Dear Mr Anaesthetist

On Wednesday night I made a new friend on twitter. Whilst broadcasting both of our, rather different, thoughts on the Channel 4 documentary One Born Every Minute, an anaesthetist and I collided across our respective wi-fi’s. You can read our discussion here (look out for @welsh_gas_doc).

I’ve had similar conversations before in the real world. They generally start off a bit less confrontational when you are face-to-face, but I’ve had to count to ten more than once to prevent myself from exploding with rage at medical professionals in my social circle when discussing issues around childbirth, safety and pain.

Here on the internet I feel less inhibited, but twitter’s 140 characters don’t lend themselves to reasoned argument. So, @welsh_gas_doc, here’s my open letter to you. Consider this cc’d to several of your twitter colleagues and a few of my own acquaintances. I’d love you to read it all the way through.

 

Dear Mr Anaesthetist,

as we established the other night you probably weren’t looking for a reasoned debate when you introduced yourself to me. I get it. Your twitter stream was pretty funny and the ‘lentil weaving banshee bashing’ that you hoped to engage in would indeed have made it funnier. Full credit to you for dropping that plan swiftly and realising that we aren’t so poles apart in our aspirations if not our methods.

Yet the catch-all unifying slogan of  ‘it’s all about informed maternal choice so we’re on the same side really’ doesn’t really get to the heart of how I feel when I read your comments and listen to the face-to-face conversations I’ve had with others in your profession. So I’m writing you this letter in the hopes I can explain myself properly and give you some insight in to my world.

First I’d like to tell you how grateful I am that:

– you and your profession exist. Without you there would be no life-saving caesarean sections, no relief for mothers at the end of their tethers, no respite for someone during a long induction of labour, no chance to sleep and rest and recuperate.

– so many of you that I encounter professionally are gentle, calming, kind and go to great lengths to treat mothers as individuals.

– you often subtly reinforce the message that choosing pain relief isn’t failure and can be a positive choice for a woman and her baby.

– you almost always let me stay in the room while you put in an epidural, recognising the support I can give not only to the mother but her (often frightened or squeamish) partner and the help I can be to you as a trusted and well-known voice who knows the ropes.

– you sometimes let me come in to theatre if a change of plan becomes necessary, presumably knowing that it is at this time that my support is often at its most valuable.

But I’d also like you to try and understand that:

– when we meet mid-labour we are at very different points in our journey with this woman. I will have been getting to know her, earning her trust, hearing her deepest fears and hopes, laughing and crying with her often since the first trimester of her pregnancy. I will have been with her for hours, sometimes days throughout her labour. I know this woman, I care deeply about this woman and I am emotionally invested in her.

– my job is not to obstruct you, it’s not to spout propaganda, it’s not to laminate a birth plan that states that pain relief is for unwomanly wimps, it’s not to wave mystic crystals and scents and it certainly isn’t to question the judgement of highly qualified medical professionals.

– maybe you don’t know much about what I do?

So, let me try and summarise for you that as a doula I:

– never advise my clients, only signpost them to resources, remind them they have choices and encourage them to ask questions. So that they never look back and say ‘I don’t really know how that happened’ or ‘why was that done to me?’

– am frequently the only ‘continuity’ person involved in this woman’s pregnancy and birth.

– do most of my work before the birth building a strong relationship, getting to know the woman and her partner, understanding what she wants and needs, encouraging her to think through her fears and hopes, building confidence in her body.

– may have worked with her on dealing with a previous traumatic birth or helped her come up with a plan to handle the impact previous sexual abuse or a phobia may have on her labour.

– have no agenda other than supporting a woman to have the most positive pregnancy, birth and postnatal period that she can. If what she needs is an early epidural, let’s see how we can make that happen. If she needs a home water birth after a previous caesarean let’s put her in touch with the Supervisor of Midwives and see what we can get agreed.

– will be supporting this woman for weeks, sometimes months after she has the baby. Providing a listening ear, feeding support, signposting her to resources, helping her process the birth – particularly if it didn’t go to plan. I will know in no uncertain terms how she felt about her care, what helped, what made her feel strong and what made her feel weak, what she regrets and what makes her proud, what helps her set off on her journey in to motherhood and what hangs like a millstone around her neck. I will know this and I will take this knowledge through to future births.

Because I try to tune in to others as part of my job, I’ve thought about the fact that we have such different experiences of birth:

– I’d guess you only (or almost only) see women at a point in their labour where they can’t manage the pain. The only thing that helps is what you can provide. You watch someone who is sometimes screaming in pain gradually relax and finally sleep peacefully. All is well again. I understand why you’d want all women to have access to this.

– I, more often, see women who never get to that point. They aren’t ‘enduring pain’ or being brave, or following an ideal to the letter because of their principles or ill-informed antenatal teachers. They are simply ok. Sometimes (like with my labour) it just isn’t really painful. I chose my positions, was well supported, it wasn’t too long, I used water, I felt relaxed, my body did its thing and you couldn’t have paid me to have sat still and had a catheter inserted in to my epidural space. I’m a wimp, terrified of needles, it would have been awful. Sometimes it’s tougher, women need lots more coping strategies, especially when they get tired. And yet for a myriad of well-thought out reasons and in the moment instincts they don’t want pain relief when it is offered and are glad afterwards that they didn’t.

– I see birth in many different settings: home, hospital, birth centre. I know the difference that a home environment makes to women’s perceptions of labour as painful. I imagine that while you’ve experienced many more labouring women that me you have only encountered them in an obstetric setting.

– I also see the difference that home can make to the management of a woman’s labour with time and space for a woman to progress in the way her body sees fit, rather than the way hospital protocol dictates. NHS homebirth midwives often agree that –  even though a mother and baby never showed any signs of distress –  the homebirth with no interventions, no tears, no episiotomy that we just witnessed would have been an augmentation of labour with all the additional stress that brings in a hospital setting.

– I see birth as a year-long journey. I get involved in the planning, the anticipation, the birth from first twinge to delivery of the placenta and the beginnings of new parenthood. I imagine you see women mainly during the first stage of labour and rarely during pregnancy or much beyond the birth.

And because of that we’ve formed different opinions around the same event. I believe firmly that:

– unmedicated birth is something to strive to protect. Not for everyone is it safe, appropriate or desired and that is fine. But in the context of our maternity services where statistics show it is getting harder to achieve, there need to be people committed to keeping women informed about the benefits of normal birth. All the while ensuring they respected a woman’s right to choose and never to be made to feel guilty about her decisions.

– there are benefits to normal birth. Like everything birth-related there are risks and benefits which must be weighed up in relation to a the individual mother and baby, but benefits there are. While you are keen to assert that the causal link between epidurals and intervention isn’t proven the strong statistical association between the two can’t be denied. For a woman who doesn’t want intervention there is a strong motivation to avoid an epidural. And interventions increase the various risks for mother and baby – the aftermath of a forceps delivery on a woman’s perineum, bladder, pelvic floor, mental health (not to mention physical trauma to the baby) spring swiftly to mind.

– there are plenty of (albeit not enough) studies which demonstrate the relationship between a more medicalised birth (especially opiate analgesia) and breastfeeding issues. So women who want to breastfeed and to experience the profound  health benefits to themselves and their babies that this confers also have a motivation to avoid a medicalised birth.

– normal birth, without anaesthesia or analgesics, is more often achievable if a woman has the kind of continuous support during labour that I provide. This support doesn’t seek to ensure women don’t use pain relief but makes it possible for them to have a positive experience without it should they want to. The support of a doula (or of another person not associated with the hospital or a member of the woman’s social or family circle) has been shown to not only decrease the need for pain relief, but improve maternal satisfaction, improve baby’s APGARs and decrease the risk of interventions like forceps or caesarean sections. You can read more about the Cochrane review I’m refering to here.

To be 100% clear about this I do want you to imprint on your mind that this very large review of studies concluded that the group of women who had this kind of labour support had less pain relief and were happier with their experiences.

So it does make me angry when you say things like:

– “homebirths are unnecessarily dangerous”

– “Nothing makes my heart sink more than the presence of a laminated birth plan and a doula in the room!”

Because those kind of blanket statements (seemingly born only from personal experience, opinion, agenda and a willful disregard for some very concrete evidence to the contrary as well as a lack of understanding of what is outside your sphere of comfort and knowledge) cause exactly the kind of problems, issues and divides that you bemoan.

Medical professionals, especially those who work in a field connected with childbirth, should be careful about expressing such negative and divisive opinions about choices. People listen to you, they take your advice, they believe you therefore you have to accept some responsibility when it comes to your publicly shared views on these choices. Especially choices like homebirth which have just been demonstrated to be safe and lower the risk of an unwanted intervention by over 30%. Especially choices like having a doula which further lower that intervention rate and improve maternal satisfaction (whether the birth goes to plan or takes a different turn). Especially when someone feels so fearful that her medical caregivers will disregard her wishes that she goes as far as laminating her birth plan.

And while maybe I was a little faecitious with my use of the word ‘friend’ at the start of this piece, I’d actually like to build bridges between our different thoughts and opinions. Because I do agree that women are unkind to women and can often be viscious about different parenting and birthing choices to those they made themselves. I concur wholeheartedly that a woman should never suffer something she can’t bear or doesn’t want to bear in childbirth. A woman should never be deprived of something she needs, or made to feel like a failure for changing her mind and taking a different option.

I’d just like you to look through my eyes and the eyes of a woman I’m supporting and ask yourself not ‘how can I save her from enduring this pain’ but ‘how can I help her make a positive, informed choice so that she is never enduring anything but simply making a series of her own good decisions that she can look back on and be proud of – whatever they are.’

With respect,

Rebecca



Comments
19 Responses to “Dear Mr Anaesthetist”
  1. gem says:

    THat was beautifully written, and uplifting, for me anyway. I had an epidural and I’m often torn about if I’m ok with that choice or not, the whole ‘well I probably could have done better’ etc (especially after whating OBEM – and seeing someone birth twins naturaly!)

    BUT after reading this, I will do my best notto feel bad, I had a negative mind set/support from my child father through out and I know this is largly to blame how ever I dod struggle to acept it. But reading this I feel, its ok and that I need. I also KNOW that ‘next time’ it will be possible to stick to my BP (and I don’t care I’m so laminating-never though of that!)

    You response is precise is the support of the mother and amazing from the point of view of someone still contemplating the choices three years on.

    Thank you x

  2. Pet says:

    An insightful letter. I was with you right up until you used the phrase ‘normal birth’.

    Please PLEASE I beg of you and every other maternity-related professional to stop using this phrase. Replace it with ‘natural birth’. Or ‘vaginal birth’. Hell, even say ‘pushing 8lbs of flesh out your fanjo’. But for the many women who feel a failure following an EMCS, the word ‘normal’ only serves to compound the problem by making us feel ABnormal.

    /end rant 🙂

  3. That is a great blog Rebecca. Well done!

    Whenever i find someone like your Mr Welsh doc guy, i always email them this fantastic article. For me, it says it all.

    http://www.pregnancy.com.au/birth-choices/homebirth/out-of-the-laboratory-back-to-the-darkened-room.shtml

    Best Wishes
    Sallyann

  4. welsh_gas_doc says:

    Hi,

    Thank you for an interesting, well written and thought provoking blog-post. I rarely reply to blogs, but will make an exception here.

    Firstly, just in-case it wasn’t clear, I wasn’t ‘trolling’ with my comments during #OneBorn or hoping to wind people up for no reason.

    I think a programme with an associated hashtag is the perfect conduit for this sort of discussion between two groups of people who may not ever speak. I tend to find that taking a polemic stance (as I often do) will (a) Save characters on Twitter, and (b) Is a good way to kick off discussion.

    The specific Tweets of mine that you reference:

    “Home births are unnecessarily dangerous”

    I accept that I, as an anaesthetist, only see the home births that have gone wrong, and I know that this may cloud my judgement, and make me see things through one end of the telescope. I accept that the absolute risk for all births is low, but the relative risk for a home birth is higher than a hospital birth. I think geographical factors are important too – I assume you are based in Hackney, with good networks and support nearby in case the worst happens. This is not the case in more rural areas. To state the obvious, you can’t anticipate the unanticipated haemorrhage, shoulder dystocia, cord prolapse.

    “Nothing makes my heart-sink more than the presence of a laminated birth plan and a doula”

    This was *not* meant to be a slur on your profession, or to mock the idea of birth plans. It really wasn’t. My point here was that it is likely to mean that a mother will have high expectations of what is going to happen – but the very fact that I, as an anaesthetist, have even entered the room means that the mother may be disappointed with the overall birthing experience, and the plan may have to be changed. Changed dramatically sometimes. Sorry if people were offended by this, it was not the point I was trying to make, but understand how it has been misinterpreted.

    The point of consent and information is an important one. It is imperative that women enter the birthing process in full possession of the facts, for them to make their own minds up. Good ante-natal counselling will allow this, but it is not infrequent that I hear of misinformation or scare stories. I know of one ANC where the session on epidurals just consisted of the midwife passing a Tuohy Needle round the class and telling people it could paralyse them. I think we’d all agree, that this is not the ideal message to be pushing.

    I think we are both in agreement that maternal choice is important, as is informed consent, militancy on either side – and the way that some mothers may feel like failures for requiring analgesia – is unhelpful. Good support to the mother from Doulas, midwives, obstetricians and anaesthetists is helpful. We all have something to bring to the party, and hopefully we can work together, rather than against each other, to meet that end.

    With best wishes,

    WGD

    • Mars Lord says:

      Good response WGD. Thank you.

      As a Doula myself, my ladies don’t go in with high expectation, but they do go in trusting their bodies. Should you (and by you I mean any from your profession) enter the room, the disappointment is normally already dealt with (hopefully) and when we work together, as you say, then all is good.

      So if you are one of the ones who smiles at the birthing mum and doesn’t throw out the “bet you’re glad I’m here, no need in this day and age…”, I salute you and I thank you.

      Mars

    • Rebecca says:

      Thanks WGD – really useful to hear your thoughts.

    • Rowena says:

      WGD,

      Thank you for the interesting response to Rebecca’s blog. I’d just like to respond to a couple of things:

      I was a client of Rebecca’s for my second labour (which was a home birth) and my birth plan was pretty comprehensive. I felt that I was treated dismissively and rudely at a number of points during my first labour (in a CLU). In particular I was scared stiff by an anaesthetist who started having a conversation behind my curled up back with the midwife about a scoliosis (a term I didn’t then understand) as blood spouted from my back. She didn’t explain anything until I managed to gasp out a question to my husband. My birth plan basically amounted to – “treat me nicely, and with respect. Please believe me when I say I have issues with certain things because of how I was treated last time. I would prefer not to have interventions, but if I need them please explain what is happening and why”.

      I do understand that you were not trying to mock birth plans, but it may also be worth bearing in mind that the woman with the three page, laminated plan (mine was actually 1.5 and not laminated…) and a doula may have had a terrifying experience in a past labour and that plan may be her way of trying to convey that fear and her very real need for involvement and control (not in how labour goes, but in how she is treated). It can be a sign of low expectations rather than high ones.

      Rebecca’s point about the benefit of continuity from a doula is absolutely why we chose to hire her. In hospital, in pain, disorientated (and, in my case, 48 hours since I had last slept), the benefit of a familiar, supportive and trusted face from someone who also had a degree of professional detachment would have been invaluable. I totally agree that all those involved in birth have something to contribute, and I would personally hope that if you ever needed to visit me for an epidural, I would be a calmer, more relaxed and happier patient for having a doula with me. Which can only make your job easier.

      I totally agree with your comments about stigmatising women for their type of birth. No woman who goes through the birth of child (whether in a pool with dimmed lights, in an elective section or anything else in between) should be made to feel she has failed. Every experience is different.

  5. Mars Lord says:

    Well said Rebecca. Recently watched a fabulous anaesthetist take time to talk my lady through her fears about a spinal block. She was about to have a second section and the anaesthetist didn’t believe her during the first one when she said that she could feel everything. She had a traumatic GA crash section. This anaesthetist really reassured her and it was a healing second section.

    Anyway… well said!

    Mars xx

  6. Grace says:

    Brilliant! So great to see these thoughts expressed clearly, and really happy to see a response too. 🙂

    Rebecca said: “I concur wholeheartedly that a woman should never suffer something she can’t bear or doesn’t want to bear in childbirth.”
    I would just like to add to that that epidurals aren’t particularly wonderful to bear. Getting it sited can be painful and scary. The recovery from mine was unpleasant and painful, even though I suffered none of the side-effects that many women do, and the impact on getting breastfeeding started caused a huge amount of distress to every member of the family. Pain relief isn’t all physiologically positive, which is something that can be forgotten when only its immediate effects are seen.

    The anaesthetist was one of the most respectful, calming people present at my son’s birth. But the birth was very traumatic, and next time I would be glad of the presence of a doula, and hopeful that hospital staff would maintain a science-based approach (rather than a culturally or personally biased one) and high standards of respect and courtesy when interacting with her and me, should we need to go to hospital again.

    • Rebecca says:

      Glad you had a calming anaesthetist but sorry to hear that the recovery from your epidural wasn’t great – really interesting to hear your thoughts. Thank you!

  7. Sheena says:

    Dear Rebecca,
    This is one of the best blogs I have ever read. I have been a midwife for more than 35 years, and I knew birth before epidurals….and obstetric anaesthetists. Your words are articulate, well balanced, sensitive and correct, in my opinion.

    Just a few points for you and @welsh_gas_doc to consider:

    – As a consultant midwife I worked closely for many years with women who endured traumatic birth, and 98% of them had an epidural. None were aware (even though they had received oral and written information) of the consequences of some of the side effects, i.e. increased intervention and a feeling of loss of control. It was the control issue that caused the trauma in MOST cases, and the perception (most important) that the baby had been extracted, not born. As you say, we are grateful for epidurals; some of my children have needed one. But they are used far too frequently, and information sharing is not adequate and realistic.

    -Giving well-balanced evidence based information isn’t a reality in other areas too, and is reflected in your comment @welsh_gas_doc. Relative risk is NOT increased with home birth. It’s a different ‘risk’. However, I don’t know any midwives or medics who inform women of the risks of hospital birth…that is, increased unnecessary intervention that enhances the risk of iatrogenic damage to mother and baby. Doctors may have a distorted view of home births because they see only those that ‘go wrong’, but jeese…they see SO MANY emergencies in hospital when the woman has no actual or expected complications.

    -I have to say the use of the word ‘normal birth’ shouldn’t evoke feelings of guilt or sadness….whatever word we use represents a fact…my daughter recently had an emergency C/S and we talk about the fact that it was a ‘positive birth’, which is the ultimate aim, surely?

    – When one profession criticises (meant or implied) the other it is so destructive, and women and families are the ones that potentially suffer. Working together, respecting roles and differences is the only way towards ensuring positive birth for all, with an ultimate aim to normalise birth (that word is important!) and reduce unnecessary interference.

    – I haven’t read all of your debate on the current hideous TV programmes showing the activities in birth rooms, but I am totally saddened by their contribution to women’s fear of the childbirth process. More could be said at this point.

    Keep up the dialogue! It is so useful and will hopefully influence the much needed change.

    Thanks Rebecca again for this blog…I am now going to share and use.

    Sheena 🙂

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