I am an NHS obstetrician hoping to share some thoughts and experiences about my working life. Maybe you enjoy call the midwife, perhaps birth fascinates, or you are simply curious about what exactly an obstetrician is? You might be pregnant and preparing for birth right now. Perhaps you work in maternity care and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case TheObsPod is for you. Each episode contains 'the zesty bit' the essence of what I hope you will take away from listening. I do hope you will subscribe and enjoy joining me. Find me on Twitter @FWmaternity & @TheObsPod & explore #MatExp matexp.org.uk to find out more about women and staff working together to improve maternity services. With thanks to Anna Geyer www.newpossibilities.co.uk for my beautiful artwork
You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod please check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
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, 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 Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience. My bea...
Florence
Hello, my name's 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. Episode sixty Overdue. I've already discussed some of what happens when you pass your due date and the baby hasn't arrived in previous episodes, in particular episode twenty-eight dates and episode thirty-five induction. So why am I coming back to it again? Well it's because of a potential change in guidance. NICE, the National Institute of Clinical Excellence, have recently published their draft of the updated induction of labour guidance. Within this, there are many changes, but one of the major shifts is how we care for women at this point in pregnancy. When should we offer induction of labour? Currently the guidance is induction somewhere between forty one and forty-two weeks. However, the new guidance suggests that forty one weeks should be the norm. Does that matter? If there's evidence, surely this is a good thing. What's the problem? The draft guidance argues that this will improve the outcome for babies. And obviously that is very important. But what's the downside? And what do we think about that? And that's what I'm aiming to explore in today's episode. My own first baby was born at forty one weeks and five days. So I'm all too familiar with the personal experience of waiting. When she arrived twelve days overdue, it seemed like it had been an age. But I also know that when my waters broke and contractions didn't particularly get started, I also felt that my body wasn't especially ready for labour. And I know that they wanted to induce me and I didn't especially want to. And I did kind of dawdle my way into hospital. So if I, as a health professional working in a maternity service, with all my knowledge and experience, couldn't say no, then what hope is there for the average pregnant woman to consider her options and do her own thing, know her own mind, know her own body. Let's start with the guidance. Have we come up with the guidance? At this point, looking at the draft, there is a whole separate document on the evidence. So I had a quick look through, and as I've mentioned in some of my previous episodes, I am not the most scientific person. Taking a look at the evidence briefly, I can tell you that some of it is as old as 1975. Most of the studies are from the twentieth century, with a small handful being more recent in 2017, 18 and 19. I can also tell you that the studies are from all over the world. And whilst that might not seem important, it is because actually we're talking about very different medical and midwifery practices depending on where in the world you are. The other thing that you can quickly gauge is well, how many women are in these studies, the so called N number? The smallest study only considers 108 women, and the largest studies had about 3,000 women in each arm. So better powered. But when you consider these small handfuls of women are going to be used to inform practice for many hundreds of thousands of women, it's important that we're sure about the results. To be fair to Nice, they've ranked the evidence in some very helpful tables. They have funnel plots so that you can see exactly where the benefits or risks are. And there are also some great tables that comment on the quality of the evidence and the importance of the evidence. But it is somewhat depressing when you look through to note that many of the studies are defined as being very low or low quality, and very few of the studies are actually high quality. How have we managed to end up with such an important decision and such important guidance being based on really quite poor quality evidence? Surely a very high quality, good study with many many women is what we need. Regardless of the evidence and what we think of it, we have to draw some conclusions. We know that studies are homogeneous in this way, having very different populations, very different practices, and very different numbers. If we become too gold standard, then we would end up with no evidence and no guidance whatsoever, which some might argue might be a good thing, but generally in the medical profession would be thought to be not that helpful. So we have to make some guidance based on our best assessment of the evidence, and if you read the guidance, the draft guidance, it very carefully includes the caveat that following the guidance or not following the guidance is the individual women's choice. So it's not the guidance itself that can be the problem. It's our implementation of the guidance. From my experience as a clinician, I can tell you that all too frequently the guidance becomes the rule. Any woman who doesn't comply and bucks the trend can be seen as selfish or ignorant and being sent to a series of consultations with ever increasing emphasis on the risks, with the increasing use of alarming language aimed at persuading her to give in. I expect this isn't a popular opinion to share, but I like to be honest. And being honest, I can tell you that's what happens. I know this because women come and ask me. How long will you let me go? How long am I allowed to wait? Allow and let. These are not words of a woman who feels that she can make her own choices for her and her baby. When you look at make birth better and their resources for professionals, one of their resources is are you coercing women? And we need to ask ourselves this question. It's difficult to face up to that, but we must. And one of the examples they give of coercion is discussion about induction of labour at term. Regardless of whether one chooses 41 weeks or 42 weeks or even 43 weeks, it's not straightforward. In my mind, I think of it a little bit like a best before date. The risk doesn't suddenly rise with a step change. If you open your fridge and choose something, the best before date, things don't go off overnight. It's not that on the stroke of midnight that cheese has gone off or gone mouldy. When you see something in the fridge that has a date on it that is maybe a few days ago, you will weigh up what you think the risks are. You'll do that by considering what is it? If it's cheese or fruit, what does it look like? You might sniff it, you might taste it, knowing that there's a small chance that it's gone off. It won't be good for you, it might make you unwell. If it's something that you know has a higher risk, like a piece of meat or a piece of fish, you might be more cautious. You know there's a higher chance of bacteria proliferating in that substance. You might be a bit less cavalier. If it's a yogurt, you might think, well, yogurt is actually kind of gone off milk anyway. I'll taste it. You might decide is it fizzy or not? Or if it's milk, you might pour a little bit into a teaspoon. Or take the top off and give it a good sniff. You might taste it and think, it's just about okay, it's on the turn, and decide to drink it anyway. Or you might taste it and think, ugh, that's disgusting, and get rid of it. So when we're talking about going overdue, it's a little bit like that. Some people will have the attitude that whatever the date says, that is the rule. We absolutely can't eat or drink whatever that was, it's gonna be food waste. Not gonna take that risk. There will be other people who will examine the food, look at something, sniff it, taste it, decide they're gonna go with it anyway. It's only a day or two out of date. Looks alright. Let's go for it. Imagine someone turned up now and went through your fridge. They took out of your fridge everything that was overdue. You're not allowed to eat this. I'm not going to let you. It's all got to go in the bin. It's over its date. Well, you wouldn't accept that, would you? You would say, Well, this looks alright. It tastes alright. I'm gonna go with that risk. It's my decision, it's my fridge, it's my food. And you'd be perfectly happy with that, and you wouldn't accept what someone else was telling you to do blindly. I'm hoping that analogy might help. I will often have a conversation with women about the statistical odds of stillbirth, the data that tells me that their pregnancy is or isn't at higher or lower chance of stillbirth. I will discuss with them the options. I may suggest some additional monitoring if they want to wait a long time. I will also discuss with them how ready is their body for labour and offer a vaginal examination because having that knowledge may help sway their decision. If their body is nearly ready, maybe they could wait a bit, it's going to happen spontaneously, or maybe it's going to be easier to be induced and less risk for them, therefore they'll go ahead. But I recognise it's easy for me. I'm a highly experienced senior consultant. I've got a lot of years under my belt, and if I make a mistake, I can justify why I did what I did. And I can be sure that I have given the woman the knowledge and information on which to make her decision. But it's much, much harder for junior obstetric staff or midwives to break the rules, to not follow the guidelines without feeling they're looking over their shoulder and worrying about if something goes wrong, the responsibility sits with them. But we need to remember the responsibility doesn't sit with us. Our responsibility is to give the woman the right information. It's not our responsibility to make the decision. That's hers. We need to make sure we've discussed the pros and cons, but we need to do it in such a way that it doesn't carry our unconscious bias, or even conscious bias for that matter. Now for the zesty bit. I think with this guidance, as with everything, we need to improve the conversation in the implementation and application of guidance. We need to treat women as adults. We need to examine the evidence, understand it ourselves, so that we're not giving confusing and contradictory advice to women. We need to present the woman with that information to help her to make her own informed choice. And I urge you to read the leaflet, which I've put a link to. Am I being coercive? It mentions are there any areas in which you're highly emotionally attached to certain decisions? Are there particular memories from your past experiences that cause you to unduly want to pressure a person into a particular decision? If so, can you think of ways to help you provide information in a more unbiased way? And what communication strategies could you use if you observe a colleague unknowingly trying to put pressure on a person to make a decision? What could you say to them in the moment? And can you act as an advocate for that person? If you're a pregnant woman listening to this, think about your attitude to risk in the rest of your life. Are you someone who enjoys risk taking? Likes the thrill? Or are you very risk averse? Someone who prefers to go with absolute certainty. And then think about your decision. And remember those three questions for decision making. What are the options for me? What are the pros and cons of each option? Do I have enough information on which to make my decision? How do I get support to make the right decision for me? Don't forget for any decision, you can talk it through with family and friends as well as health professionals. You shouldn't be pressured into making a decision on the spot. You should be given time to think about it. Think about what matters to you, what's important. And then and only then make the decision. And it's alright to change a decision. If you make a decision and then actually you go and you feel that wasn't quite the right decision, I'm now worrying about that decision. That's okay too. Go back to the healthcare professionals, ask more questions, let them know. Actually, I'm not sure that was the right decision after all. Can I talk about it again? So ultimately, I don't have any answers for overdue because it's a personal preference. But that person, that personal preference should be that of the pregnant woman, not the professional looking after them. I do hope you've enjoyed listening to this episode of The Obspod. Feel free to contact me on Twitter at FW Maternity or at the Obspod to ask me questions, give me topics for future episodes, or let me know what you think. Absolutely fantastic when you get in touch. I really enjoy reading your comments. Usual I've tried to include in the programme notes some extra reading about this particular topic, both for professionals working in maternity care and for pregnant women using services. I'd like to reassure you that although I'm talking about my experiences working in maternity care, I take confidentiality very seriously and do not give any personal information about any of my patients. If you've enjoyed listening, I'd love you to recommend the Obspod to friends or colleagues, and please do leave me a review on whichever podcast directory you find my episodes. Many thanks for listening.
.jpg)