I’ve lost count how often I say “You could request an appointment to discuss with a Consultant Midwife / Head of Midwifery / Supervisor of Midwives. I’ve often found them to be very sensible” in our Facebook information and support group. I regularly suggest people speak to a senior midwife whenever anyone has questions or concerns about their care. But why?
The Problem
Pregnancy, particularly if it’s your first, or if you’ve had previous poor experiences, is daunting. There’s a reason why people make jokes referencing the movie ‘Alien’ – it can be a surreal and unnerving experience!
If you’re pregnant in a bigger body, there’s often an added pressure that we are outside the norm. Even though the recent NMPA audit found “21.8% of women giving birth had a BMI of 30 kg/m2 or above”. So while we are in a minority, we’re a sizeable one (ha ha!), representing over a fifth of pregnancies. As soon as we get off the scales (if we agree to be weighed), we often find ourselves labelled ‘high-risk’, told all the ways in which our pregnancy is more likely to go wrong, recommended that we submit to all manner of extra interventions as a result, and left to ingest this as we head home.
For me, this meant that I really didn’t believe I’d get through 9 months to bring home a live baby. If I did, I reasoned, this would be in spite of the many conditions I was undoubtedly going to develop. All of which would be my fault. I’m stunned now that I was made to feel like this. It was only through looking at statistics and guidance for myself that I realised that this is far from the truth!
My odds of having a successful pregnancy with a BMI 40+ were always good. For example, my odds of an ‘unassisted’ vaginal birth, even as someone who’d never birthed before, was actually around 40%. My odds of NOT developing Gestational Diabetes was 90.5%. My odds of NOT having a stillbirth was 99.4%. And so on. That certainly wasn’t my impression after a few maternity appointments.
The Precautionary Principle
To be honest, I was lucky with my experience of fat-bias in maternity care, although it didn’t feel like it!
I wasn’t pushed into an induction for a suspected big baby that turned out to be average-sized. I managed to avoid continuous fetal monitoring that might have impeded my ability to stay active in labour. Although I was advised to have an early epidural ‘just in case’, this wasn’t pushed too forcefully. These, and more, are regular experiences for bigger women and birthing people, which can negatively impact the progression of labour.
When recommending interventions (or worse, telling us we ‘need’ the intervention as if we don’t have a choice), healthcare professionals are usually applying what’s known as the precautionary principle:
If an action, or inaction, is suspected to risk harm, protective measures should be supported even if there is a lack of scientific proof of that risk.
This is why, for example, we’re told to completely abstain from alcohol in pregnancy, even though there is no good evidence that occasional ingestion in small amounts does any harm.
As a friend of mine explained – if we know an intervention X has the potential to reduce the risk of a negative consequence Y, how many unnecessary Xs are acceptable to prevent a single Y? The trouble is, answering that depends on many factors – how unacceptable/invasive X is as an intervention, what are the potential risks of X itself, how catastrophic Y would be, and what our own personal attitude to all this is.
All interventions have pros and cons, and we need to carefully consider the implications.
Information Is Key
So, seeking out the background of data and research that informs our care is vital. We need to understand our risks, and understand how we feel about them, in order to make informed decisions.
But when we do seek out this clarity, this often places us at odds with our care providers.
I couldn’t see why, given that I’d had a straightforward pregnancy with no complications or concerns, (particularly the second time, when I’d already had one completely drama-free pregnancy, labour and birth) why I had to go to the obstetric suite to birth, rather than the alongside Midwife-led unit. Couldn’t see why I was denied access to labour and birth in water. Couldn’t see why the obstetrician was completely against me having a home birth. I understood that they were concerned I might develop complications… But I hadn’t developed them?
My obstetrician was likely applying the precautionary principle – this might happen, so better do that to make it less likely. Except I was approaching the same situation from the perspective of this isn’t very likely, so unless anything changes, no reason to act as if there’s an issue!
What’s The Right Answer?
There’s no right or wrong answers to the conundrum above, only different perspectives on the risks at play!
For me, I chose a home birth. My friend, for whom avoiding an emergency caesarean was paramount, the only way to guarantee this was an elective c-section. Both our choices, in very similar circumstances, were the right choices for us, and that’s what’s important.
Exploring all this, in a general antenatal appointment where there’s many demands on time is difficult to do properly. This is especially confounded when the midwife is either not very experienced, or feels constrained by local policies. It can be very stressful on both sides to try to discuss options if a midwife is worried their practice will come under scrutiny if they can’t convince you to follow the ‘standard’ path.
Consultant Perspective Can Be Skewed
If trying to explore options with an obstetric consultant (assuming you have one), their perspective is likely to be coloured by the fact that they will have seen a disproportionate number of difficult and traumatic births. They are understandably likely to want to avoid this at almost all costs. They want to see a healthy mum and baby leave the delivery suite. Any other considerations are not really on their radar, because they don’t have to deal with any of it! So to them, 1,000 episiotomies to prevent one shoulder dystocia (and it’s not as simple as that!) may seem a reasonable trade off. But it’s not their body, so the ultimate decision is not theirs. It’s yours.
Some consultants (in my experience) may feel threatened by your questioning their recommendations. A good consultant won’t dig their heels in and insist that they know best. They will calmly and patiently explain their perspective but ultimately concede that the decision is yours. But many consultants don’t like challenge, and feel their recommendations should followed at all times. This obviously isn’t a great basis for open discussion and informed decision making.
So, why speak to a senior midwife?
By definition, a senior midwife will have many years experience. Yes, they will have seen births that have gone wrong, but they will also have seen many, many births that have gone right. They should have a good understanding and perspective on the possible options, relative likelihood of various outcomes, and strategies for dealing with potential complications. They should hopefully have good, informed instincts on when to intervene and when to let nature take its course. Because of this wealth of experience, senior midwives are often more comfortable with care that falls outside the ‘usual’.
For example, Shoulder Dystocia is often flagged as a risk. Because of a (marginally) increased risk if you’ve got a higher BMI, it might be recommended you approach labour differently. Shoulder Dystocia does carry the risk of significant injury. But it’s also true that when it occurs, it is overwhelmingly resolved quickly by the same manoeuvre in all settings. It is only in the rare event the manoeuvre doesn’t work, not being in an obstetric setting might cause delay leading to potentially significant consequences.
Take Your Time
If you get an appointment to speak to a senior midwife, you’ll have the benefit of their undivided attention. They won’t need to take blood pressure, dip your urine, listen to the baby etc and all the other things your antenatal midwife needs to do in an appointment. This should mean you’ll have the time to explore the issue in depth.
If you only get “do X because there’s a high risk of Y”, you haven’t got enough information to make an informed decision. I’ve got a whole other article on how using the acronym BRAIN can help you to make informed decisions. A fuller discussion can help iron out any concerns regarding the pros and cons of various options. Not only what the likelihood of Y is, but how severe the consequences of that might or might not be. If you’re considering X, what are the potential negative consequences of it as well as the positives? What could be the consequences of the consequences, and so on?
Use The Opportunity To Reflect On Previous Experience
If you have had previous poor experience, you can seek feedback on what went wrong. This is especially important when what happened in a previous pregnancy is causing you great anxiety about this one. You can look for reassurance on how they will strive to make this experience better. You can hope that feedback on poor treatment either in the past or currently might feed into training for the professional(s) in question.
Get Anything Agreed In Writing!
Crucially, a senior midwife often holds the keys to ‘unlock’ access to treatment options. Their status, to some degree, grants an element of ‘the buck stops here’. If you can convince them that you are fully aware of the potential benefits and pitfalls of whatever you’re suggesting/rejecting, they should support you in that decision, even if it’s not one they would make for themselves.
But it’s not unheard of for midwifery staff to not follow agreements if there’s no proof. People in the Big Birthas Facebook group have sometimes reported successful meetings with a senior midwife, being told they can use the Midwife Led Unit for example, only to be turned away at the door on the day they’re in labour. So remember, get it in writing, with the senior midwife’s signature. That way you can wave it in people’s faces if need be.
What If Your Meeting Isn’t Successful?
While it’s my experience, reflected by other Big Birthas, that getting to speak to a senior midwife is very helpful, it’s not always the case.
For example, this recent news article shows that not everyone promoted to a position of seniority deserves to be there:
So what would be your options then?
Well, you can follow the chain of superiority. You can always ask to speak to, or write to whoever is their superior. Alternatively, you could request to speak to a different senior midwife. You can raise the issue with PALS, your local Maternity Voices Partnership, and ultimately even transfer to another Trust, if there are others nearby. Hopefully that won’t be necessary, as the vast majority of senior midwives I’ve spoken to have been completely lovely.
Fingers crossed the one you see is too.
x Big Birtha