Maternity matters

It's almost Babs' first birthday. It's played on my mind for months that I never got round to writing to the head of midwifery and the director of maternity services where I gave birth, to feed back on my experiences. I don't want to complain; really, I just want to let them know what happened, where there were failings, and where some of their development activity should focus. Everyone whose birth stories I have heard in the last year have included aspects which disappointed them - apart from the women who were able to give birth at home. Now, possibly this is because the home births, by definition, required the least intervention - were the most 'natural' - but it is not intervention per se that causes dissatisfaction (disappointment, maybe, but that's a very different thing). Dissatisfaction comes from the way we are spoken to, consulted (or not), treated, and the mis-match between expectation and experience. Sometimes this mis-match is due to the degree of intervention: I think it's reasonable for decisions to be taken without laborious explanation and formal consent when the degree of risk requires fast, decisive action. Hence I have little sympathy for the indignance of my contemporary who was not consented for an episiotomy when the baby clearly needed to be delivered as quickly as possible - but this post hoc indignance could have been mitigated by some sensitive and informative explanation following the events.

Partly, the problem could be attributed to the 'empowerment' of women by encouraging them to write a birth plan, without fully preparing them for the deviations from normality that could indicate wide deviation from this list of hopes for their care. Our antenatal community midwife ran through the ways some of my points might not work out, and encouraged us to think flexibly; she tried to impress on us that things might not go smoothly, and so, for example my desire for no epidural might not be realistic. I could accept this; but I (unlike so many others) was able to think flexibly because I was well prepared for many of the possible deviations from normality because of the work I do. For several years, I have worked with midwives and doctors and have become well acquainted with the work of the delivery suite, the language of maternity, the roles and responsibilities of the different professions and the ways that even initially straightforward labours and deliveries can be complicated. But for this experience, my understanding would have been patchy. Were it left entirely to the PCT (the primary care trust, which organises and delivers primary care in an area approximate to the borough) and the antenatal classes they provided, it would have been woefully limited.

The PCT provided a 4 week programme of antenatal classes. The first, 'normal labour' was reasonably useful and complete. The second 'deviation from normality', given by a different midwife, was appallingly inadequate. The scheduled 2 hour session lasted barely an hour. Deviation from normality covered precisely one possibility - the need for induction of labour. And even this did little to explain what might occur, and over what timescale. (Only when my induction was booked when I was >40 weeks was I told I would need to attend the night before.)

Anyway, this lengthy preamble is to introduce the letter I have finally, belatedly, hopefully sent to the hospital I gave birth in. I have so far only sent it to the PALS (patient advice and liaison service) team, because there was no address for the head of midwifery or the director of maternity. Because of the way maternity care is structured and funded, I should also send it to the PCT maternity lead. I would seriously urge others to feed back their experiences - importantly, good and bad - to the people who organised and delivered their care. In the climate of chronic underfunding, poor staffing and competing priorities, it's important to lobby - hard - for attention here.

Dear ...

I gave birth at [hospital] in March 2008 after a transfer from home, and though my experience was reasonable, there are several points on which I think Maternity Services requires feedback.

I had two brilliant community midwives overnight, and they persuaded me by the early morning that due to my slow progress, it would probably be best to transfer to hospital for syntocinon to speed things up and an epidural for a bit of a rest. My labour had been long and slow and I totally saw the logic in reserving energy for pushing (ie, intervention now might save intervention later).

I transferred in by ambulance at about 6am, and my care (after a while, possibly via the labour ward co-ordinator) was handed over to Midwife1. Midwife1barely acknowledged us when she took the handover, and this lack of eye contact and engagement with myself and my partner set the tone of the care she offered and the experience we had with her.

A cannula was put into the back of my left hand reasonably quickly and I was kept supine with the CTG - something the community midwives had tried to avoid when we arrived: they had put me on the CTG but standing up, to try and keep things moving. Mariam barely talked to me about what she was doing, never told me why things were necessary. I was not treated as a partner in my care. I was the object of a course of treatment/action.

Given that we arrived at around 6.30 or 7am, I was surprised when, at about 11am, Mariam started doing something with the drip. I asked her what she was doing and was told she was putting the syntocinon in. I couldn't believe this was only happening now, hours after we arrived. No explanation was given, so I don't know whether this represented a delay or whether this time lag was normal. It would have helped considerably if she had talked to us when we arrived about what needed doing in what order and how long the process might take. Given that I was transferred to speed things up, this felt like an incredibly long time for things to be taking.

At one point, without warning, while I was talkling to my partner on my right, Midwife1 picked up my left hand, and did something which sent a fierce, shooting pain into my hand and up my arm. I was alarmed, and asked what on earth she was doing. She told me she had had to flush the line; end of story. No further explanation was given of what this meant or why it was indicated. But more shocking than the pain was that she did it without gaining my attention first, let alone my permission.

Later, when I started to shake, I worked out that I hadn't eaten since 8pm the previous evening, and thought it could be low blood sugar. I knew (through common sense, not from Midwife1) that because of the chance of going to theatre, I could not eat, and framing it thus, I explained I was hungry and asked if there was any glucose in the drip. She told me I couldn't eat, so I explained that I understood this, but that I was concerned about my energy etc, and again asked if there was glucose in the drip. She told me she didn't know. This in itself is slightly concerning - the qualified midwife doesn't know what's in her client's drip - and she read the bag to see. It was Hartmann's solution, and I now know what that means. My concern is that, again, no explanation was given when the drip went up of what it was or what it was for. Midwife1 couldn't engage with me further about my hunger; I tried to tell her I was shaking and I hadn't eaten; she told me it was labour. I sent my partner out to ask for the co-ordinator, and she came and also told me it was labour. Nothing was done to address the issue that it was now more than 12 hours since I had eaten. (I have since found out that shaking in labour is not unusual, but neither the midwife of the co-ordinator explained this to me satisfactorily).

After this series of events, I was so fed up I asked my partner to ask the co-ordinator for a new midwife. Midwife1 was sent for lunch and reassigned on her return. As she left she engaged with us for the first time in the way I would have expected a midwife to behave all along, telling us she hoped to be back to see the birth. Fortunately the next midwife was brilliant; engaged, supportive, discursive, informative and friendly. Everything the previous midwife wasn't.

I realise it's almost a year, and Midwife1 may not even be working at the hospital any longer, but my complaint is not about her per se; I really just want to highlight, with concrete examples, how the service can be disappointing. Clearly this midwife needs some direct performance management; her communication skills and professionalism were lacking. I was lucky - empowered because I am articulate, knowledgeable, and undaunted about challenging poor practice. Not all the women in the catchment area would be able to challenge this, and without complaints poor practice is able to continue.

My experiences with the post-natal midwives and the limitations of their breastfeeding support (my baby could not latch on) were also disappointing. I requested the support of the breastfeeding leader, which was documented in my notes, but I never saw her; I was discharged with no further mention of it, and unclear about what or how much to feed my baby. I think it was just assumed that she would eventually latch on or that in my sleep-deprived and hormone-addled state i would be able to figure out formula feeding - even though I had made it clear I wanted to breastfeed and the PCT breastfeeding talk had discussed nipple confusion, so I was (and told them I was) adamantly against bottles. I was desperately confused on discharge, and though I made extensive use of the breastfeeding network in the few days postnatally, I had no formal support, my baby absolutely could not latch on, and she undoubtedly suffered because we were discharged home at 4pm with no idea how we were going to feed her, or how much and how often she needed to be fed.

I hope that these comments will be of use to the service. This is absolutely not about pointing the finger at particular members of staff, just about highlighting areas for development. I understand that there are competing priorities for training, x days mandatory training have to be undertaken, the service is short-staffed, making backfill difficult, etc; but there is clearly a need for training on breastfeeding support, and making sure that no woman leaves the service as I did, with no way of breastfeeding and no resources for expressing (no one showed me how or even mentioned it) or feeding by other means (eg syringe).

Yours faithfully,