A British mother and child have won a record payment of £14.6 million in a case of midwifery incomptence. Coming hard of the heels of the release of the Morecambe Bay report, a stunning indictment of UK midwives’ lack of clinical skills and obsession with “normal” (unmedicated, vaginal) birth, it is yet another example of the failure of midwife led care.
According to The Mail Online:
A mother whose son suffered severe brain damage during birth is set to receive potentially the biggest medical negligence payout in history.
The High Court ruled today that United Lincolnshire Hospitals NHS Trust must pay in excess of £14.6 million for birth injuries, after failing to carry out a Caesarean section on Suzanne Adams and properly monitor her during labour.
The hospital’s negligence led to her son James Robshaw, now 12, being born with cerebral palsy.
The decision, believed to be one of the most significant in a case of medical negligence and the largest ever such court-ordered award for birth injury, reflects the lifetime care that James needs…
What happened?
Ms Adams was in labour when she was admitted to Lincoln County hospital in 2002.
Although her baby’s heart was monitored after her arrival, midwives either ignored or could not interpret the CTG trace – which detects foetal heart rate – correctly…
The confusion about CTG interpretation and the additional failure to carry out a timely Caesarean section meant there was a delay in delivering James.
Resuscitation procedures were then carried out in the delivery room before he was transferred to the Special Care Baby Unit.
Just as at Morecambe Bay, midwives either didn’t understand or ignored evidence that a baby was in distress.
More stomach churning allegations of midwifery incompetence at Morecambe Bay continue to emerge. The Nursing and Midwifery Council will hold hearings later this month about a midwife, alleging:
That you, whilst employed as a Band 7 Midwife at Furness General Hospital (“the Hospital”) by University Hospitals of Morecambe Bay NHS Foundation Trust (“the Trust”) between 15 February 2004 and 10 September 2013:
1) On 25 February 2004 an in relation to Patient A
1.1 Failed to and/or failed to ensure that the fetal heart rate was adequately monitored after 20:15 and up until the time that Patient A’s baby was delivered.
1.2 Failed to request assistance from a Doctor and/or any other suitably qualified medical professional when you had difficulty auscultating the fetal heart.
1.3 Caused distress to Patient A by inappropriately placing Patient A’s baby by her side
1.4 Your conduct contributed to the death of Patient A’s baby and/or caused Patient A’s baby to lose a significant chance of survival.
2) On 6 September 2008 in relation to Patient B
2.1 In relation to Patient B’s pain relief;
i) Advised Patient B that she could not have an epidural
ii) Failed to document your discussions with Patient B regarding pain2.2 Failed to and/or failed to ensure that the fetal heart rate was monitored at 15-30 minute intervals during the first stage of labour …
i) Failed to and/or failed to ensure that continuous electronic fetal monitoring was in place and/or
ii) Failed to and/or failed to ensure that the fetal heart rate was auscultated every 5 minutes …
2.5 Failed to adequately escalate the delay in the second stage of labour to an obstetrician at approximately 20:45
2.6 Your conduct contributed to the death of Patient B’s baby and/or caused Patient B’s baby to lose a significant chance of survival
These are just the most egregious of 15 separate allegations against the midwife.
Both these case are part of a disturbing pattern of injuries to and deaths of babies, questionable midwifery competence, and failure to call for interventions.
UK midwives need to stop pledging allegiance to normal birth and start protecting babies.
Good lord, even MORE mothers and babies dead in the UK due to incompetent midwives:
http://www.telegraph.co.uk/news/health/news/9233608/Deaths-in-childbirth-rise-amid-struggle-with-complex-cases.html
“In the past year, healthcare regulators have issued a series of
damning reports about Queens Hospital in Romford, in the London Borough
of Havering, over the deaths of mothers and babies.
Sareena Ali, 27, from Ilford, Essex, died in January last year after staff failed to failed to notice she had suffered a ruptured womb that triggered a
cardiac arrest and then later tried to revive her using a disconnected
oxygen mask. Her daughter Zainab was born lifeless.
Mrs Ali’s husband said she was in “unbearable pain” and his pleas for help were ignored by “uncaring, incompetent” midwives.
Three months later Violet Stephens, 35, from Brentwood, Essex, died
after midwives failed to spot she was suffering from pre-eclampsia,
which leads to abnormally high blood pressure.
She waited four days to have an emergency caesarean and then died hours later. Her baby son Christian was delivered healthy and is now being brought up by her sister…”
Can you write an article on Jill Duggar and her 41 5/7 pregnancy? There is a lot of fodder on the Duggar Family official FB page right now.
I don’t want to give them click traffic. I think she’s taking an incredible gamble with her and her baby’s life, and they should just stop and think about what they’re doing.
But that’s probably too much to hope for.
That’s what services like donotlink.com are for.
Sorry, brainfog.
I wasn’t trying to correct you, just wanted to be helpful.
Thank you. I hate my brain some days.
Don’t we all? I want to upvote that more than once.
With proper monitoring it is not the worst thing at her age though I would never take that risk. But I doubt she is getting proper monitoring. And in induction at 41 weeks would have increased her chances of a vaginal birth. You would think with how many pregnancies she is likely to have, she would want to reduce the odds of getting into a situation where emergency CS becomes the only option.
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Really? Tell us all about it. Eyeroll.
As this story shows, there are competing forces. On the one hand, the ideological drive to minimise intervention and “protect” a process rather than an outcome. On the other hand, a massive penalty for failing to apply interventions and for a disastrous outcome.
How can we expect clinicians to work to “minimise” the cesarean rate while crucifying them for not doing one? There is no amount of “I didn;t get my ideal birth” lamenting that weighs against an avoidably disabled baby.
The wilful abuse of the concept of ‘maternal autonomy’, together with the ridiculous and anachronistic belief that the fetus has no rights before birth, unfortunately sustains these deluded woo-infested killers.
A fetus doesn’t have any rights before birth. The problem is that they are defining “maternal autonomy” to mean “maternal autonomy to do what I think is right.” The right to pain relief in labor? Doesn’t exist. The right to prioritize a healthy, living child over vaginal delivery? Ditto.
Yes and the concept (of no rights before birth) is anachronistic and ridiculous.
Why bother with antenatal care and monitoring a fetus during labor at all?
The mother wants a live baby, perhaps? You keep a fetus alive during labor because the mother prioritizes having a live baby at the end of labor.
Yes, healthcare for baby prior to birth has nothing to do with the legal rights of the baby. Women are free to choose. The vast majority of women make their choices of pre-natal care with consideration to the interests of their unborn baby. I don’t see it as either anachronistic nor ridiculous.
If it is not anachronistic, why not go back to the time it was decided?
Let the bay take its chances and only give a shit when it is born alive.
Just like natural childbirth.
Because I care about my unborn babies. Like most women I want them born alive and healthy. It has nothing to do with what their rights are legally. I care for my kids beyond what is legally necessary because I’m human and I love them. Even before they are born.
Yet you deny that it is entitled to any rights?
The topic under discussion is midwive’s allegiance to normal birth and their lack of protection of babies.
For Sarah’s benefit, that is the point I am trying to make.
Why should natural birth advocates care if a baby dies during their performance art, if you agree that it has no rights anyway.
I know this is a bit deep for Sarah but I thought I would give it a go in the hope that she doesn’t vomit again.
I agree that it has no legal rights. Ethically I believe that parents should care for their unborn child. Adding a legal rights layer to the fetus means that the mother’s legal rights are imposed upon. I don’t need a law to tell me to love and care for my kids, most people don’t. For a midwife’s allegiance to normal birth there are malpracrice laws that should cover poor care.
But that is the point.
If a midwife is completely incompetent, the baby is born dead.
Because you believe the bay has no rights, there is no recourse to the law. (Stillbirths are specifically excluded from investigation by the coroner).
Why would/should the midwife give a damn?
Ironically if she is not quite so incompetent and the baby lives, then she can be held accountable.
The lack of legal rights for the fetus makes it more advantageous if the baby dies in birth, than if it is born damaged.
if the midwife had insurance (which almost no HB midwives in the US do), the mother could still sue, but I believe only for malpractice and not wrongful death
That is interesting, thanks.
So, some states do recognise that the fetus has legal rights before birth?
They don’t find it a revolting sentiment?
I should tell Sarah.
in the context of wrongful death for either malpractice or a crime that caused its death, yes. though the purpose is to provide the parent(s) recourse for their loss.
Why do you think you should tell Sarah?
Apparently it isn’t a revolting sentiment.
Of course there is recourse to the law if a midwife (or doctor) does something or fails to do something that causes a baby to die during labor. It’s called malpractice suits, although it’s pointless bringing such a suit against a homebirth midwife because in the US homebirth midwives almost never have liability insurance, so when you sue them they declare bankruptcy and lose nothing.
Back to my original point (thanks for the troll comment, by the way).
Let’s cast our minds back to that delightful and iconic role model of midwifery, Lisa Barrett.
5 (probably more) babies die during her homebirths – she claims the coroner can’t investigate her because they were all stillbirths.
Point number 1 – she is supported by the concept that the fetus has no rights before birth.
Then she claims that she was only supporting the mothers ‘maternal autonomy.’
Point number 2 – she is supported by the concept (although twisted and abused) of maternal autonomy.
These are the standard responses given by midwives internationally when faced with the inevitable result of their bullshit.
Hence my initial statement – they draw support from both these concepts.
The coroner did investigate Lisa Barrett, so I don’t know where you’re getting your misinformation. A prohibition order was entered banning her from providing any services whatsoever to pregnant women.
Australian news article:
http://www.adelaidenow.com.au/news/south-australia/police-investigating-homebirth-advocate-lisa-barrett-over-deaths-of-five-newborn-babies/story-fni6uo1m-1226987048463
Skeptical OB article:
http://www.skepticalob.com/2012/06/coroner-homebirth-deaths-at-lisa.html
Intimately familiar with the case thanks, Daleth.
Actually it went further and the legislation was changed in South Australia as a result.
Still does not change the fact that stillbirths are excluded from investigation by the coroner.
In this case PEA was recognised as a ‘sign of life’ for the first time ever.
If you are really interested you should read the entire judgement and related case law eg. R v Iby.
Because the mothers haven’t consented to the risks their providers are taking. The fact that a woman has the right to terminate a pregnancy doesn’t give me the right to walk up to her and punch her in the belly.
The fact that the baby has no rights certainly covers your butt if you kill it negligently during labor.
It covers you from criminal charges of murder and manslaughter, yes.
But doctors aren’t charged with criminal murder or manslaughter when an adult patient dies by their negligence, so your argument is not as effective as you think it is.
What there needs to be is proper regulation of midwifery, with mandatory clinical standards and guidelines and mandatory malpractice insurance.
Tort reform, maybe, actually turning CPMs in the effectively self regulated professional midwives, sure.
Giving foetuses personhood and legal right…unnecessary and likely to lead to more injustice and heartbreak than it prevents.
Doctors can be charged with manslaughter in cases of gross negligence.
Stillbirths are specifically excluded from investigation by the coroner in my country. Midwives escape scrutiny as a result.
I agree with you about regulation of midwifery.
Trying, perhaps, but failing.
Metoclopromide?
Same!
Because it’s not like antenatal care ever keeps the mother healthy, or has any health benefits for her at all.
What does this have to do with the rights of the baby?
Nothing. It does, however, have everything to do with the ‘point’ (go on, I’ll be generous) you’re making, which is to ask why bother with antenatal care if the foetus has no rights pre birth. The fact is that there are health benefits to the pregnant mother in providing antenatal care, quite aside from those to the foetus.
I actually think you went off half-cocked and missed the point completely.
That’s ok. Anyone who thinks there’s no point in antenatal care if the foetus doesn’t have any rights before birth is someone whose point-seeing abilities are insufficient to be able to assess those of others.
Wot, that’s relevant.
Just because a fetus doesn’t have rights doesn’t mean that its parents don’t want it to be born alive and neurologically intact. Also, let’s be honest, a lot of prenatal care is intended to uncover defects that may lead the parents to decide to terminate.
So, monitoring the fetus during labor, is to hedge our bets?
It has no rights during labor (before birth) but god forbid it should be born damaged.
I have no concerns about the termination aspect you mention at all.
Guest1 brings up an interesting point, SporkParade.
Is antenatal monitoring one of the things that NCB advocates embrace or shun?
On the other side of the coin, a lot of antenatal care is the fetal version of “well baby checks”. Even with defects, some parents may still choose to keep the baby.
No, it’s not to hedge bets. The mother wants a living, healthy baby. Monitoring increases the odds of that happening.
Aborting fetuses with health problems doesn’t bother you? So you are saying that fetuses have rights unless they are disabled? Is that what you’re arguing here?
“The wilful abuse of the concept of ‘maternal autonomy’, together with the ridiculous and anachronistic belief that the fetus has no rights before birth, unfortunately sustains these deluded woo-infested killers.”
That is what I’m arguing.
Yes, but you’re wrong. Even if the fetus doesn’t have rights before birth, the woman is going to the hospital to give birth because she wants both her and the soon-to-be-baby to survive the process and be healthy afterwards. Therefore, compromising the health of the fetus without the woman’s explicit consent is medical malpractice and a violation of maternal autonomy.
That doesn’t convince me that I’m wrong at all.
Which ‘deluded woo-infested killers’ do you think deliver babies in hospitals, exactly.
Dude, we get it and we got it the last time you parachuted in here. You believe that *you* ought to be the final arbiter of what constitutes an adequate reason to have an abortion rather than the actual pregnant woman, and you want to use the fact that various legal systems around the world have adopted your sexist and patronizing attitude towards women to justify yourself. But since we are taking about irresponsible midwives misusing the concept of maternal autonomy, that’s the hook you are using for your anti-choice, anti-autonomy rhetoric.
Gosh, I guess you told me.
You still haven’t really addressed the point though.
Just a lot of incorrect assumptions, I am neither anti choice or anti autonomy, just anti bullshit.
These:
http://www.skepticalob.com/2015/03/maternity-horror-at-morecambe-bay-is-the-inevitable-result-of-the-radicalization-of-midwifery.html
http://www.skepticalob.com/2015/03/midwife-led-care-kills-babies-and-mothers.html
Excellent examples – I believe that most of the crazies deliver out of hospital though.
Any bets thathemes of “maternal autonomy’ and fetal rights, aka some babies aren’t meant to live, feature in their rationalisations?
perhaps he thinks viable fetuses should have rights and non viable ones shouldn’t? if not for the anti abortion lobby in this country, I’d be all for giving viable fetuses rights in criminal and negligence cases. I don’t think a non viable fetus should ever have rights (unless we invent a risk free artificial womb someday).
But a lot of the defects women abort for don’t affect viability. For example, the overwhelming majority of women carrying fetuses with Down Syndrome choose to abort. Then there are cases where the baby could survive with intensive but expensive medical care that the parents can’t afford.
at the time of the procedure, the fetus isn’t viable yet. Might be someday, but not at the time.
Isn’t there a crime called “unjustified abortional act on a fetus”?
There is ‘child destruction’ legislation in some jurisdictions.
Some disabled people can go through life with very few health problems. Others, such as Ivan Cameron, late son of David Cameron, cannot.
Vomit.
Wow, that’s deep.
And yet it conveys all that needs to be conveyed.
What does it convey exactly?
Which bit didn’t you understand?
The topic under discussion? Anachronistic? Ridiculous?
The utter contempt that your revolting sentiments deserve, of course.
But they aren’t my sentiments.
They simply reflect 2 very common arguments regularly utilised by midwives.
Perhaps you should read the comment again.
They do not become any more or less revolting, whoever espouses them. Having read your comments, it is clear that your views are repellent. Contempt is the appropriate response to someone who thinks a foetus has rights before birth.
So you would regard the High Court of Australia and multiple courts in the US with contempt?
The implication that because a US court said something about abortion, it couldn’t be contemptuous, is rather an amusing one.
Not to side with the trollish “guest1” at all, but it kind of surprises me that educated Americans don’t know that our Constitutional right to an abortion–i.e. the absolute primacy of the mother’s rights over the fetus–ends once the fetus is viable. Under Roe v. Wade, states can flat-out prohibit all abortions (except to save the mother’s life or, under later case law, her health) after viability, which is defined as the beginning of the third trimester.
Are you referring to me? If so, I’m not any kind of American. Educated or otherwise.
I don’t think I quite understand. Technically speaking the fetus doesn’t have any rights prior to birth. At least not in competition with the rights and decisions of the mother. Or am I mistaken?
Only in certain theocracies, like North Ireland and Indiana. 🙂
I feel so sad for women in those places 🙁 sorry autonomous adult human, you are now walking, talking, breathing incubator, you were assaulted, or your contraceptive failed, or you just don’t want a baby…tough, you had a miscarriage? You are clearly a baby killer and should go to prison, men can do no wrong however.
Do you know the case of Savita Halappanavar? In October 2012, she was denied an abortion in an Irish hospital when it was clear she was having a miscarriage and wanted an abortion. They were told by doctors and nurses that according to Irish law, because the fetus had a heartbeat, an abortion could not be performed. It didn’t matter that Savita herself was not Catholic. She was Hindu.
A couple days later, Savita got septic, and died. She didn’t have to: a graph compiled by HIQA showed 13 separate opportunities in which staff could have stepped in to save her life. http://www.thejournal.ie/savita-halappanavar-missed-opportunities-timeline-1121510-Oct2013/
Ireland signed into law allowing abortions under certain circumstances. In my opinin, it’s not good enough because it doesn’t appear to cover ALL circumstances in which a woman might request an abortion. http://www.dnaindia.com/world/report-savita-halappanavar-effect-irish-president-signs-first-abortion-bill-into-law-1867644
Yes, it was all over the news, heartbreaking 🙁 and so so unnecessary. If you hadn’t heard of them, there’s a pretty amazing organisation called Women on Waves that as well as campaigning for countries to change their restrictive abortion laws they provide safe medical abortion (pills) along with information on how to take the pills to women in those countries, either by boat or by mail. There’s a documentary that I think is on Netflix now (and also on iTunes) called Vessel all about them 🙂
That’s great! I’ll check it out.
Correction: “Both these case” to “Both of these cases”.
Heartbreaking. Trying to fit EVERY birth into the paradigm of ‘normal birth’ is like trying to fit a square peg in a round hole. It’s not gonna work. It’s frightening how reluctant they are to call for consult. If I lived in the UK I would certainly insist on an OB rather than a midwife.
you’d have to go private, because even with consultant led care on the NHS, intrapartum care is carried out by midwives, although I would encourage anyone to try and meet the midwifery team working at the hospital before they paid for private care, some units are very good, and private care is v expensive
You also just can’t give birth in a private facility in most areas of the country. They don’t exist. I know there’s the Portland in London, but not sure there’s anything else.
There are a few in London, but that is about it. Also, if anything goes seriously wrong you move to the NHS anyway.
Yeh, it’s limited (although I guess if there was more of a demand that would probably improve.) Although we don’t want that, we want to feel that we can all have confidence in the NHS wherever we live and that even if we can’t choose to have our babies delivered by an OB (should be a choice, although can see in the context of the NHS why it might be a challenge) that the midwives caring for us our capable, compassionate and have our safety/wellbeing and that of our babies at the centre of their care 100% of the time.
I’m just not sure we have a large enough population of people willing and able to drop five figures on private obstetric care outside London, tbh. There are some hugely wealthy enclaves elsewhere in the country, but they don’t hold enough women to create sufficient demand really.
Yeh, I don’t think the answer is more private hospitals, just big improvements to the NHS, and they will only come from people using the service and speaking up about their care…good and bad.
Australia has a dual public-private system. Public hospital labor wards are staffed by midwives, providing both nursing care and birth management, consulting and collaborating with doctors (OBs and trainee OBs).
The private system in Aus is also staffed by midwives, but with OBs providing ante- and post-natal care and managing the birth process. There is a big difference in cesarean rates between public and private systems, which some people treat with concern, but others explain as a combination of maternal demographics and maternal choice.
Yes – that c-section rate difference is funny. Certainly we had one mother in my hospital tour who went public the first time, had a traumatic vaginal birth and said no more and had booked into the private hospital to feel more certain she could access a c-section for her second child.
But I also know of another woman who went private, had a long labour followed by a c-section and who went public the second time around to feel more supported in having a VBAC.
Good luck with that one.
Poor mom and child. My brother was born that way and no one knows why. I know it would be so much harder for my Mom and family if he had been hurt because someone did not do their jobs. In this case, it was not just one mistake, it was several. What the heck? I am glad they are getting money to help take care of him and to highlight the recklessness.
The more accurate term for “normal birth” is “religious birth.” Worshipping vaginal birth is ritualistic to put it kindly.
Who’s the midwife at fault and have they shown any remorse?
Marie Ratcliffe, and I can’t speak for this person individually but the general response from the organization as well as the midwifery community at large has been to circle the wagons and plead for everyone to just forget it and move on.
That does seem to be the knee-jerk response, shame as seems that if the midwives that actually care and are skilled and work tirelessly (often in less than desirable staffing conditions) actually loudly, and aggressively distanced themselves from those in the profession who are incompetent and dangerous in their promotion of unmedicated vaginal birth, new midwives would be more inclined to work on the right side, and to be more careful with their practice…if you don’t know a CTG or aren’t sure, for God’s sake ASK someone else, don’t just ignore it. Some skills are harder for some people, CTG can sometimes be a bit ‘iffy’ before it’s obviously terrible, but best to get someone more qualified, or better at interpreting CTG, then not only do you improve your skills but also the baby is healthy which is the most important thing.
Mattie – here’s a question I’ve asked before, and I’ll pose it to you. If rational, competent clinicians are the majority in midwifery, why don’t their organisations speak out against the cowgirls, loudly, clearly and publicly, and make it clear that they are not considered part of the mainstream?
I did actually respond to this sort of on yesterday’s post (hopefully this is the right link https://disqus.com/home/discussion/skepticalob/nature_thinks_babies_are_expendable/#comment-1943033988) But I do agree that the NMC in particular needs to be louder, they are doing a lot with regard to appropriately sanctioning midwives, but a lot of that seems to be behind the scenes. I feel they need to create more of a climate in maternity care that all midwives are accountable for their colleagues as well as themselves, if a midwife or two midwives or ten midwives in your department are acting unprofessionally, or are endangering women and babies through incompetence or ideology, you need to speak up because if you don’t, you’re also putting women in danger.
By not speaking out, you’re also creating the impression that what’s going on is normal, that it IS the standard of care. As a result, some women won’t recognize that what’s happening to them isn’t normal. The press takes their cues from official statements, that’s how we ended up with the ridiculous “breastfed babies cannot be starved!” line in the first place. And then they repeat it a hundred times until people take it as God’s truth.
Definitely, although I’ve never heard the breastfed babies can’t be starved thing, that’s just daft.
No one in their right mind would say that breastfed babies can’t be starved. “Starved” and “baby” don’t belong in the same sentence, as almost all mothers, even the ones who are most devoted to breastfeeding, recognize. Say, “starved”, and mothers will start wondering whether they ARE starving their baby. No, the marketing method is claiming that the body of each mother is best prepared to adequately nourish her child and when the baby is hungry enough, it will draw what it needs.
Which is basically the same, just avoiding the statement that might scare mothers off.
Because the RCOM is an entity unto itself? There’s only so much that doctors can do. How do you fight an idea?
With another idea.
Yes, “Let’s not wallow in mistakes of the past, let’s move on” seems to be the party line. Not “We’re so sorry we messed up so badly, we’ll make changes to ensure this will never happen again.” Shocking.
No, no lessons will be learnt. Always the passive voice.
Bottom line is that this promotion of ‘physiologic birth’ means that the midwife is fine with the baby and/or mother dying in the process. They feel that the strongest will survive. If your child dies then it wasn’t meant to live. If you die then you weren’t meant to survive. PERIOD. This is the bottom line for them. The real crime is in promoting that ‘physiologic birth’ is safer or better. That is how they fool people into thinking midwife care is somehow superior. It is not.
Has that midwife been suspended?
As far as I know Maria Ratcliffe has decided to retire, but the NMC imposed an 18month suspension order while it investigates the charges against her.
The charges are so serious that if found proven she will be struck off. I have absolutely no doubt of that.
The NMC strikes nurses off for lying about giving medication when nobody dies, so I can’t see her being allowed to practice if it is found that she didn’t chart properly and provided negligent care.
http://www.bbc.co.uk/news/uk-england-cumbria-25976664
I also doubt that she’ll be granted the option to voluntarily leave the register, so she will be made to answer to the charges and I agree with Dr Kitty, it is pretty much a given that she’ll be struck off.
Contrast this with the treatment of negligent midwives in the US. They are “peer reviewed” and continue to practice, like nothing ever happened.
well, they don’t really have any rules or standards to break =/ so like it’s literally a case of ‘well, I wouldn’t know how to do that because I have no real education or skills, and I wouldn’t want to be punished either so…carry on’ *thumbs down*
“2.1 In relation to Patient B’s pain relief;
i) Advised Patient B that she could not have an epidural
ii) Failed to document your discussions with Patient B regarding pain”
I have to say, at least someone is finally being called on that…!
Seriously. Based on the number of posts about this on UK mothering forums, it’s an epidemic problem.
I would call the police if they denied me an epidural without sound medical reason to. I really would.
Would they be able to do anything about it? No, but when they inevitably lie about my status, there will be a record of it to take to court when I file a formal complaint against them to the medical board.
Those people don’t know the women they’re treating and what they’ve been through. Not everyone’s physiology allows them to give vaginal birth, or at least without an unbearable amount of pain. I myself have a hip-less rectangle body and suffered a broken tailbone which makes me seriously doubt whether vaginal birth would go smoothly for myself or hypothetical babbies; if being forced to birth vaginally resulted in a quite agonizing, debilitating injury which prevented me from being able to properly enjoy my new baby, both because of pain and an inability to move up and down to tend them, I’d be beyond pissed and it wouldn’t be unreasonable for me to be put off of birth all together.
Blergh. These people and their things with the stuff.
Having a fixed tailbone is a solid issue to base a MRCS on. Or just a medically required c/s.
Yeah, but normal birth and stuff!
I had tiny hips until I had kids, and 3 occiput posterior vaginal births over an oddly healed tailbone. Which promptly rebroke every time. I found it uncomfortable but not terrible (about a 4/10 for the girls and 6/10 for the youngest – mild shoulder dystocia after getting hung up briefly in my pelvis), however, my body is kinda weird and I REALLY lucked out, so I recommend having a caesarean if you or your ob/gyn have any concerns. Avoiding a broken tailbone is most definitely a valid concern!!
Sure. I don’t think many providers would consider it an absolute no (and as for hips, the qualifications for allowing vaginal birth are not always visible from the outside). However history of fused tailbone might increase your likelihood of needing a c/s after laboring, which is worst case scenario for fetal and maternal outcomes. If you didn’t want to risk it, any doc or MEDwife would probably support a scheduled c/s. At least in the US!
Exactly! So while I managed it and it wasn’t horrible for me, that was just due to sheer luck and an incredibly high pain threshold. I wouldn’t recommend it because it could have ended really badly, and broken bones are not an outcome that should be normal for a birth.
You wouldn’t believe the cringing and four-letter words that went with reading that haha!
I’m not expecting, but plan on doing that whole reproduction thing someday and just had a feeling that having a human being pressing where it is on its way out couldn’t be good for a tailbone which had previously been broken. You’re a trooper, just thinking about it brings to mind the breathless, shocking pain from being hurt like that.
But then, my injury came from falling out of a building and landing on the hard ground. There’s a traumatic injury attached to it that would probably cause more panic than actual physical pain, and that’s just from an accidental injury. I think of the poor women who suffered abuse and whose trauma is triggered by untranquilized messing about in that area, who live with significant mental illness and have likely been undermedicated throughout their pregnancy, or have especially low pain tolerance.
The fact that these so-called professionals remain stoic about those issues drives me absolutely crazy. It’s a government sanctioned cult mentality.
I can imagine!! It’s why I only mention it in context, because I don’t like the whole “I did it, you can too!!” mentality. It’s unfair and dangerous. I managed to have vaginal deliveries and it turned out okay but because I did it and I understand that it could have gone badly, I fully support people opting for a MRCS for that reason (along with any other reason because MRCS should be available to all).
Oh, yeah! That’s way more traumatic than my original break, and it makes perfect sense that you’d be concerned about it happening again. Besides which, broken bones shouldn’t happen when you’re welcoming a baby into the world. My original break was from messing around on the parallel bars. I dismounted, hit the mat at the wrong angle, it slid across the polished timber floor and I thumped onto that lovely floor full-speed on my butt. My mother insisted it was fine, refused medical care, and I felt incredibly vindicated 2 years later when the radiologist asked when I’d broken it.
Oh ho ho my, I broke my nose doing a face plant onto the mat from uneven parallel bars! Gymnastics prepare us for the pain of childbirth I guess, lol.
It’s amazing to think of what we can do to ourselves and then just keep putting along. Anatomy is so cool.
Oh ouch!! That would have been awful!
Hahaha yes, I think gymnastics was rather useful in that regard. I learnt to distinguish between different types of pain and know my body (and it’s limitations) so much better than I think I would have without it.
Yes, it definitely happens a lot and that sucks. I think if more women knew that they could complain about it, and not just to the hospital, more midwives would be brought up about it. I think they should, because it’s only with it being brought up in hearings that other midwives will actually think ‘oh wait, I could actually get in trouble for this, better not’. It’s sad that it would take that for some midwives to care for women, but it does 🙁
Even better than ” ‘oh wait, I could actually get in trouble for this, better not’.” might be “Oh, wait – I’m actually here for the benefit of the mother and their family, not for my own ideology.”
Yeh, I should have been clearer. The latter is definitely the right response, but for those midwives who aren’t doing their job properly because of shitty ideology at least if the former is making them change, it’s protecting women and babies. Attitude is a lot harder to fix than action, but if people keep their ideology to themselves then it’s less harmful than the current situation, at least until general attitude changes.
Yep.
Being 7 months pregnant, it’s definitely something I’m worried about. I know that it’s not every midwife, but I’ve come across enough stories both online and from friends who work in Obs and paeds that I believe that there are almost certainly midwives who will try and discourage pain relief and that unfortunately there are at least a few midwives who will do dishonest things like claiming the anaesthetist is busy without actually calling them. Luckily for me, my husband is a surgical reg in the same hospital I will give birth in, so if I suspect that I’m being mislead, I will ask him to give the anaesthetist a call.
ANother reason that women in Australia might use a private hospital – the anaesthetist is seen as part of the team – not a “luxury” to be withheld from the undeserving.
Much as I admire the UK for many reasons, there does appear to be an abiding culture of austerity in the NHS that values “doing without”. The UK NHS is very good at controlling costs and maintaining universal access, but probably at the cost of individual choice.
What do the UK people here think?
That sometimes happens yes. Not always, by any means, possibly not even the majority of the time, but sometimes.
I think also in maternity, usually the service is at its best when the shit hits the fan (not always of course, hence Morecambe) but the flipside to this is cost cutting elsewhere. St Marys in Manchester, for example, takes a lot of the most complex cases in the region. More ‘straightforward’ cases therefore often don’t get the epidurals or one to one care they want, anecdotally.
When the midwives say “the anaesthetist is in theatre”, usually the anaesthetist is actually in theatre, and will be a while.
Very few maternity units are big enough to have two obstetric anaesthetists on duty 24/7, with one in theatre and one providing epidurals on the delivery ward.
HOWEVER, what is much more likely to happen (and I’ve seen it, personally) is that the MW will jolly someone along between 4 and 8 cm with “you can do it, try some gas and air, don’t give up now, how about some remifentanyl, what about changing position, maybe a nice hot shower will help” and don’t actually bleep the anaesthetist…
Then, four hours after the patient first requested an epidural “Oh I’m sorry you’re 8cm and I’ve just bleeped the anaesthetist and they’re in theatre in the middle of a complicated case. The anaesthetist will be at least another hour in theatre, by which point it’ll be too late, so let’s just forget about that option, shall we?”
My advice is that if you want an epidural you ask for it early, and either ask the MW to bleep the anaesthetist from the phone in your room, or send your support person with her to the phone at the nurses’ station to make sure it is actually done and the time documented.
Ask for an estimate of how long the anaesthetist will be, and if they do not arrive in the expected time, ensure that they are called again.
Acceptable reasons for delay are:
they are in theatre,
they are with another patient,
they are at handover
there has been an emergency.
Unacceptable reasons for delay are:
they aren’t answering their phone,
I think they’re on a break,
I’m not sure what is taking them
I don’t know where they are
Just FYI- most planned CS are done on a morning theatre list between 9am-12pm… so that is usually not a good time window to try and get an epidural.
Have your support person document times of request for epidural, times when anaesthetist bleeped, and any reasons given for delay or refusal.
If you want an epidural, you want consultant led care in a hospital. You will not have that option at home or in a MLU.
From NICE guidance on intrapartum pain management:
“Timing of regional analgesia
1.9.3
If a woman in labour asks for regional analgesia, comply with her request. This includes women in severe pain in the latent first stage of labour. [2007]”
Which means that no, you don’t have to wait until 4cm, and no 8cm isn’t too late. You ask and you should get. It’s the logistics of WHEN you get that might be an issue.
Print out that bit of the guidance, highlight it and stick it on your birth plan.
Point to it and ask why best practice guidelines are not being followed if you get any push back.
I am afraid I recommend a rather assertive, “this is what I want, I know what you should be able to get me, and I’m both likely to make a formal complaint and highly likely to become litigious should my care fall below accepted standards” attitude if you feel that you aren’t being listened too.
Rather your midwife thinks you’re obnoxious and demanding and you get the care you want, than they think you’re a lovely, undemanding patient and you don’t.
What is physiologic birth? I see this on the ACNM website. Is it just vaginal birth? How is it different from promoting normal birth like the UK midwives do?
As far as I can tell it is a big fancy word that means the exact same thing as “normal birth” with the extra connotation that the birth progresses completely without intervention. The idea is that a pregnant woman’s body is a delicate flower of chemicals and even the slightest touch of a stethescope can throw off the balance irreperably leading to a c-section which naturally ruins the baby for life.
I wonder how these people rationalize their lack of physiological transportation (using shoes, cars, elevators), seeing (glasses, mirrors, electric lighting) and food acquisition (slaughtering and/or foraging)? How is it okay for people to do any of those unnatural things, but in childbirth a mother must figuratively squat in a field or she is doing it wrong?
I have no idea. My pet theory is that it is all about control in a frightening transitional period. Most people don’t want to conceptualize pregnancy and motherhood in cold, scientific terms and nobody wants to imagine that their health or life could be at risk so women try to regain control of the narrative and dispel their fear by telling a fairy story to themselves about the beauty and natural joy in childbirth where nothing goes wrong unless you fail to follow the time honored script of fearlessly squatting in a field.
If the natural types talk about women delivering a baby in a field and then strapping it to their back and going back to work – why don’t they do that?
Why do they need all the frou frou stuff – the doula, the midwife, the birthing tub, candles, essential oils, music and affirmations?
Or, in the case of that lame Born in the Wild show, not so figuratively. *eye roll*
If I tried to rely on physiological seeing, I’d be dead by now. My physiological eyes can’t see 5 feet in front of me. With intervention (contacts), my vision is 20/20. And I’m alive. Intervention FTW!
Same here. When left on the mercy of physiological seeing, I see blobs. With glasses, blobs miraculously transform into people and faces. Hey, that’s my mom over there. The former blue blob. It’s as if Professor McGonagall has paid me a visit!
It means:
No induction- waiting for spontaneous onset of labour
No augmentation of contractions.
No epidural.
Vaginal delivery- no forceps, no ventouse.
It CAN also mean no active management of third stage…but I’m hoping ACNM aren’t advocating that.
It is pretty much the same as “normal” birth.
I think “physiologic” is a better term than “normal”, though. It’s a more honest and less inherently judgemental description. “Non-physiologic” doesn’t have the baseline offensiveness or absurd implications of “abnormal” or “artificial”.
That may change as it becomes more NCBified, but for now it just sounds neutral.
Normal doesn’t really bother me, bc I didn’t care if I had a “normal” birth. Either way it’s bs.
“Physiologic” could function has shorthand for “straightforward vaginal birth at term of healthy infant to without need for or use of medical intervention”, but I don’t think there’s really a big need for it as a term. It’s a description, and it’s good to be able to be precise, but outside of medical conversations, there’s not really a big authentic market for it.
“Normal” is so subjective as to be uselessly imprecise, but is still used to denigrate. That’s my objection to its use.
The problem with your definition is that the key word is “straightforward.” I would go with “uncomplicated.”
But the problem with going with uncomplicated is that it’s out of anyone’s control. Yeah, of course we all want an uncomplicated delivery. But wishing for it doesn’t make it so.
You could have physiologic birth as a default preference, as opposed to requesting a cesarean or an induction, but declaring it a definitive plan invites disaster, as does adding a moral imperative.
It’s like declaring that all transit should run on schedule, because the schedule is perfectly designed and morally superior. Well, it sure is nice when it does all go according to the book, but that doesn’t mean I want my plane taking off directly into a hurricane, or my bus leaving the station while I’m still in line to board.
I would have loved an uncomplicated delivery at 40 weeks. I got a CS at 28 weeks. You know what? The only problem were the 28 weeks. The CS was lovely.
The problem with that definition is that it is, of necessity, a retroactive definition.
You can’t say “I want an uncomplicated vaginal birth. Make it so!”. It would lovely if we could order one up, but it’s only after all the bodily fluids have ceased to flow that we can declare a birth “uncomplicated”.
It’s not the retroactive part that’s problematic, that’s just truth. Problematic comes in when it is misunderstood, misused, or elevated beyond its worth. A description is just a description, and there’s not but so much language I’m willing to cede to NCB-only territory.
Those terms (physiological/normal birth) infuriate me.
Those terms inspire epic middle school style eye rolls in me. Seriously, in a choice between even the most picturesque “physiological” birth and a good old fashioned hospital epidural with netflix, netflix will take it every time
So let’s take the case of augmenting labor. How is a doctor going to manage that differently than a CNM, who values physiologic birth? Would they use different criteria to decide when to administer pitocin and how much to give? If they are both following evidence-based recommendations, why would there even be a difference in their practice?
Well, that’s the crux of the matter, isn’t it.
It all just comes down to personal comfort levels with risk.
If you wait until the risk of not augmenting or inducing are very clear (lets say you wait until first stage is 18hrs before you augment or 43w to induce) you’re going to have fewer iatrogenic complications of interventions, but you might actually have more morbidity.
If you DON’T wait until it is clear cut, you risk more iatrogenic complications, but you hope that this is balanced by a reduction in morbidity.
This is where medicine is an art- one provider based on experience and gut instinct and personal comfort with risk may be happy to wait, another may not. All the guidelines are quite cler where the bright lines are, but really less clear about the grey areas, because the evidence is less clear, and the grey areas are where the drive for normal birth suggests reducing interventions.
Only with the benefit of hindsight or a crystal ball will you ever know who was right…
Just as a question to earlier post, is there something ‘wrong’ with physiologic third stage (rather than managed), or are they wrong because they are riskier? In the UK women are offered the choice, unless at the time there is a bleed or other indication for managed third stage in which case all that is possibly done is done to keep the woman safe.
It has been shown that actively managed third stage reduces maternal mortality. I’m not sure why anyone would want a “choice” about a potentially lifesaving intervention.
IMO it should be SOP with an opt out, like HIV testing, not a “here are two choices, both are fine, pick one”.
Fair enough, can you still have delayed cord-clamping with managed third stage? I really didn’t know, we were sort of given the impression that there are two choices both are fine =/
yes
Thanks 🙂 Yeh I just did some of my own quick google research and found this, which isn’t super recent (2009) but does give some interesting points on pros and cons of DCC as well as how it could be facilitated when using active management, for anyone else who’s interested. http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/cd004074_abalose_com/en/
What is the current thinking on risk/benefit for delayed cord clamping?
I did delayed cord-clamping and had a managed 3rd stage. I read (here?) that it does raise the risk of the baby developing jaundice, and asked the midwife (CNM, hospital birth) and was told that it wasn’t a big deal. I didn’t feel like arguing about it, as I figured the worst-case scenario would probably involve formula, which was fine by me.
I’m glad I did it, as I was able to cut the cord (my husband didn’t want to) and it was absolutely the best part of my “birth experience”–probably because it meant that labor was really over.
However, if I had to choose between a managed 3rd stage and delayed cord-clamping I’d choose managed 3rd stage all the way. My mother had a PPH after my birth (twins, vaginal birth) and required 2 units of blood. I don’t know if she was given pitocin after we were born, but her PPH was discovered around 5? 6? hours post-birth. She’d told the nurses repeatedly that something wasn’t right but they all told her everything was normal but without checking her bleeding, which seems insane to me.
When my husband said “oh they’re giving you pitocin” I thought THANK GOD.
It is entirely possible to have delayed cord clamping with managed third stage, this is what the WHO recommends as the routine for every delivery.
I don’t know much about actively managed/not managed third stage but I have noticed that both our doctors and our medwives here seem to recommend the first option. Each time I hear the phrase “physiologic third stage”, I am reminded of my late grandmother’s worldly wisdom, “A man who has not done his military service is no man and a woman who has not given birth is no woman”. I don’t need to say that it wasn’t something she invented. It was just the way her fellow countrywomen lived 80 something years ago. Fortunately, nowadays we can consider ourselves “true” men and women without those societal pressures. The pressure to give birth to be considered a true woman seems to have given way to the pressure of doing it the natcherel way to be considered a good mother.
People don’t change this much, after all. I wonder what comes next, when physiological birth loses its inherent value.
That is how it works in the hospitals I’ve delivered in or rotated through in Aus
Some people are totally sold on pit being an evil substance that will only hurt them. They think it will make the third stage more painful. However I have always managed (so far) to persuade women to let me do active management.
The Nice Intrapartum guidance on third stage is actually…interesting.
1.14.7Explain to the woman that active management:
shortens the third stage compared with physiological management
is associated with nausea and vomiting in about 100 in 1000 women
is associated with an approximate risk of 13 in 1000 of a haemorrhage of more than 1 litre
is associated with an approximate risk of 14 in 1000 of a blood transfusion. [new 2014]
1.14.8Explain to the woman that physiological management:
is associated with nausea and vomiting in about 50 in 1000 women
is associated with an approximate risk of 29 in 1000 of a haemorrhage of more than 1 litre
is associated with an approximate risk of 40 in 1000 of a blood transfusion. [new 2014]
So…active management doubles your risk of nausea and vomiting from 5% to 10%, but more than halves your risk of major haemorrhage and cuts your risk of needing a blood transfusion by two thirds.
I’ll take the puking over the blood transfusion and major bleeding, thanks. I’m unsure why anyone given that data in that way would decline active management.
Are midwives following evidence based recommendations? It sure doesn’t seem like it.
I guess there might be different ‘escalation’ with induction, so rather than starting at Pitocin, they might start with Propess, which can be enough to kick start labour, but the contractions are ‘physiological’? I don’t really know, because induction is usually overseen by a doctor anyway so it’s a total *shrug* I know we told women to go for a walk, or did a membrane sweep, and keep mobile, to try and get things going, but sometimes all that will work with an induction is oxytocin
http://mana.org/pdfs/Physiological-Birth-Consensus-Statement.pdf
But….
But sometimes normal physiologic birth simply doesn’t work! It does not perform! It does not fulfill the promises made by its supporters.
A woman could be allowed to labor undisturbed and have her phsyiologic birth be a failure.
Who can we blame for that? I honestly want to know. If it’s modern medicine to blame for everything else – then who can we blame when a “normal” birth fails?
The patient, via natural selection.
Physiologic birth is a made up marketing term. It has no empirical basis; it was created to serve the marketing needs of the natural childbirth industry.
It encompasses most everything a midwife can do and excludes anything that requires a doctor. It is not natural as waterbirth, craniosacral therapy, and supplements are all compatible with physiologic birth.
It doesn’t exclude technology. Midwives have no problems with blood pressure monitoring and auscultation of the fetal heart, because they can easily do those things.
Physiologic birth is basically a piece of performance art that midwives imagine recapitulates birth in nature. They see themselves as critical actors in the performance, along with the mother; everyone else, including the baby, is an extra.
I dislike the term for those reasons.
I love that description.
I think it’s also about claiming they do something doctors don’t, whereas I see their skills as strictly a subset of what doctors do. That they are willing to delay or skip interventions altogether, willing to be comfortable with a higher risk as Dr Kitty was talking about, to appease women’s desire for fewer interventions. So it would be a way they are “with women” that doctors aren’t. Really I think it shows their values are out of whack, especially since MANA is on board with this.
It’s a very selective exclusion of technology: why aren’t blood pressure cuffs and stethoscopes (fetalscopes?) forbidden? They’re technically medical tools. I know you said they’re relatively easy to use, but I’m not sure why they continue to use them instead of “letting nature take its course”. If they really wanted to go au naturel, at some point, someone would have to say “Hey, those are EVIL MEDICAL THINGIES! We don’t need them!”
The great irony is that an entire health care industry exists to manage physiology-gone-wrong – from appendicitis to impacted wisdom teeth, from atrial fibrillation to osteoarthritis, migraine, back pain…