Podcast: Birthing Outside of Guidelines with Guest, Midwife Rebecca Savage
Birthing Outside of Guidelines with Guest, Midwife Rebecca Savage
Season 1, Episode 11
Have you been told you 'have' to give birth in a certain way? That you're 'not allowed' to do something, like have an elective caesarean, give birth at home or in water?
This week I am joined by Rebecca Savage, experienced midwife of 15 years and trainee Consultant Midwife. We discuss the role of a consultant midwife in accessing birth choices that do not sit within the 'normal' guidelines or care pathways.
This episode is an absolute must listen if you want to feel informed and supported about making choices for birth that feel right for you and your baby.
TRANSCRIPT
AI GENERATE
I know right now you have no idea what to expect from birth, what it's going to feel like, how it's going to pan out.
And so what you thought was going to be this glowing experience of pregnancy has turned you into a bunch of nerves.
Well, you were in the right place because I am here to hold your hand as you prepare for the birth of your baby through the birth-ed online course, the course that gives you the information you thought you were going to get from your antenatal appointments and didn't.
The birth-ed course opens your eyes to everything you need to navigate your pregnancy and birth choices so you can feel confident, informed, and ready to take back control.
Available worldwide for just £40 or $50, sign up now via the link in the show notes.
Welcome to the birth-ed podcast, where we open up conversations about all aspects of pregnancy, birth, and parenthood, so you feel fully informed, confident, and positive about what this journey might entail.
I'm Megan Rossiter, founder of birth-ed, and your host here at the birth-ed podcast.
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Believe me when I say we will leave no stone unturned when it comes to preparing you for your pregnancy, birth and the postnatal period.
Before we kick off today, I just wanted to take a moment to tell you about the courses offered by birth-ed, because we are actually a little bit more than just a pregnancy, birth, and parenthood podcast.
We offer in-person courses in the UK and an online course which is accessible worldwide.
The birth-ed course is totally unique in that it offers both a comprehensive antinatal preparation, so covering everything, all your birth choices possible interventions, decision-making tools, your pain relief options, your birthplace choices, optimal positioning, kind of everything that you might want to know about having a baby.
But also included in that is a full hypnobirthing course.
So giving you practical tools and techniques that you can use in labour to help you feel calm, to help you feel comfortable.
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Thousands of parents have accessed the birth-ed courses now.
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Hi, everybody.
Welcome to The birth-ed podcast.
I am joined today by a very exciting guest.
I'm joined by midwife Rebecca Savage.
Becca is a trainee consultant midwife.
She's been a midwife for nearly 15 years, working predominantly in the community and on the birth center settings.
And she's also been a practice educator in the hospital and a university lecturer.
And importantly, she's also a mom of two children.
Becca, welcome.
Thanks so much for joining me today.
Well, thank you very much for having me, Megan.
It's really lovely to chat.
So I suppose to kind of kick us off, a good place to start when people are thinking, what actually is a consultant midwife, and how is that different to a midwife that they would just meet in their normal antenatal appointments or in labor?
Yeah, so a consultant midwife basically brings together four different aspects of the wider role that we have within the midwifery service.
So we have an element of expert clinical practice, often in an area specifically.
That might be community, labor ward, birth centers.
We're involved in education in the hospitals and within the university links as well, we do a lot of service improvement work.
So that's looking at how we can provide best quality and safe care.
And then we're also kind of overarching all of this, providing a leadership within the midwifery workforce.
Role modeling, I suppose, really, all of these things combine together.
So we're not managers or matrons, but we work within and with these people to provide hopefully the best care we possibly can within the maternity services.
Fantastic.
And so what is generally women's interaction with Consultant Midwives?
Kind of what is it that you meet with women specifically for?
So very often, we run a lot of Midwives, Consultant Midwives run specific clinics, which is how we meet women with specific needs to birth plan or provide supportive care planning.
As it's called birth choices, it might have a different name in different hospitals.
So we work with women in lots of different ways, but we do have a nice one-on-one role with women as well.
And so we can work with them just on a one-off basis, or again, everyone does it very differently.
It might be a supportive process through pregnancy alongside your community midwife.
I mean, it really is for quite a wide variety of reasons, which I can talk to you about as well, if you like.
So it's not all women that will meet a consultant midwife with them?
No, it's not.
It's probably quite a small subset of women, really.
You can be referred via your community midwives or via the doctors that you see.
I'd say a large proportion of the women that we see in our clinics are under consultants' obstetric care.
And then they come along to our clinic for another kind of additional higher-level conversation, supportive planning, so that we can help bring everything together from a midwifery perspective, I think probably is the easiest way to explain it.
Yeah.
But like I said, it really varies as to why a woman might come and see us.
So can you give us a couple of examples?
So kind of what are the main reasons then that you see women during pregnancy?
What is it that causes them to say, you know, I think I'd like to chat to a consultant midwife about X, Y, or Z.
Yeah.
So in our birth choices clinic, for example, nearly half of the women that we see are for birth trauma or fear of birth, conversations and support.
So that's either in the first, second, third, fourth pregnancy.
It's not discriminatory at all as to who this affects.
And obviously, again, this comes from a massive variation of reasons as well.
But that's a significant proportion of the women that we see.
This often can come about from a feeling or a desire for an elective caesarean section.
So and then when we look a little bit deeper, there's it's because of an experience previously in a previous labor or birth, or because they've had a very, very long standing fear of birth prior to pregnancy even, but they found themselves pregnant or wanted to have a child.
So that's a large proportion of the women that we help and see.
Then the other section of women are probably those who are looking to have a certain kind of birth or an environment such as home or a birth center, which wouldn't normally be recommended within our local or national guidance.
So for those women who are requesting to give birth somewhere where we are concerned that there are potential, I don't like the word risk at all, but a higher likelihood of things or problems, which we would not try and reduce that likelihood of happening by being in one area with a certain plan of care.
They would like to birth somewhere else.
So we have those discussions and try and pull everything together to create a plan that everyone is happy with and is safe.
Yeah, I think and I think that's a really helpful thing for kind of for lots of women to know, because a lot of women that I work with often before we've kind of worked together, before we've had the conversations that we have in our antenatal classes and meetings, often women think that they have to give birth in a certain place or a certain way.
So, can you just kind of explain to everybody what guidelines are, what they're there for, what local protocols are, and the kind of the differences, I suppose, between those things?
Yeah, so a guideline is basically guidance for us.
As professionals, we work to guidelines.
They are based on the best available evidence, which obviously varies quite significantly, depending on what it is that we're looking at.
And maternity is quite a difficult thing to research, in some cases, obviously, we can imagine.
So it's based on the best available evidence, and this is also continually changing.
So we are constantly updating our guidance.
This is what the midwives use as their kind of parameters for providing safe care because it has been suggested.
And again, these come from usually national.
We have NICE guidance, which is our national guidance set by a broad, broad panel of multidisciplinary professionals come together to look at all of the evidence and then suggest what we should be doing on a local level.
For the majority of hospitals, we follow and take this guidance, but it can also be influenced by other research that we have found or are aware of if it hasn't been inputted into the national.
So it's not completely set.
And again, guidance is suggested best practice.
A policy is different.
That is something that must be followed, and it's really important that it is followed.
So we do have policies within maternity services, but the majority of our clinical care obviously has to be a lot more individualized than that, allows for.
And so our clinical practice is guidelines.
They are guidelines, basically.
So for some women, there are elements of some guidelines which they may not agree with, or they may want to discuss further and have a more individualized approach to.
Yeah, and I think that's just a really helpful thing for women kind of going into birth, to know and to understand and to be able to explore.
I'm going to give you all the consultant midwives just a load more work after this episode now.
People are going, oh, I didn't realize I could do XYZ.
But I suppose it's just a case of opening up those conversations and realizing that actually, even from one hospital to another, there might be differences in what you're being offered.
And so knowing that and knowing that nothing is, it's not a law, you don't have to do anything.
Nobody can unallow you for doing anything.
And having those conversations means that you can hopefully all be on the same page by the time it comes to the birth itself, would you say?
Yeah, I think that's the most important thing you just said there.
I think it's really important if you've got questions and if you've got things that you've read about, to have the conversations just with your community midwife.
And if she can't answer them in the way that you feel you would like to discuss them, then to seek further support from either a consultant midwife or from a senior midwife in your local trust to discuss it with.
Because it is something that is much, much better dealt with in the antenatal period so that we can all try and work to a plan of care that, like I said, everyone is aware of and therefore is communicated to, and everyone has the right expectations of what is going to happen and why.
And also what the limitations might be, what is actually available physically or possibly within a service.
And these are conversations that really do need to be had in the antenatal period.
And ultimately, as far in advance, as you are possibly aware of having these thoughts and discussions that you kind of want them, because having them at 36 and 37 weeks is also quite hard.
But we do it quite a lot.
It's quite a common time for women to realize that they have got, you know, it's becoming a lot more real.
You have the birth chat with your midwife often at home at 36 weeks.
And all of a sudden, you're thinking actually, oh, I want to reconsider this a little bit.
So we do a fair amount at that kind of time, but we prefer to do it earlier if we can, so that we can have the discussions with as many people as need to be had with, depending on what obviously the issue or the preferences, basically.
Yeah, and I suppose that's it, because often in the kind of the guide thing that you get given when you fall pregnant, it says that you're going to talk about your birth at 36 weeks.
I think people think that they have to save up all their questions until this time.
But if you've got questions at 16 weeks, you can ask it in your 16-week appointment.
And if it's something that can kind of, a conversation that can be had later, you can have it later, but you can absolutely ask your midwife anything at any time, can't you?
Yeah, and I really, really encourage that as well.
The sooner you can be thinking about all these different things, or deal with them as they come up for you, because it will be different for everybody, the better.
Your midwife can answer all of your questions.
And she might ask to pick out one particular thing per time, I suppose, because like all health professionals, we're under time in clinics, unfortunately.
It really varies where you are as to how long you've got in for a clinic appointment.
I know GPs, for example, have 10 minutes.
I don't know any midwives that have 10 minutes, but I could be wrong on that one.
We have 20 minutes, for example, which should be time to have a discussion about something and to deal with the normal checks and anything else that crops up.
And if you need longer, you have got a lot on your mind and you feel like you do need more, then you can always ask your midwife for a telephone conversation.
And she might well offer, actually, to come around, if that is within her ability.
It really depends on the service and how stretched that service is.
But again, I certainly have done that as a community midwife before.
So it's always worth asking, basically.
And again, yeah, to have it at any point in the pregnancy is really important.
I've actually just written a guideline as well, really specifically asking midwives to open up this conversation at a much earlier gestation because of the high numbers of women that we're getting through our clinic at later gestation.
So that's how far you are on your pregnancy.
So in later pregnancy, with quite a severe anxiety and fear around and needing birth planning later on, which we would have much preferred to have helped and supported through pregnancy a lot more.
The questions that we are asking our midwives to ask all women is, how do you feel about your pregnancy?
How do you feel about the labor and birth?
And how do you feel about your previous labor, if you had one, obviously?
So there's kind of three really, really open questions from 16 weeks, pretty much every time, depending on what it is that the midwife is picking out.
You know, is there one thing, i.e.
the pregnancy, or is it more specific to birth that this woman is kind of worrying or thinking about or needs their questions answered, but so that the midwife has opened up the dialogue?
And I think that's really important that we do that.
Yeah, absolutely, because sometimes, until somebody asks you, you don't even really, you maybe haven't even let your mind go there.
You haven't.
I was working with a couple recently and had had lots of previous difficulties falling pregnant and had kind of struggled with this pregnancy a lot.
And we got to the first session of our courses, and I sort of said to them, what is it that you want from the birth?
And they're like, do you know what we've not, like, we haven't even let our minds go there or think about it yet.
And so sometimes it does take somebody to ask the question to even acknowledge that there is something there that needs talking about.
And it's, they're often not quick fix things, are they?
They're kind of things that need kind of ongoing support so that earlier you can have those conversations and those thoughts, the more time you've got to come up with a plan to kind of arrange support throughout that period.
Yeah, absolutely.
And I think what you said there about not really knowing what you feel until someone asks you, it's a bit like when someone says, are you okay?
And then you suddenly think, no, I'm not.
You know, we really need to be able to give that time and compassion because the pregnancy, we all know whether you're experiencing it or whether you are a health professional with the theoretical knowledge or whatever, or you've been through it yourself previously, we all know that it throws up completely different things for every person and very often that you weren't expecting either.
And I think that's part of the transition to motherhood.
It really does start as you are thinking about conceiving or as you find out you're pregnant for the first time.
You know, that is at the point at which you start psychologically adapting slowly to the changes that are happening in your life.
And it does throw things up and they are unexpected.
And I think we need as healthcare professionals and midwives to be a bit more aware possibly and have the time to help women through this transitional period as a transition as well as, because we are very good at looking after the physical.
And that's just health, that's the health service in general.
We all know it, we are all talking about it.
We are very good at looking after the physical.
But the psychological and emotional impact of pregnancy and birth and motherhood is massive and really needs that also, you know, awareness and support as well.
So, let's imagine then that you are meeting with a woman who has had struggling emotionally with pregnancy, potentially kind of fearful either about giving birth again or about giving birth at all.
I mean, I imagine it's probably totally kind of different for each individual, but in that meeting, kind of what conversations are you opening up?
What are you asking them?
And what sort of outcomes are women hoping for?
What sort of outcomes are you recommending or suggesting or kind of supporting them to make?
Wow, it's really individual.
So it's quite hard to have a standardised answer.
I suppose the way I generally approach it is to let the woman and partner tell me their story, basically, and just to tell it to me rather than me look at any notes, certainly.
And if we need to check in on facts or what happened last time from that point of view, then we can very often while we're there.
But we're not the debriefing service that is also offered by the majority of hospitals, such as Birth Afterthoughts.
So we can offer additional sessions slightly different for that specifically.
So I kind of really am just listening to what it is is that they are telling me and thinking about the layer underneath, the initial problem that they're presenting with, I suppose.
So very often, as we said, the tip of the iceberg that the community midwife maybe comes across is that I would like an elective caesarean section.
Because I think that's just what I want.
And the community midwife, again, very much depending on time or how confident they feel having these conversations potentially, or how well they know you, will maybe start to engage in this kind of conversation.
And there'll be a different couple of routes that they could take at this point, depending on where they work.
But then very often, we would, as consultant midwives, see you in a more in that clinic.
So then we would want to just hear where this has come from, really.
And it's not a judging.
It's not a trying to position ourselves so that we can then persuade you of anything.
It's so that we can understand you and your experience.
And to really validate that, I think, is really important, because whatever people are feeling is true for them at that point in time, completely regardless of anyone else.
So we will unpick things if we need to unpick it.
But again, I'm not a psychologist or a counselor, so I do have to be very aware that I am a midwife.
And to then offer support in those ways if they should be needed.
Yeah, so many places will have a psychologist working within their service, which they can refer to.
We have a maternity counselor.
We don't have a psychologist just yet.
So again, it does really vary.
And there will be some other place that we could get psychological support if that is also needed.
But sometimes it's not at all.
It's just a case of expressing what the need is, unpicking a little bit, being heard, and then making a plan to move forward.
So it really depends on where it's all come from, really, and how much it's affecting a person's day-to-day life, I would say, for this example.
And so if women are requesting AESA's area, either for that reason or for any other reason, does it become a kind of longer conversation where you access kind of other services before making the final decision, or does it tend to be granted in the initial appointment, or again, does it just totally depend?
So I would say that the majority of hospitals now, I'd say we all work fairly similarly in that it's changed a lot, basically.
We are generally speaking for a primary, that's a first caesarean section.
So whether it be your first baby or your second baby, but your first caesarean section, we generally really want to make sure that that is the right option for you.
So we would encourage and we enable a two appointment, basically a two conversation points happen before then that is kind of booked in.
And that can be an obstetrician and a consultant midwife, or it can be two obstetrician appointments depending on where you are.
That will vary as well.
There is no protocol to have to go through.
It's not about kind of jumping through hoops.
It's about making a informed decision and the best decision, the right decision for you as a person and as a family.
So, it has changed significantly in the time that I have been a midwife, certainly from that point of view.
And there are many women who still come in really concerned that this is going to be a really hard appointment and I have to convince you of what it is I want and need.
And we all basically want the best thing for you.
And that may at the end of it still be a caesarean section, or it may at the end of it not be a caesarean section.
And we come to understand your fears or issues and what happened last time or what it is you're trying to avoid this time.
And we can come to another plan that actually is really satisfactory as it were for you as a person and does avoid the caesarean section.
So it really does vary.
Yeah, absolutely.
And I probably meet with maybe one half of people that are in a similar situation with that.
And I do find that people tend to swing one of two extreme ends of the spectrum.
So what they're often deciding between is a elective caesarean where they feel very in control, where they feel very calm, where they feel very supported in that where potentially previously they might not have done in another birth, or swinging right to the other end of the spectrum and going, I'm planning a home birth.
I want absolute minimum kind of intervention.
And sometimes that's the decision, which seems outwardly before you kind of understand what those women have been through, seems like how on earth could you possibly just be deciding between like something with like barely any pain relief kind of in your house with just a midwife, or elective caesarean surrounded by loads of people.
Like the two things seem kind of very, very far apart, but often that's where I see women kind of swinging from one to the other, I suppose.
Yes, 100%, I would say exactly the same.
And it is it all comes down to, I'd say in the most cases comes down to control.
And in both of those examples, like you said, there is the feeling and the control over what is happening.
And for some in the elected caesarean section case, obviously, when it is happening, where it is happening, and you know, you are you can be very prepared for that in every way, really.
Yeah.
And not too dissimilar with the home birth, or often kind of have that same thing.
And it's a pool birth, or it's an elected caesarean section.
And yes, it might be a home pool, or it might be a birth center pool.
Yeah, there's definitely that element of, I want it really, really low risk kind of environment and support and care.
Or actually, I want to bypass everything in the middle and go for the other end, because I just can't do that bit in the middle again.
Yeah.
So 100%, it is all about control and where people feel they have the most control.
And I think it really, a lot of which way people go, they do tend to have a personal leaning one way or another, even if they feel like it's, they are the two ends of the spectrum that they've got.
And I do, I get people to imagine, regardless of everything that they are kind of thinking, just for a minute, to take themselves out and to imagine their ideal birth, and then to start, so that we're kind of getting rid of the fear aspect, and we're getting rid of the additional complications, for example, at the moment, and just think about what is your ideal birth and why, and then let's start working, because understanding the why is really important, understanding how we can facilitate something that most matches that.
And I think it's really important also to note that we know from research that whilst low-risk environments, so birth centers, home births, have really good outcomes for women who are appropriate to attend those environments to give birth, in terms of likelihoods of risk factors and things like that.
We know that, but also we know that your birth experience is actually much more dependent on the interpersonal factors of your birth.
So we really need to be less scared of when birth slightly goes off-piste, as I call it, down a different run of the mountain.
We have to switch lanes slightly and have support from the Labour wards and everything that that encompasses, because it really is less about that and much more about how you are treated, how you are cared for, how you are spoken to.
Do you feel like you've got an element of shared decision making?
Are you active in your care?
Are you listened to and are you respected?
And if those things all happen, then regardless of the outcome, you are more likely, we know, to feel like you have had an empowering, positive birth.
And that's the key, I think, to a lot of this in terms of when I'm thinking about educating midwives and student midwives, and also when we're trying to talk to women about birth preparation.
Because yes, we want them to understand their bodies and how it should work, but we know that in some cases, it just doesn't happen for a variety of really different reasons and ones that none of us are ultimately in control of on the day.
And so that's where that weird phrase, I kind of hate going with the flow, is useful.
And it's knowing that the care you receive is the bit that's going to give you the positive or the slightly less positive experience of that overall experience.
And that's such a huge thing that I focus on when I am teaching is that, yeah, there is a lot that we can do to stack all of the odds in our favor to support the physiology of birth, which doesn't always happen in the kind of bright lights, noisy, labour-ward environment.
And so even in that situation, things like turning out the lights, minimizing conversation and stuff, it is going to alter the physiology, what is going on inside your body.
But ultimately, exactly as you said, sometimes the right choice on the day is to accept intervention of some kind, and having tools at your fingertips to remain in control of those decisions, to kind of be able to ask questions.
And so much of it comes from that education, like conversations that we're having right now, is that often, I would say, 75% of people don't know that they have choices, that they can ask questions, that they are ultimately in charge of the decisions in the end.
And even things like people going, oh, but am I allowed to turn the lights off?
And in my head, I'm like, what do you mean?
Of course, you're allowed to turn the lights off.
But I suppose it's just remembering that, remembering that actually people don't even know that they can do that, and you absolutely can.
Yes, and that really comes down to really subtle, subconscious things that we don't realize at all that we are experiencing or thinking.
Like, you know, for you and me, having worked in hospitals, that's our environment.
We're very used to that.
And it wouldn't make us think twice to even say, as a person in the service, can you turn that light off, please?
We just do it.
But when you are coming in, and I did this actually for a group of students recently, I videoed just literally walking in and what you were to see coming into our service and how that would make you feel if you were looking this way and that way and what you saw and how you were greeted.
You know, it's not your environment.
It's not your natural habitat.
Your natural habitat is actually home and the places you frequent.
And you are subconsciously coming in to other people's environments.
So there's a really, there is a power into play, which we are not intending at all.
We're not there for that.
We don't want to encourage that power at all.
But we need the, we need women and families to also recognize that they, it's their birthing room, it's their birthing environment.
And if we are not thinking about the lights, for example, because we're just very used to it, we've got horrible strip lighting in the hallways.
Just say, can you turn the light off, please?
And their midwife will go, oh gosh, absolutely, of course.
And they absolutely should be thinking this too.
But there is no harm at all in just asking if they haven't done it for you.
And it's something that you know is important.
And like I said, and we had this discussion before about how birth centers and in home births, in your mind as a midwife, those things are possibly even like really on the front of your, the forefront of your brain, because you know them.
They're really simple things that can have big effects on, like you said, the physiology and the hormones of labor.
You just do them.
And it might be a really simple also shift in thinking for the midwife.
You know, I've gone into a different labor environment now.
I need to slightly shift what I'm doing, and I need to remember all of those other things about the physiology that I still do over in this environment.
I need to bring those with me, because it can be easy to forget.
It's not an excuse at all.
But, you know, I've seen it, and I've had to remind each other to turn the lights off and to do simple things and to not have so many people on the ward rounds to coming into a room.
They are things we continually have to keep saying because of, I suppose, how busy potentially labour wards are these days.
Yeah, yeah, absolutely.
So this kind of leads on nicely, then, probably to the kind of other subset of women that you meet in kind of antenatal appointments as a consultant midwife, is the women that are kind of wanting to, almost kind of wanting to birth outside of the system or kind of going against the initial recommended guidance, whatever the reason for that is, whether that's for giving vaginal birth after a cesarean or after a tear, after a heavy bleed or something in a previous birth, even things like maybe gestational diabetes and things like that.
With a lot of these things, the kind of current guidance is to recommend, to give birth on a labour ward where there's kind of obstetric-led care alongside midwives.
But some women, it's important to them, again, like we were talking about, to maintain an environment that really does support the physiology and for whatever reason, the labour ward doesn't do that for them.
And so in those kind of meetings with people, what are the kind of top reasons, you'd say, that women come to you for trying to kind of come up with a different plan kind of in the opposite direction?
So I say most of them are, like you mentioned, vaginal birth after the caesarean section, which I think then the guidance is slowly, slowly going towards the right direction.
It's just a very slow process.
Research and evidence, I think they say it takes about 17 years to ultimately to really fully become embedded in clinical practice.
And the guidance on that changed last year a little bit, didn't it?
A little bit.
And then they rescinded, rescinded.
So we kind of had a moving forward.
But I think that has really made people stop and look and really think about the individual a little bit more now.
And previous PPHs, that's where you have a significant bleed after birth.
Then coming back through with your next pregnancy, women often don't realize or have maybe told quite how much they lost initially with the first birth or in a birth.
And then when they're pregnant again, they're under consultant-led care because it was, say, a liter, so 1,000 mils.
And this potentially, depending on where you, depending on how much you lost and where you live and what your service does, will generally depend where we would recommend for you to give birth.
So yeah, those I'd say the two main ones.
We also have GBS positive as well as an upcoming issue.
But again, a lot of places are now widening their birth center environments to include a lot of things that we really didn't before.
So in a way, we've never been more inclusive of what I kind of call the gray area.
You know, it's not the really super straightforward, but it's not the super kind of complicated.
We really need to be very careful here either.
It's the gray area in the middle.
We are generally across the country a lot, lot better, but it really varies.
And UK mids are doing a lot of work, research into birth centers and different aspects of that to look at the care that's provided and who can come in and what we do for certain different things.
And PPH, for example, is one of those that they're looking at currently, so that will be interesting when it comes out.
So they are probably the two main ones.
And again, like I said, it really does depend on what else is going on within the pregnancy as to what your ultimate end outcome is.
But it's done with the women, and it's done very often within the wider multidisciplinary team as well with obstetricians so that everyone is kind of understanding because it's got to be something that the service can support safely.
I suppose there are some things which ultimately will be off limits because it puts the service and other women at risk, which we can't do either.
But where we can, we really do work to find that middle ground so that we've got a safe and a personalised option.
And I think that personalised is the absolute key, really, isn't it?
Because a PPH for one reason in a birth is somebody who's had an induction and an episiotomy is very different from a PPH that actually happened on a birth centre, in the water birth.
The reasons for those things are kind of different.
Yeah, look into that, when we're considering all of the different things, we really do look into what happened last time, how do we think it came about, and then what are the likelihoods of it happening again, depending on why it happened last time, basically.
And that goes with vaginal birth, when we talk about caesarean sections and options for next time as well, you know, why did you end up with an emergency caesarean last time?
And what are the likelihoods of those kinds of things happening again?
So and having that information is really, really useful because women often don't know really completely.
And also you're just not in that headspace to really take it all on board or to remember stuff anyway.
So I think it's really useful to come back.
And we certainly offer where we work, where I work, a obstetric kind of more debriefing service for women who have had slightly bigger outcomes in terms of blood loss or tears that have extended into the anal area.
We bring women back and really go through and make sure that they understand what's happened, why things were done, and so that people have got a clear understanding at a point where they can actually remember six weeks after birth.
Yeah.
So I suppose to finish off then, there might be some people listening either going, yes, I had a traumatic birth last time, and I really desperately want to have a cesarean, or they're thinking, I had a cesarean last time, and I actually want to have a home birth this time.
How do they, I know this is different again, depending on the kind of system, but as a general rule, how do they go about accessing the support of a consultant midwife?
So we've, there are 93 in the country, and 40% of trusts have consultant midwives.
So there will be pockets, fairly large area pockets, where you won't have one at all, in which case you want, however you, whoever you've got, you can talk to your community midwife, your named midwife, or if you have an obstetrician caring for you, then ask either of your obstetrician or your community midwife, and they will know the next best person to put you in touch with to go through these issues and to work towards a birth plan with you.
We used to have people called supervisors of midwives who did a similar job and worked to make safe plans that were individualized for women.
We don't have those any longer.
And the role that has superseded that is not quite the same.
They're more likely to be your birth afterthoughts.
So it might be that you see a senior midwife lead of a birth center or a senior lead of the labor ward or one of the matrons instead who will be able to do this with you.
It just will vary.
OK, fantastic.
And I suppose one final thing that's worth pointing out about a consultant midwife appointment that I think is kind of, for me, is a really, really important thing to understand is the difference between having these conversations with your consultant's obstetrician and having these conversations with a consultant midwife.
And I'll ask you what you think the kind of biggest differences are.
But from my perspective, a consultant obstetrician is basically an expert in pathology or illness or complications of pregnancy.
And a midwife is an expert in the normal physiology of birth.
And so I always say it's really helpful to have those conversations with both of those people because you often get quite different perspectives.
And so I find when women have conversations with both their obstetrician and with whether it's a consultant midwife or a midwife that's kind of fulfilling that role, you get kind of a balanced picture because whether there's complications of pregnancy or not, unless it is a cesarean section, the physiology of birth still has to happen and we still have to be able to support it as best we can.
Would you say there's kind of any other key differences?
No, so I think you're spot on there.
And the other thing that we generally have, certainly in our practice, is time.
We have an awful lot more time to deal with the issues holistically.
So generally speaking, the consultant obstetricians have really, really busy full clinics.
And you may be, obviously, they run with registrars and SHOs as well, so differing grades.
So you'll have probably differing levels of conversations going on during those clinics anyway, depending on who you see.
So as a consultant midwives, you're getting experienced midwives, and you're getting a good, generally, I would say 45 minutes minimum of their time and expertise to look at your whole issue from a whole person perspective, and also not just you.
We very much do put it into place within the wider family, and we understand how it implicates on every other aspect of your life.
So I think it's more that we've got that time and ability to do that wider thinking with you, and then to drill back down in to what we can do to move forward as well.
Yeah, so if you're listening and you're thinking, oh, well, I've already got this conversation booked in with my obstetrician, there's absolutely no harm or no reason not to also kind of have a similar conversation again with a consultant midwife, just to be sure that you're getting the kind of really the right choice or the right outcome and support for you personally.
Yeah, and we work really closely with our obstetric colleagues actually as well.
So very often, they're very aware that they don't have as much time as they would like to go through everything in the instance that it's brought up as well.
Yeah.
They will have the initial discussions.
They're very good at thinking about it and looking at it from their perspectives and the service.
And then they will say, we are going to refer you, because a lot of our referrals come from the obstetric.
So they will say, we're going to refer you on to the consultant midwife now.
And especially in the case of kind of what mode of birth am I going to choose?
I'm not sure.
At that point, you know, you've seen two people, you've had some time to think, you've gone through everything, and then we can book things on from that point onwards as well.
So we do have that ability.
So we do work really closely with them, and that plans back and forth, and we discuss and make sure that we are on the same page, and we understand what we're doing and why for the women, because obviously we work as a whole service, which is really important.
Yeah.
And so once you've got a plan, how does this go ahead and kind of, how does it go into place so that women can be sure that applies, whether that's being able to use water or being able to use the birth center, so they're not turning up in labor going, but they said we could use the birth center, and now you're saying we have to be in the labor ward.
How is that kind of communicated?
I think a lot of it is actually in how embedded the role is, for example, certainly within consultancy, within the hospital, and ours is fairly well established.
We've got good communication and links with all of the midwifery leaders and the obstetric team.
So when we are making a plan, like I said, we don't do it in a silo.
We make it with the wider team that it is actually going to affect us writing something with you, needs to translate into that happening.
So we really make sure that everyone is aware of the what, the whys, and is this plausible?
Is it going to be likely to happen?
So that when you get to Labour Ward, it's written and documented on your hospital notes.
So we send a letter to you documenting the discussions that we've had, but then actually we upload that onto the medical notes so that, and there's a little alert saying, consultant midwife plan that pops up when someone enters those records.
And so that's a really quick, easy, oh, I must go and have a look at that because this woman has gone for a reason and we need to know what that reason is.
It's not foolproof, obviously.
There will be circumstances that things that change or happen, but we work hard to make sure that the plans we make are realistic and communicated and that we've got good relationships with the teams so that they are respected for the women's experience.
Fantastic.
I think that's going to be such a huge, hugely useful conversation for anybody listening that's got any complexity of pregnancy, that they've been told they've got to do something, they have to do something.
Hopefully, that's opened up just a few questions in their mind and they can hopefully go forwards and know now who to start asking, basically.
So my apologies if your workload goes up considerably after this episode.
It might prompt to employ more consultant midwives.
Yes, absolutely.
Fantastic.
So that kind of wraps us up.
Before we finish, now I don't know if I briefed you on this or not, I can't really remember when we last chatted, but I always ask everybody at the end of the podcast if you could gift a pregnant or a birthing person one thing, it can be a hypothetical thing or a real gift, what would you give them?
Oh, I should be proud, shouldn't I?
I've got so many different things going on in my mind.
I think ultimately it kind of comes down to the, I would gift them the ability to surrender.
And that might sound initially a little negative or weird, but it's not a negative connotation of the word at all.
It's something I think I probably learned the hard way, for example, and it extends through the entire process of pregnancy, birthing, and motherhood.
There is so much about this whole process that we cannot control from a rational, logical thinking.
It's a bodily function which is going on, and it's amazing, and it's immense.
And so to be able to psychologically surrender to that process, to let it happen, to try, obviously, and enjoy the process to varying degrees, I appreciate, and depending on what is happening during pregnancy for you.
And obviously, birth, everyone thinks relaxation, and you don't say that.
It's simple to relax, it's the hardest thing to do.
But to give over to the process and let it happen.
And then the same thing with motherhood as well.
The more you fight anything, I feel, and personal experience has showed me, then the harder it is or the harder it physically feels.
So to be able to let it go, and this is something you need help with, I think, probably.
I think all women do.
It's not our normal.
It's not the way we're taught culturally to be.
And we're very much, you know, control.
We like control.
It's what we're good at.
And I think this whole process is a learning to let that go a little bit.
And that's why it is so hard.
It's so monumental for us physically, emotionally and psychologically.
So I think that would be my gift.
I love that.
I think that's my favorite answer so far.
That is, it's so true.
Yeah, it's exactly that.
It's just kind of trusting it, allowing the process to go in whichever way it's going to go.
Yeah.
And obviously, I mean, I'm a big fan of hypnobirthing.
So I think that's a massive part of how you can start to learn to do this, because it's not something that we do actually know how to do very well these days, I don't think.
Yeah.
So it's the hardest, the hardest thing.
I was thinking, if I had a magic power, it would be able to be to tell people when they were going to go into labour, and how long their labours were going to be, because I can't, every single person I work with ask me these questions.
And so much of it is exactly as you say, it's just trying to let go of the need to know, and knowing that it's okay to not know.
And that is so much easier said than done.
It's really, really difficult thing to do.
It is.
Not knowing is okay.
Yeah.
Once you've got it, once you've recognized that need almost, you start extending it out to your entire life, don't you?
Yeah.
You then start going, oh, well, I really, I, you know, because you're a mother or a parent, and you don't know how your child's going to develop, or what they're going to be, and you have to let it all go completely.
Yeah.
Yeah.
Amazing.
Thank you so much for joining me.
It's been such a pleasure.
Thank you so much for having me on.
Thank you so much for listening to this week's episode.
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