the key to a fast recovery is good food, supportive company, and good quality rest (even if it's in small doses). I got none of these the first time.
The hospital was an old one, built in the 70s and never massively updated. The obstetric area was split into antenatal assessment, central delivery suite and antenatal longstay/postnatal. I had care on all three of these areas across my two pregnancies.
The antenatal assessment unit was shared with the abortion clinic and women's gynae/urodynamic department. I went there once for a scan with my eldest and twice for assessment with my youngest. He wasn't growing properly. They failed to identify a cause, and he was born with two true knots in his cord. This should have been seen on scan. He nearly died when he was being born. Thankfully he didn't, and I'm glad I was able to have him at home instead of by caesarean at 38 weeks.
Central Delivery Suite was amazing. I had multiple observations done there, and I delivered my eldest there, 90ish minutes after arriving. They kept me waiting 20 minutes when I got there, and I needed to push. Not the snappiest service, but once I was pushing, all was fine. They also stitched me up after the birth of my youngest. Ambulance transfer after you've managed to have a (miraculous) safe homebirth is a bit gutting, but they got me a comfortable bed to lie on and left me to it, discharging me after 6 hours.
However, the antenatal longstay/postnatal ward was dreadful. In modern hospitals, the two are kept broadly separate. If you're pregnant and in hospital for more than a day, there's probably something amiss and you don't want to be hearing newborns cry all day.
I was put in a four bed bay with two other women and newborns. One had been there a week while her baby was in SCBU and went home fairly early. The other was a spanish lady who was on her third baby and quite indignant about not being immediately discharged. I had asked for 6 hour discharge, but had torn quite badly after having a large baby. They wanted me to stay in overnight (he was born just after 4am) and I was vehemently against this. I went on the ward at 9am, and saw a midwife at 11am and 2pm. Then a paediatrician came and did newborn obs and declared that since my baby had been fast asleep for 5 hours and thus not fed (despite feeding 3 times in the first 5 hours), there was something wrong with him and we'd have to stay in.
We tried to wake him up to feed him, but he was having none of it. He'd had a fast, wet delivery and was snotty, sicky and tired.
No midwives came to see us. A snotty auxillary told us that we wouldn't be allowed home til feeding established. The window was wide open and it was freezing (he was born in March). I kept closing the curtains to try and sleep - they kept opening them. I had a fluorescent light over my head that I couldn't switch off. I couldn't sleep, and hadn't slept for over 36 hours by then (and had delivered a baby!). The food was dreadful - dried out pizza and chips, with no ketchup, and a tiny pot of jelly. Had I known I was allowed to bring my own food in, I would have sent my husband out for a McDonalds, but nobody told me that.
Eventually, they rang the 8pm gong to tell all the fathers to bugger off and I burst into tears. My husband went and found a midwife and bellowed at her. She was head of delivery, and tried to persuade me to stay in overnight, so I said I would self discharge. Finally, a midwife came round and checked me over (for the first time in over 6 hours) and said that it was totally normal for newborns to sleep after birth, and the paediatrician was wrong. We got home at 10pm and lo! The baby woke up and fed every half hour for the whole night.
Newborns are not easy, but if I'd been allowed home, or to stay on CDS, I would've slept and I would have coped and maybe I wouldn't have had postnatal depression.
The postnatal stay was the reason I had a planned homebirth second time round, and when I had to go into hospital afterwards, I asked to remain on CDS.
My best hospital stay wasn't for me, I was in with my eldest, who was having a tonsillectomy. He had them out in a brand new hospital, with a very well designed children's ward. He was in a four bed bay, designed in a cross shape, rather than 2 facing 2. There was loads of room and toys for him to play with and the whole bay was closed off with a nursing bay and locked door. When he went to theatre, he walked down, rather than go on a huge scary bed. He sat on my knee while they cannulated him and sat and watched when they anaesthetised him. It was nothing like the various general anaesthetics I had as a child, where I was gassed twice because I was hysterical and terrified. I was older than him, and more aware, but being stuck on a huge bed while men fiddle about round your hands and arms and everyone's dressed in scrubs is SCARY. However, he took it like a pro.
My current OU unit is on hospital design, and deisgn really makes a difference. Being treated (or ignored) in an overbright, cold, friendless room when you're feeling weak, battered and emotional is horrible. It's not really treatment at all - any medicinal benefit I was supposed to get from the 'rest' was lost. I don't class uncomplicated childbirth as something to be overmedicalised: the key to a fast recovery is good food, supportive company, and good quality rest (even if it's in small doses). I got none of these the first time.
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