Episode 166 Personalised Care

As we navigate the intricate journey of childbirth, there is a  balance between a mother's autonomy and stringent clinical guidelines.  Step into the world of Personalised Care in maternity services, where my discussion sheds light on the emotional complexities of honouring the unique birth plans of expectant mothers. This episode is a clarion call for healthcare providers to listen deeply, advocate for informed consent, and partner with pregnant women to create empowering birth experiences that resonate with their individual wishes.

Join us for an engaging exploration of the challenges and triumphs in the quest for Personalised Care. From the implementation of a cutting-edge maternity teaching module to the role of the Personalised Care Institute's e-learning, we uncover the ways in which professionals are striving to marry personalized care with the realities of clinical practice. As we close, I extend an invitation to contribute ideas for future discussions, and share the means to support the continuation of our enriching, conversation-led journey through the landscape of obstetrics.

Want to know more?
https://learn.personalisedcareinstitute.org.uk/
https://learn.personalisedcareinstitute.org.uk/course/view.php?id=35
https://www.england.nhs.uk/wp-content/uploads/2021/03/B0423-personalised-care-and-support-planning-guidance-for-lms.pdf

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Florence: 0:00

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you.

Florence: 0:45

Episode 166, personalised Care. I have consciously chosen the title of this episode to be Personalised Care, but what I've had some requests to discuss is that so-called outside of guidance care. I hate the term outside of guidance and, yes, I know it's used quite a lot in services, but I want to shift the conversation. So I'm going to talk about Personalised Care today, why it's important and why it's something we really need to get our heads around. It seems unbelievable to me that Better Births the National Maternity Review was in 2016, eight years ago and I can't help but feel that, whilst lots of good came from that review, in some aspects it's been a missed opportunity, and that's not necessarily anyone's fault. Part of the problem was a worldwide pandemic, but it was an opportunity to put maternity at the top of the agenda and I can't help but feel that it's slipped down again. Chronic staffing shortages have meant that continuity of care the ideal, has been quite difficult to implement and although some units have gone some way towards it, we're not there yet. Why am I mentioning Better Births? Well, the main strap line for Better Births was safe and personalised care, and it's going to be easier to deliver properly personalised care when there's continuity of care and the midwife gets to know the woman and the woman gets to know the midwife, no question. But we are where we are, and so today I'm going to focus a bit on personalised care, some general things to think about, but also how that feels for the obstetrician, the obstetric view, because that's what listeners have been asking for.

Florence: 3:32

As is my habit preparing for the podcast, I've done a bit of reading, so I'm going to start by talking about what is personalised care, because, wouldn't you know, there's an actual definition. I've turned to personalised care and support planning, guidance, guidance for local maternity systems. This was published in 2021. And it gives that little intro about personalised care being central to Better Burst and then incorporated into the NHS long term plan which, in my mind, kind of gobbled up the maternity transformation programme. This gives a definition of universal personalised care People having proactive, personalised conversations which focus on what matters to them and paying attention to their clinical needs as well as their wider health and wellbeing.

Florence: 4:35

I mean it's slightly unbelievable that we actually need a definition of that. That is obviously what we should be doing in healthcare, isn't it? Thinking about when someone has an illness or condition, how important things are to them and what their personal goals are, both clinically and holistically in their life. So it's a no-brainer. Then the document goes on to talk about personalised care and support planning. It talks about holistic initial assessment of women's health and wellbeing needs and the women working hand in hand with her healthcare professionals to complete this assessment. The agreed personalised care and support plan should set out the decisions she makes about the care and support she wants to receive. Then go on to show a little Venn diagram and they talk about personalised care and informed consent and the overlap in the middle being informed decision making. That's interesting because this is all wrapped up in consent and in fact I thought to go with this episode. I would do a specific episode on consent. So far, that's all super dreamy. We have conversations with women and we think about what's important to them and we design the care around them.

Florence: 6:16

So you might ask what's the problem? Well, part of the problem is that we actually work in a massively regulated system. So the woman is thinking that she wants all these choices and these are the things that are important to her and that's super straightforward For the clinician. They're thinking well, that may go against this guidance, that guidance, the other guidance, and as a service we get audited against that guidance and we have to be either compliant with nice guidance or justify why we're not compliant with nice guidance and maybe I'll get told off if I don't follow that guidance. Yes, I know we theoretically work in a no-blame culture but, believe me, that's not how it actually feels all the time. How am I going to marry up what the woman wants and holistically caring for her? Because after all, that is the whole point of the maternity service and I don't want to give you the impression that all guidance is negative and enforcing things. There is guidance with good reason to try and ensure that we're providing the right standard of care to women across the maternity system and we are operating within the constraints not only presented by guidance, but the limits presented by staffing capacity, what drugs we do and don't have available and all sorts of other parameters. So in my mind, I think personalised care comes where we try and marry the two together.

Florence: 8:27

I appreciate it may be relatively easy for me, a consultant who's been in the department for many years, to support women with personalised care plans and requests, but as a more junior member of staff, someone earlier in their career, it can feel very daunting and potentially quite risky, which is why I was thrilled a little while ago to discover a collaboration between the Personalised Care Institute and NHS maternity to design a small maternity teaching module to help maternity clinicians think through what is personalised care and also how to apply it in a clinical situation. When I did the training initially I thought this training isn't really for me. This is my bread and butter, this is what I do day in, day out, have this sort of conversation. But then I realised that actually it was really valuable because Within my maternity service I am one end of a spectrum. I know that many of the women that ask for something a bit outside the norm end up coming to me for that very reason and whilst some of my colleagues also work in this very holistic way, as with many things, there is a spectrum of practice and some clinicians struggle to appreciate and understand why a woman would want to do something different to what they're recommending. It isn't that they don't want to support women, they just come at it with a more risk perspective. But if you're starting out in your maternity career or you're partway through and you're struggling with these conversations, then I highly recommend that e-learning training module to help you think about how you might approach this sort of conversation.

Florence: 11:19

Like I just said, there's a spectrum of practice within maternity professionals. There's also a spectrum of requests and ideas within the women we're caring for. Sometimes it's as simple as I don't want to be induced. At the point you want me to be induced, and that's relatively straightforward and in fact has become so commonplace that we are getting to a point where many of the midwives, supported by a consultant midwife, can have that conversation. You may have listened to some of my episodes on fetal monitoring and intermittent auscultation with Dr Kirsten Small and when one of the key things a woman wants is intermittent auscultation and birth in the birth centre rather than continuous CTG. She's obviously making a very rational and well-informed choice and we're the ones that are giving her advice that is not evidence-based. We can find ourselves in the weird position of saying to her well, I have to tell you that this is the recommendation and this is the national guidance. For these reasons but yes, I agree, the evidence isn't there One of the things I slightly struggle with is we then make a very specific personalized set of birth preferences, a written document for the staff to give staff confidence and know that this has been pre-agreed and discussed, and for the woman so that it's set out what are the implications of the choices she's making.

Florence: 13:28

And whilst that is a good tool in terms of making sure the woman has understood the information you've given her and written information is important in backing up that decision-making when you look at the guidance on how to consent people, it can sometimes feel a little bit defensive. We've had a conversation with her, we've told her the pros and cons, we've given her time to think about it, we've made a plan usually by 36 or 37 weeks, because most of the personalized care we're doing is intrapartum choices and then we're laying it all out for her in black and white, and I do sometimes worry that women find that quite kind of in your face, almost risk averse, defensive medicine. But some of them have said, actually, I found that document really helpful to read through. Therefore, as with everything, it's personalized, isn't it? It's got to be individual and what works for one person doesn't work for another.

Florence: 15:03

Much more difficult, I think, other conversations where a woman wants to do something that really goes against what I think is safe. It's rare but it does happen, and that's difficult because you've got to contain your own emotions, your own opinions and your fear of something going horribly wrong, because she wants to do something that is way beyond the spectrum of practice that you're comfortable with and used to. And often that is about having a series of conversations making that woman feel well supported, exploring the issues with her. And this is where time comes into it, because the earlier you can start having the conversation, the longer you can have to build trust and a relationship with that woman as a midwife or as an obstetrician, and you might find some middle ground. It may be that you work out what are the elements of her preferences that are really, really non-negotiable, most important to her, and what are a bit less so, and then you can adapt things a bit with her and have a series of conversations in which she may modify and change her plans, and it's not that I'm trying to coerce her into changing plans, it's just I'm trying to make sure she's really well informed, and often you can find a middle ground where things become what you feel maybe a bit safer, but which meet her needs.

Florence: 17:07

Sometimes, though, we do support plans and preferences that we think are well beyond our scope of practice, because that's what a woman wants and it is our job to do that. It's her body, it's her birth, she's an autonomous person, and if she's got capacity to make those decisions, those are her decisions, but that can leave us as health professionals in a very uncomfortable place, and that's when the members of the team need support. I work very closely with my consultant midwife, and indeed we have a joint birth options clinic now, because we do have a considerable number of women who want, or need that more bespoke care planning than the sort of slight diversion outside of guidance, the more basic personalized care planning, which is now well within the remit of the continuity of care team leader, with support of the consultant midwife. But for women that want something quite complex or that has more obstetric implications, such as maybe a home VBAC or twins at home or a combination of multiple high risk factors, then we will see a woman together jointly, ideally around 24 weeks, so that the conversation can evolve over time and we'll come to a final decision with her and possibly a series of birth preferences at 36 weeks.

Florence: 19:10

Another key aspect of personalized care is that I've discovered for a lot of women it doesn't necessarily matter what the eventual outcome is, what the eventual birth is like, and that sounds really uncaring and stupid. But actually I've had women who have wanted something and they have known that staff didn't agree and that this was a high risk situation and even though actually they ended up with a very different birth from what they'd expected or hoped for because they had felt completely supported in pregnancy and able to make those decisions and make those decisions in their own time and then, when it came down to it, either in labor or, if their water's not well enough in labor or if their water's broke, be able to step wise, change those decisions to whatever the eventual outcome was they still feel that they've had a really good experience because they've been in control of their birth, whatever that has been, and they've really appreciated that and it's made them feel safe and it's made them feel at peace with whatever the eventual outcome was, because they feel they were taking those decisions and directing their care from the get-go right through to the end. So I think when you see women in clinic that want something that makes you feel uncomfortable or that you find challenging, really try and hear and understand why they're asking for what they're asking for and set aside your own biases and conditioning from the births you've seen the guidance you work under your own cultural background and try and hear and understand why she's asking for these particular things and what's important to her and what are the key elements. And tell her that we're going to explore this and draw in other members of the team that are available, such as your consultant midwife or your PMA professional midwifery advocate or your obstetric consultant, and work through with her, because don't get stuck on her initial ask and how terrifying that might feel to you. Building that relationship, building that trust, may lead her to a very different decision, or it might not. It might be that you do need to support that.

Florence: 22:37

The other aspect of personalised care planning. Which is difficult for us as professionals is when things go wrong because they do, you do get burnt. I have had women that I've supported, some of whom been asking for things that are way beyond my comfort zone, but also some that are asking for things that are well within my comfort zone, and sometimes there is a bad outcome, sometimes it doesn't work out and that leaves you in an extremely vulnerable and difficult place. Obviously, it's far worse for the women that made those decisions and some women come back and say you didn't tell me, you shouldn't have let me. If I'd understood, I wouldn't have made those choices. And then that's really harsh and you have to understand that that's their way of dealing with what's happened to them and their pain and distress needs them to rationalise that and it's really difficult and it's really difficult not to find that that changes your practice and influences the conversations you have with the next person. But it's not always like that when things go wrong. Other times there's been a less good outcome.

Florence: 24:14

I've had women who have rationalised it. Well, I'm glad I've made those choices, because if I'd made other choices I would have blamed that on whatever the outcome was and, as I've said, they feel they were heard, they were listened to, what was important to them was respected and, however distressing and upsetting the outcome may have been, either for mother or baby, they felt that they made the right choices. And I do grapple with this and I do find it difficult, and it's difficult as the obstetrician at one end of the spectrum and in fact had a great meeting across London with some fellow obstetricians that are supporting so-called care outside of guidance or more personalized care, about how we might network together a bit more because there are maybe one or two obstetricians in each unit that are supporting this more personalized care or get to see the women that want something a bit different or a bit more wacky, because staff know that those particular obstetricians may be a bit more amenable to listen and support them. It can leave us as quite vulnerable and with difficult emotions and therefore being able to network and connect with other obstetricians that are doing similar, whether that's in your region or up and down the country, can be really helpful. And in fact one of the contributors to the personalized care institute training is the wonderful Sarah Winfield, my fellow fab obstetrician who is in the North East, and I do grapple with responsibility when women make choices that I find, even for me, push me way outside my comfort zone, and that's where working in partnership with my consultant midwife is really helpful. It means we're both not out on a limb on our own, but equally.

Florence: 26:44

One of the wisest things I heard was from Dr Rachel Reed on the caldron podcast. In one of the episodes about working in the system, she talked about the fact that if a woman, you give her all the information, it's well informed consent If she chooses to jump off a cliff. I know that sounds dramatic, but this is how Dr Rachel Reed described it If she chooses to jump off a cliff, you don't have to jump off the cliff with her. You've given her all the information about what's going to happen when she jumps off the cliff. It's hard to stand and watch her jump off the cliff, but you don't have to jump off too, and that may sound a bit weird out of context. So maybe go and listen to that episode of the midwives call dream, but that's helped me understand that it's my job to try and provide the right information so that the woman can make that personalised decision, but it's not my responsibility. In the same way that I've said, she's autonomous. She can make decisions about her birth. Those are her decisions and she's taking responsibility for those decisions. I think that's pretty much it for this episode.

Florence: 28:12

So what about a zesty bit? Well, if you haven't done the personalised care Institute e-learning, it's a great little resource, doesn't take long maybe an hour or so and it's really valuable in helping you think through personalised care planning. I'm also going to put some other links in the show notes. If you're a pregnant woman listening to this, then absolutely it is your choice what you do, what birth preferences or care during pregnancy because there are personalised preferences there too, which we need to work with, although that's a bit less common. Know that when we're giving you risks and benefits and written information, it really is because we're trying to provide you with the ability to make that informed consent. And when we're suggesting other things, we really are well meaning. We're not meaning to press gang unit doing something you don't want to do. If you're struggling to get on with the midwife that you're seeing, then again you can ask for an appointment with a consultant midwife A lot of units do have them now or a consultant obstetrician, and ask around, find out who local to you, might be a bit more amenable to help making a personalised care plan. That's a bit different, that contains what's important to you, because we're not quite up to speed yet. We're catching up, we're getting there. But if you can't get what you want where you're booked, then there are other routes to explore. And don't feel that it isn't that we don't care. We absolutely do.

Florence: 30:17

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic If you could subscribe, rate and review on whatever platform you find your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Florence: 31:16

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links If you want to get in touch to suggest topics for future episodes. You can find me at the OBS pod on Twitter and Instagram and you can email me at theobspodcom. Finally, it's very important to me to keep the OBS pod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.