March 1, 2024 • 32 mins
As we navigate the intricate journey of childbirth, there is a balance between a mother's autonomy and stringent clinical guidelines. Step into the world of Personalised Care in maternity services, where my discussion sheds light on the emotional complexities of honouring the unique birth plans of expectant mothers. This episode is a clarion call for healthcare providers to listen deeply, advocate for informed consent, and partner with pregnant women to create empowering birth experiences that resonate with their individual wishes.
Join us for an engaging exploration of the challenges and triumphs in the quest for Personalised Care. From the implementation of a cutting-edge maternity teaching module to the role of the Personalised Care Institute's e-learning, we uncover the ways in which professionals are striving to marry personalized care with the realities of clinical practice. As we close, I extend an invitation to contribute ideas for future discussions, and share the means to support the continuation of our enriching, conversation-led journey through the landscape of obstetrics.
Want to know more?
https://learn.personalisedcareinstitute.org.uk/
https://learn.personalisedcareinstitute.org.uk/course/view.php?id=35
https://www.england.nhs.uk/wp-content/uploads/2021/03/B0423-personalised-care-and-support-planning-guidance-for-lms.pdf
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Florence (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:45):
Episode 166, personalised Care.
I have consciously chosen thetitle of this episode to be
Personalised Care, but what I'vehad some requests to discuss is
(01:07):
that so-called outside ofguidance care.
I hate the term outside ofguidance and, yes, I know it's
used quite a lot in services,but I want to shift the
conversation.
So I'm going to talk aboutPersonalised Care today, why
(01:29):
it's important and why it'ssomething we really need to get
our heads around.
It seems unbelievable to methat Better Births the National
Maternity Review was in 2016,eight years ago and I can't help
(01:50):
but feel that, whilst lots ofgood came from that review, in
some aspects it's been a missedopportunity, and that's not
necessarily anyone's fault.
Part of the problem was aworldwide pandemic, but it was
(02:13):
an opportunity to put maternityat the top of the agenda and I
can't help but feel that it'sslipped down again.
Chronic staffing shortages havemeant that continuity of care
the ideal, has been quitedifficult to implement and
although some units have gonesome way towards it, we're not
(02:38):
there yet.
Why am I mentioning BetterBirths?
Well, the main strap line forBetter Births was safe and
personalised care, and it'sgoing to be easier to deliver
properly personalised care whenthere's continuity of care and
(03:01):
the midwife gets to know thewoman and the woman gets to know
the midwife, no question.
But we are where we are, and sotoday I'm going to focus a bit
on personalised care, somegeneral things to think about,
but also how that feels for theobstetrician, the obstetric view
(03:26):
, because that's what listenershave been asking for.
As is my habit preparing for thepodcast, I've done a bit of
reading, so I'm going to startby talking about what is
personalised care, because,wouldn't you know, there's an
actual definition.
I've turned to personalisedcare and support planning,
(03:52):
guidance, guidance for localmaternity systems.
This was published in 2021.
And it gives that little introabout personalised care being
central to Better Burst and thenincorporated into the NHS long
term plan which, in my mind,kind of gobbled up the maternity
(04:13):
transformation programme.
This gives a definition ofuniversal personalised care
People having proactive,personalised conversations which
focus on what matters to themand paying attention to their
clinical needs as well as theirwider health and wellbeing.
(04:35):
I mean it's slightlyunbelievable that we actually
need a definition of that.
That is obviously what weshould be doing in healthcare,
isn't it?
Thinking about when someone hasan illness or condition, how
(04:58):
important things are to them andwhat their personal goals are,
both clinically and holisticallyin their life.
So it's a no-brainer.
Then the document goes on totalk about personalised care and
support planning.
It talks about holistic initialassessment of women's health
(05:23):
and wellbeing needs and thewomen working hand in hand with
her healthcare professionals tocomplete this assessment.
The agreed personalised careand support plan should set out
the decisions she makes aboutthe care and support she wants
to receive.
Then go on to show a littleVenn diagram and they talk about
(05:44):
personalised care and informedconsent and the overlap in the
middle being informed decisionmaking.
That's interesting because thisis all wrapped up in consent
and in fact I thought to go withthis episode.
I would do a specific episodeon consent.
(06:05):
So far, that's all super dreamy.
We have conversations withwomen and we think about what's
important to them and we designthe care around them.
So you might ask what's theproblem?
Well, part of the problem isthat we actually work in a
massively regulated system.
So the woman is thinking thatshe wants all these choices and
(06:35):
these are the things that areimportant to her and that's
super straightforward For theclinician.
They're thinking well, that maygo against this guidance, that
guidance, the other guidance,and as a service we get audited
(06:56):
against that guidance and wehave to be either compliant with
nice guidance or justify whywe're not compliant with nice
guidance and maybe I'll get toldoff if I don't follow that
guidance.
Yes, I know we theoreticallywork in a no-blame culture but,
(07:16):
believe me, that's not how itactually feels all the time.
How am I going to marry up whatthe woman wants and
holistically caring for her?
Because after all, that is thewhole point of the maternity
service and I don't want to giveyou the impression that all
(07:37):
guidance is negative andenforcing things.
There is guidance with goodreason to try and ensure that
we're providing the rightstandard of care to women across
the maternity system and we areoperating within the
(07:57):
constraints not only presentedby guidance, but the limits
presented by staffing capacity,what drugs we do and don't have
available and all sorts of otherparameters.
So in my mind, I thinkpersonalised care comes where we
(08:24):
try and marry the two together.
I appreciate it may berelatively easy for me, a
consultant who's been in thedepartment for many years, to
support women with personalisedcare plans and requests, but as
(08:50):
a more junior member of staff,someone earlier in their career,
it can feel very daunting andpotentially quite risky, which
is why I was thrilled a littlewhile ago to discover a
(09:10):
collaboration between thePersonalised Care Institute and
NHS maternity to design a smallmaternity teaching module to
help maternity clinicians thinkthrough what is personalised
care and also how to apply it ina clinical situation.
(09:36):
When I did the traininginitially I thought this
training isn't really for me.
This is my bread and butter,this is what I do day in, day
out, have this sort ofconversation.
But then I realised thatactually it was really valuable
because Within my maternityservice I am one end of a
(10:01):
spectrum.
I know that many of the womenthat ask for something a bit
outside the norm end up comingto me for that very reason and
whilst some of my colleaguesalso work in this very holistic
(10:25):
way, as with many things, thereis a spectrum of practice and
some clinicians struggle toappreciate and understand why a
woman would want to do somethingdifferent to what they're
recommending.
It isn't that they don't wantto support women, they just come
(10:46):
at it with a more riskperspective.
But if you're starting out inyour maternity career or you're
partway through and you'restruggling with these
conversations, then I highlyrecommend that e-learning
(11:08):
training module to help youthink about how you might
approach this sort ofconversation.
Like I just said, there's aspectrum of practice within
maternity professionals.
There's also a spectrum ofrequests and ideas within the
(11:31):
women we're caring for.
Sometimes it's as simple as Idon't want to be induced.
At the point you want me to beinduced, and that's relatively
straightforward and in fact hasbecome so commonplace that we
are getting to a point wheremany of the midwives, supported
(11:57):
by a consultant midwife, canhave that conversation.
You may have listened to someof my episodes on fetal
monitoring and intermittentauscultation with Dr Kirsten
Small and when one of the keythings a woman wants is
(12:18):
intermittent auscultation andbirth in the birth centre rather
than continuous CTG.
She's obviously making a veryrational and well-informed
choice and we're the ones thatare giving her advice that is
not evidence-based.
We can find ourselves in theweird position of saying to her
(12:45):
well, I have to tell you thatthis is the recommendation and
this is the national guidance.
For these reasons but yes, Iagree, the evidence isn't there
One of the things I slightlystruggle with is we then make a
(13:05):
very specific personalized setof birth preferences, a written
document for the staff to givestaff confidence and know that
this has been pre-agreed anddiscussed, and for the woman so
that it's set out what are theimplications of the choices
she's making.
(13:28):
And whilst that is a good toolin terms of making sure the
woman has understood theinformation you've given her and
written information isimportant in backing up that
decision-making when you look atthe guidance on how to consent
(13:51):
people, it can sometimes feel alittle bit defensive.
We've had a conversation withher, we've told her the pros and
cons, we've given her time tothink about it, we've made a
plan usually by 36 or 37 weeks,because most of the personalized
(14:12):
care we're doing is intrapartumchoices and then we're laying
it all out for her in black andwhite, and I do sometimes worry
that women find that quite kindof in your face, almost risk
(14:37):
averse, defensive medicine.
But some of them have said,actually, I found that document
really helpful to read through.
Therefore, as with everything,it's personalized, isn't it?
It's got to be individual andwhat works for one person
(14:58):
doesn't work for another.
Much more difficult, I think,other conversations where a
woman wants to do something thatreally goes against what I
think is safe.
It's rare but it does happen,and that's difficult because
(15:28):
you've got to contain your ownemotions, your own opinions and
your fear of something goinghorribly wrong, because she
wants to do something that isway beyond the spectrum of
practice that you're comfortablewith and used to.
And often that is about havinga series of conversations making
(15:54):
that woman feel well supported,exploring the issues with her.
And this is where time comesinto it, because the earlier you
can start having theconversation, the longer you can
have to build trust and arelationship with that woman as
a midwife or as an obstetrician,and you might find some middle
(16:15):
ground.
It may be that you work outwhat are the elements of her
preferences that are really,really non-negotiable, most
important to her, and what are abit less so, and then you can
adapt things a bit with her andhave a series of conversations
(16:38):
in which she may modify andchange her plans, and it's not
that I'm trying to coerce herinto changing plans, it's just
I'm trying to make sure she'sreally well informed, and often
you can find a middle groundwhere things become what you
(16:58):
feel maybe a bit safer, butwhich meet her needs.
Sometimes, though, we do supportplans and preferences that we
think are well beyond our scopeof practice, because that's what
(17:21):
a woman wants and it is our jobto do that.
It's her body, it's her birth,she's an autonomous person, and
if she's got capacity to makethose decisions, those are her
decisions, but that can leave usas health professionals in a
very uncomfortable place, andthat's when the members of the
(17:43):
team need support.
I work very closely with myconsultant midwife, and indeed
we have a joint birth optionsclinic now, because we do have a
considerable number of womenwho want, or need that more
bespoke care planning than thesort of slight diversion outside
(18:12):
of guidance, the more basicpersonalized care planning,
which is now well within theremit of the continuity of care
team leader, with support of theconsultant midwife.
But for women that wantsomething quite complex or that
(18:33):
has more obstetric implications,such as maybe a home VBAC or
twins at home or a combinationof multiple high risk factors,
then we will see a womantogether jointly, ideally around
(18:54):
24 weeks, so that theconversation can evolve over
time and we'll come to a finaldecision with her and possibly a
series of birth preferences at36 weeks.
Another key aspect ofpersonalized care is that I've
(19:17):
discovered for a lot of women itdoesn't necessarily matter what
the eventual outcome is, whatthe eventual birth is like, and
that sounds really uncaring andstupid.
But actually I've had women whohave wanted something and they
(19:44):
have known that staff didn'tagree and that this was a high
risk situation and even thoughactually they ended up with a
very different birth from whatthey'd expected or hoped for
(20:08):
because they had felt completelysupported in pregnancy and able
to make those decisions andmake those decisions in their
own time and then, when it camedown to it, either in labor or,
if their water's not well enoughin labor or if their water's
(20:30):
broke, be able to step wise,change those decisions to
whatever the eventual outcomewas they still feel that they've
had a really good experiencebecause they've been in control
of their birth, whatever thathas been, and they've really
(20:51):
appreciated that and it's madethem feel safe and it's made
them feel at peace with whateverthe eventual outcome was,
because they feel they weretaking those decisions and
directing their care from theget-go right through to the end.
So I think when you see womenin clinic that want something
(21:16):
that makes you feeluncomfortable or that you find
challenging, really try and hearand understand why they're
asking for what they're askingfor and set aside your own
biases and conditioning from thebirths you've seen the guidance
(21:37):
you work under your owncultural background and try and
hear and understand why she'sasking for these particular
things and what's important toher and what are the key
elements.
And tell her that we're goingto explore this and draw in
(22:01):
other members of the team thatare available, such as your
consultant midwife or your PMAprofessional midwifery advocate
or your obstetric consultant,and work through with her,
because don't get stuck on herinitial ask and how terrifying
(22:23):
that might feel to you.
Building that relationship,building that trust, may lead
her to a very different decision, or it might not.
It might be that you do need tosupport that.
The other aspect of personalisedcare planning.
Which is difficult for us asprofessionals is when things go
(22:44):
wrong because they do, you doget burnt.
I have had women that I'vesupported, some of whom been
asking for things that are waybeyond my comfort zone, but also
some that are asking for thingsthat are well within my comfort
zone, and sometimes there is abad outcome, sometimes it
(23:11):
doesn't work out and that leavesyou in an extremely vulnerable
and difficult place.
Obviously, it's far worse forthe women that made those
decisions and some women comeback and say you didn't tell me,
you shouldn't have let me.
If I'd understood, I wouldn'thave made those choices.
(23:35):
And then that's really harshand you have to understand that
that's their way of dealing withwhat's happened to them and
their pain and distress needsthem to rationalise that and
it's really difficult and it'sreally difficult not to find
(23:57):
that that changes your practiceand influences the conversations
you have with the next person.
But it's not always like thatwhen things go wrong.
Other times there's been a lessgood outcome.
I've had women who haverationalised it.
Well, I'm glad I've made thosechoices, because if I'd made
(24:20):
other choices I would haveblamed that on whatever the
outcome was and, as I've said,they feel they were heard, they
were listened to, what wasimportant to them was respected
and, however distressing andupsetting the outcome may have
(24:42):
been, either for mother or baby,they felt that they made the
right choices.
And I do grapple with this andI do find it difficult, and it's
difficult as the obstetricianat one end of the spectrum and
(25:02):
in fact had a great meetingacross London with some fellow
obstetricians that aresupporting so-called care
outside of guidance or morepersonalized care, about how we
might network together a bitmore because there are maybe one
or two obstetricians in eachunit that are supporting this
(25:24):
more personalized care or get tosee the women that want
something a bit different or abit more wacky, because staff
know that those particularobstetricians may be a bit more
amenable to listen and supportthem.
It can leave us as quitevulnerable and with difficult
(25:48):
emotions and therefore beingable to network and connect with
other obstetricians that aredoing similar, whether that's in
your region or up and down thecountry, can be really helpful.
And in fact one of thecontributors to the personalized
care institute training is thewonderful Sarah Winfield, my
(26:09):
fellow fab obstetrician who isin the North East, and I do
grapple with responsibility whenwomen make choices that I find,
even for me, push me wayoutside my comfort zone, and
that's where working inpartnership with my consultant
(26:31):
midwife is really helpful.
It means we're both not out ona limb on our own, but equally.
One of the wisest things I heardwas from Dr Rachel Reed on the
caldron podcast.
In one of the episodes aboutworking in the system, she
(26:56):
talked about the fact that if awoman, you give her all the
information, it's well informedconsent If she chooses to jump
off a cliff.
I know that sounds dramatic,but this is how Dr Rachel Reed
described it If she chooses tojump off a cliff, you don't have
(27:20):
to jump off the cliff with her.
You've given her all theinformation about what's going
to happen when she jumps off thecliff.
It's hard to stand and watchher jump off the cliff, but you
don't have to jump off too, andthat may sound a bit weird out
of context.
So maybe go and listen to thatepisode of the midwives call
dream, but that's helped meunderstand that it's my job to
(27:45):
try and provide the rightinformation so that the woman
can make that personaliseddecision, but it's not my
responsibility.
In the same way that I've said,she's autonomous.
She can make decisions abouther birth.
Those are her decisions andshe's taking responsibility for
those decisions.
(28:05):
I think that's pretty much itfor this episode.
So what about a zesty bit?
Well, if you haven't done thepersonalised care Institute
e-learning, it's a great littleresource, doesn't take long
maybe an hour or so and it'sreally valuable in helping you
(28:29):
think through personalised careplanning.
I'm also going to put someother links in the show notes.
If you're a pregnant womanlistening to this, then
absolutely it is your choicewhat you do, what birth
preferences or care duringpregnancy because there are
(28:52):
personalised preferences theretoo, which we need to work with,
although that's a bit lesscommon.
Know that when we're giving yourisks and benefits and written
information, it really isbecause we're trying to provide
you with the ability to makethat informed consent.
(29:12):
And when we're suggesting otherthings, we really are well
meaning.
We're not meaning to press gangunit doing something you don't
want to do.
If you're struggling to get onwith the midwife that you're
seeing, then again you can askfor an appointment with a
(29:34):
consultant midwife A lot ofunits do have them now or a
consultant obstetrician, and askaround, find out who local to
you, might be a bit moreamenable to help making a
personalised care plan.
That's a bit different, thatcontains what's important to you
(29:56):
, because we're not quite up tospeed yet.
We're catching up, we'regetting there.
But if you can't get what youwant where you're booked, then
there are other routes toexplore.
And don't feel that it isn'tthat we don't care.
We absolutely do.
(30:17):
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
(30:37):
interesting.
There's also tons of episodesto explore in my back catalogue
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(31:02):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(31:26):
the programme notes, where I'veattached some links If you want
to get in touch to suggesttopics for future episodes.
You can find me at the OBS podon Twitter and Instagram and you
can email me at theobspodcom.
Finally, it's very important tome to keep the OBS pod free and
(31:52):
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
(32:18):
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:45):
Episode 166, personalised Care.
I have consciously chosen thetitle of this episode to be
Personalised Care, but what I'vehad some requests to discuss is
(01:07):
that so-called outside ofguidance care.
I hate the term outside ofguidance and, yes, I know it's
used quite a lot in services,but I want to shift the
conversation.
So I'm going to talk aboutPersonalised Care today, why
(01:29):
it's important and why it'ssomething we really need to get
our heads around.
It seems unbelievable to methat Better Births the National
Maternity Review was in 2016,eight years ago and I can't help
(01:50):
but feel that, whilst lots ofgood came from that review, in
some aspects it's been a missedopportunity, and that's not
necessarily anyone's fault.
Part of the problem was aworldwide pandemic, but it was
(02:13):
an opportunity to put maternityat the top of the agenda and I
can't help but feel that it'sslipped down again.
Chronic staffing shortages havemeant that continuity of care
the ideal, has been quitedifficult to implement and
although some units have gonesome way towards it, we're not
(02:38):
there yet.
Why am I mentioning BetterBirths?
Well, the main strap line forBetter Births was safe and
personalised care, and it'sgoing to be easier to deliver
properly personalised care whenthere's continuity of care and
(03:01):
the midwife gets to know thewoman and the woman gets to know
the midwife, no question.
But we are where we are, and sotoday I'm going to focus a bit
on personalised care, somegeneral things to think about,
but also how that feels for theobstetrician, the obstetric view
(03:26):
, because that's what listenershave been asking for.
As is my habit preparing for thepodcast, I've done a bit of
reading, so I'm going to startby talking about what is
personalised care, because,wouldn't you know, there's an
actual definition.
I've turned to personalisedcare and support planning,
(03:52):
guidance, guidance for localmaternity systems.
This was published in 2021.
And it gives that little introabout personalised care being
central to Better Burst and thenincorporated into the NHS long
term plan which, in my mind,kind of gobbled up the maternity
(04:13):
transformation programme.
This gives a definition ofuniversal personalised care
People having proactive,personalised conversations which
focus on what matters to themand paying attention to their
clinical needs as well as theirwider health and wellbeing.
(04:35):
I mean it's slightlyunbelievable that we actually
need a definition of that.
That is obviously what weshould be doing in healthcare,
isn't it?
Thinking about when someone hasan illness or condition, how
(04:58):
important things are to them andwhat their personal goals are,
both clinically and holisticallyin their life.
So it's a no-brainer.
Then the document goes on totalk about personalised care and
support planning.
It talks about holistic initialassessment of women's health
(05:23):
and wellbeing needs and thewomen working hand in hand with
her healthcare professionals tocomplete this assessment.
The agreed personalised careand support plan should set out
the decisions she makes aboutthe care and support she wants
to receive.
Then go on to show a littleVenn diagram and they talk about
(05:44):
personalised care and informedconsent and the overlap in the
middle being informed decisionmaking.
That's interesting because thisis all wrapped up in consent
and in fact I thought to go withthis episode.
I would do a specific episodeon consent.
(06:05):
So far, that's all super dreamy.
We have conversations withwomen and we think about what's
important to them and we designthe care around them.
So you might ask what's theproblem?
Well, part of the problem isthat we actually work in a
massively regulated system.
So the woman is thinking thatshe wants all these choices and
(06:35):
these are the things that areimportant to her and that's
super straightforward For theclinician.
They're thinking well, that maygo against this guidance, that
guidance, the other guidance,and as a service we get audited
(06:56):
against that guidance and wehave to be either compliant with
nice guidance or justify whywe're not compliant with nice
guidance and maybe I'll get toldoff if I don't follow that
guidance.
Yes, I know we theoreticallywork in a no-blame culture but,
(07:16):
believe me, that's not how itactually feels all the time.
How am I going to marry up whatthe woman wants and
holistically caring for her?
Because after all, that is thewhole point of the maternity
service and I don't want to giveyou the impression that all
(07:37):
guidance is negative andenforcing things.
There is guidance with goodreason to try and ensure that
we're providing the rightstandard of care to women across
the maternity system and we areoperating within the
(07:57):
constraints not only presentedby guidance, but the limits
presented by staffing capacity,what drugs we do and don't have
available and all sorts of otherparameters.
So in my mind, I thinkpersonalised care comes where we
(08:24):
try and marry the two together.
I appreciate it may berelatively easy for me, a
consultant who's been in thedepartment for many years, to
support women with personalisedcare plans and requests, but as
(08:50):
a more junior member of staff,someone earlier in their career,
it can feel very daunting andpotentially quite risky, which
is why I was thrilled a littlewhile ago to discover a
(09:10):
collaboration between thePersonalised Care Institute and
NHS maternity to design a smallmaternity teaching module to
help maternity clinicians thinkthrough what is personalised
care and also how to apply it ina clinical situation.
(09:36):
When I did the traininginitially I thought this
training isn't really for me.
This is my bread and butter,this is what I do day in, day
out, have this sort ofconversation.
But then I realised thatactually it was really valuable
because Within my maternityservice I am one end of a
(10:01):
spectrum.
I know that many of the womenthat ask for something a bit
outside the norm end up comingto me for that very reason and
whilst some of my colleaguesalso work in this very holistic
(10:25):
way, as with many things, thereis a spectrum of practice and
some clinicians struggle toappreciate and understand why a
woman would want to do somethingdifferent to what they're
recommending.
It isn't that they don't wantto support women, they just come
(10:46):
at it with a more riskperspective.
But if you're starting out inyour maternity career or you're
partway through and you'restruggling with these
conversations, then I highlyrecommend that e-learning
(11:08):
training module to help youthink about how you might
approach this sort ofconversation.
Like I just said, there's aspectrum of practice within
maternity professionals.
There's also a spectrum ofrequests and ideas within the
(11:31):
women we're caring for.
Sometimes it's as simple as Idon't want to be induced.
At the point you want me to beinduced, and that's relatively
straightforward and in fact hasbecome so commonplace that we
are getting to a point wheremany of the midwives, supported
(11:57):
by a consultant midwife, canhave that conversation.
You may have listened to someof my episodes on fetal
monitoring and intermittentauscultation with Dr Kirsten
Small and when one of the keythings a woman wants is
(12:18):
intermittent auscultation andbirth in the birth centre rather
than continuous CTG.
She's obviously making a veryrational and well-informed
choice and we're the ones thatare giving her advice that is
not evidence-based.
We can find ourselves in theweird position of saying to her
(12:45):
well, I have to tell you thatthis is the recommendation and
this is the national guidance.
For these reasons but yes, Iagree, the evidence isn't there
One of the things I slightlystruggle with is we then make a
(13:05):
very specific personalized setof birth preferences, a written
document for the staff to givestaff confidence and know that
this has been pre-agreed anddiscussed, and for the woman so
that it's set out what are theimplications of the choices
she's making.
(13:28):
And whilst that is a good toolin terms of making sure the
woman has understood theinformation you've given her and
written information isimportant in backing up that
decision-making when you look atthe guidance on how to consent
(13:51):
people, it can sometimes feel alittle bit defensive.
We've had a conversation withher, we've told her the pros and
cons, we've given her time tothink about it, we've made a
plan usually by 36 or 37 weeks,because most of the personalized
(14:12):
care we're doing is intrapartumchoices and then we're laying
it all out for her in black andwhite, and I do sometimes worry
that women find that quite kindof in your face, almost risk
(14:37):
averse, defensive medicine.
But some of them have said,actually, I found that document
really helpful to read through.
Therefore, as with everything,it's personalized, isn't it?
It's got to be individual andwhat works for one person
(14:58):
doesn't work for another.
Much more difficult, I think,other conversations where a
woman wants to do something thatreally goes against what I
think is safe.
It's rare but it does happen,and that's difficult because
(15:28):
you've got to contain your ownemotions, your own opinions and
your fear of something goinghorribly wrong, because she
wants to do something that isway beyond the spectrum of
practice that you're comfortablewith and used to.
And often that is about havinga series of conversations making
(15:54):
that woman feel well supported,exploring the issues with her.
And this is where time comesinto it, because the earlier you
can start having theconversation, the longer you can
have to build trust and arelationship with that woman as
a midwife or as an obstetrician,and you might find some middle
(16:15):
ground.
It may be that you work outwhat are the elements of her
preferences that are really,really non-negotiable, most
important to her, and what are abit less so, and then you can
adapt things a bit with her andhave a series of conversations
(16:38):
in which she may modify andchange her plans, and it's not
that I'm trying to coerce herinto changing plans, it's just
I'm trying to make sure she'sreally well informed, and often
you can find a middle groundwhere things become what you
(16:58):
feel maybe a bit safer, butwhich meet her needs.
Sometimes, though, we do supportplans and preferences that we
think are well beyond our scopeof practice, because that's what
(17:21):
a woman wants and it is our jobto do that.
It's her body, it's her birth,she's an autonomous person, and
if she's got capacity to makethose decisions, those are her
decisions, but that can leave usas health professionals in a
very uncomfortable place, andthat's when the members of the
(17:43):
team need support.
I work very closely with myconsultant midwife, and indeed
we have a joint birth optionsclinic now, because we do have a
considerable number of womenwho want, or need that more
bespoke care planning than thesort of slight diversion outside
(18:12):
of guidance, the more basicpersonalized care planning,
which is now well within theremit of the continuity of care
team leader, with support of theconsultant midwife.
But for women that wantsomething quite complex or that
(18:33):
has more obstetric implications,such as maybe a home VBAC or
twins at home or a combinationof multiple high risk factors,
then we will see a womantogether jointly, ideally around
(18:54):
24 weeks, so that theconversation can evolve over
time and we'll come to a finaldecision with her and possibly a
series of birth preferences at36 weeks.
Another key aspect ofpersonalized care is that I've
(19:17):
discovered for a lot of women itdoesn't necessarily matter what
the eventual outcome is, whatthe eventual birth is like, and
that sounds really uncaring andstupid.
But actually I've had women whohave wanted something and they
(19:44):
have known that staff didn'tagree and that this was a high
risk situation and even thoughactually they ended up with a
very different birth from whatthey'd expected or hoped for
(20:08):
because they had felt completelysupported in pregnancy and able
to make those decisions andmake those decisions in their
own time and then, when it camedown to it, either in labor or,
if their water's not well enoughin labor or if their water's
(20:30):
broke, be able to step wise,change those decisions to
whatever the eventual outcomewas they still feel that they've
had a really good experiencebecause they've been in control
of their birth, whatever thathas been, and they've really
(20:51):
appreciated that and it's madethem feel safe and it's made
them feel at peace with whateverthe eventual outcome was,
because they feel they weretaking those decisions and
directing their care from theget-go right through to the end.
So I think when you see womenin clinic that want something
(21:16):
that makes you feeluncomfortable or that you find
challenging, really try and hearand understand why they're
asking for what they're askingfor and set aside your own
biases and conditioning from thebirths you've seen the guidance
(21:37):
you work under your owncultural background and try and
hear and understand why she'sasking for these particular
things and what's important toher and what are the key
elements.
And tell her that we're goingto explore this and draw in
(22:01):
other members of the team thatare available, such as your
consultant midwife or your PMAprofessional midwifery advocate
or your obstetric consultant,and work through with her,
because don't get stuck on herinitial ask and how terrifying
(22:23):
that might feel to you.
Building that relationship,building that trust, may lead
her to a very different decision, or it might not.
It might be that you do need tosupport that.
The other aspect of personalisedcare planning.
Which is difficult for us asprofessionals is when things go
(22:44):
wrong because they do, you doget burnt.
I have had women that I'vesupported, some of whom been
asking for things that are waybeyond my comfort zone, but also
some that are asking for thingsthat are well within my comfort
zone, and sometimes there is abad outcome, sometimes it
(23:11):
doesn't work out and that leavesyou in an extremely vulnerable
and difficult place.
Obviously, it's far worse forthe women that made those
decisions and some women comeback and say you didn't tell me,
you shouldn't have let me.
If I'd understood, I wouldn'thave made those choices.
(23:35):
And then that's really harshand you have to understand that
that's their way of dealing withwhat's happened to them and
their pain and distress needsthem to rationalise that and
it's really difficult and it'sreally difficult not to find
(23:57):
that that changes your practiceand influences the conversations
you have with the next person.
But it's not always like thatwhen things go wrong.
Other times there's been a lessgood outcome.
I've had women who haverationalised it.
Well, I'm glad I've made thosechoices, because if I'd made
(24:20):
other choices I would haveblamed that on whatever the
outcome was and, as I've said,they feel they were heard, they
were listened to, what wasimportant to them was respected
and, however distressing andupsetting the outcome may have
(24:42):
been, either for mother or baby,they felt that they made the
right choices.
And I do grapple with this andI do find it difficult, and it's
difficult as the obstetricianat one end of the spectrum and
(25:02):
in fact had a great meetingacross London with some fellow
obstetricians that aresupporting so-called care
outside of guidance or morepersonalized care, about how we
might network together a bitmore because there are maybe one
or two obstetricians in eachunit that are supporting this
(25:24):
more personalized care or get tosee the women that want
something a bit different or abit more wacky, because staff
know that those particularobstetricians may be a bit more
amenable to listen and supportthem.
It can leave us as quitevulnerable and with difficult
(25:48):
emotions and therefore beingable to network and connect with
other obstetricians that aredoing similar, whether that's in
your region or up and down thecountry, can be really helpful.
And in fact one of thecontributors to the personalized
care institute training is thewonderful Sarah Winfield, my
(26:09):
fellow fab obstetrician who isin the North East, and I do
grapple with responsibility whenwomen make choices that I find,
even for me, push me wayoutside my comfort zone, and
that's where working inpartnership with my consultant
(26:31):
midwife is really helpful.
It means we're both not out ona limb on our own, but equally.
One of the wisest things I heardwas from Dr Rachel Reed on the
caldron podcast.
In one of the episodes aboutworking in the system, she
(26:56):
talked about the fact that if awoman, you give her all the
information, it's well informedconsent If she chooses to jump
off a cliff.
I know that sounds dramatic,but this is how Dr Rachel Reed
described it If she chooses tojump off a cliff, you don't have
(27:20):
to jump off the cliff with her.
You've given her all theinformation about what's going
to happen when she jumps off thecliff.
It's hard to stand and watchher jump off the cliff, but you
don't have to jump off too, andthat may sound a bit weird out
of context.
So maybe go and listen to thatepisode of the midwives call
dream, but that's helped meunderstand that it's my job to
(27:45):
try and provide the rightinformation so that the woman
can make that personaliseddecision, but it's not my
responsibility.
In the same way that I've said,she's autonomous.
She can make decisions abouther birth.
Those are her decisions andshe's taking responsibility for
those decisions.
(28:05):
I think that's pretty much itfor this episode.
So what about a zesty bit?
Well, if you haven't done thepersonalised care Institute
e-learning, it's a great littleresource, doesn't take long
maybe an hour or so and it'sreally valuable in helping you
(28:29):
think through personalised careplanning.
I'm also going to put someother links in the show notes.
If you're a pregnant womanlistening to this, then
absolutely it is your choicewhat you do, what birth
preferences or care duringpregnancy because there are
(28:52):
personalised preferences theretoo, which we need to work with,
although that's a bit lesscommon.
Know that when we're giving yourisks and benefits and written
information, it really isbecause we're trying to provide
you with the ability to makethat informed consent.
(29:12):
And when we're suggesting otherthings, we really are well
meaning.
We're not meaning to press gangunit doing something you don't
want to do.
If you're struggling to get onwith the midwife that you're
seeing, then again you can askfor an appointment with a
(29:34):
consultant midwife A lot ofunits do have them now or a
consultant obstetrician, and askaround, find out who local to
you, might be a bit moreamenable to help making a
personalised care plan.
That's a bit different, thatcontains what's important to you
(29:56):
, because we're not quite up tospeed yet.
We're catching up, we'regetting there.
But if you can't get what youwant where you're booked, then
there are other routes toexplore.
And don't feel that it isn'tthat we don't care.
We absolutely do.
(30:17):
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
(30:37):
interesting.
There's also tons of episodesto explore in my back catalogue
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(31:02):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(31:26):
the programme notes, where I'veattached some links If you want
to get in touch to suggesttopics for future episodes.
You can find me at the OBS podon Twitter and Instagram and you
can email me at theobspodcom.
Finally, it's very important tome to keep the OBS pod free and
(31:52):
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
(32:18):
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
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