The role of the consultant obstetrician in midwifery led care

Midwives do not work in a silo but are part of a team to provide the best care to women and birthing people. Recent reports have highlighted poor relationships between members of the team. In contrast in this article Florence Wilcock, consultant obstetrician at Kingston hospital in London, points out important ways she works with the midwives to enable women to receive care in line with Better Births and help facilitate the best experience.

The role of the in midwifery led care.

Hello, my name is Florence.

I am an obstetrician working in NHS maternity services for more than 25years.

As a clinician I have a special interest in improving women’s experience of maternity care. I have been a consultant in London since 2007. At my hospital I am currently the lead obstetrician for Perinatal mental health as well as working with the Birth Options team, homebirth team and Emerald team to support personalised intrapartum care.

As a member of the London Maternity Clinical Network I was responsible for the innovative Maternity ‘Whose Shoes’ co production workshops piloted across London in 2014. As a result, I co-founded #MatExp with Gill Phillips; a grassroots movement of women, families and staff caring for them working together to improve maternity services. I continued to co-chair London Maternity Voices Strategic group supporting co production in maternity services across London 2013-20 and am now a clinical representative on the RCOG women’s network.

The evidence demonstrating the benefit of midwifery care to both mother and baby is compelling. In the UK this is reflected in the current national drive to improve continuity of care and support choice of place of birth in midwifery led settings as a result of Better Births (National Maternity Review 2015). The commitment and focus on the importance of midwifery and improvements in midwifery led care can leave obstetricians feeling somewhat overlooked, unacknowledged and uncelebrated. Certainly, when our local midwifery led unit (MLU) and homebirth rates are applauded our obstetric unit team can feel unappreciated. This is unnecessarily divisive, and a simplistic way of viewing midwifery led care. The Birthplace study that so robustly demonstrated the safety of homebirth talked about the importance of clear referral pathways to obstetric care when something deviates from expected. Every midwifery led pregnancy and birth happens within the context of obstetric provision being available in the background. Likewise, the success of continuity of care, and birth in midwifery led settings rely on a broader network of maternity professionals.

 

So where do I fit in this midwifery model in my role as a consultant obstetrician? I would argue doing less is more; what we do as obstetricians in the antenatal period can make a big difference. The outcomes many obstetricians are concerned to avoid, such as severe perineal trauma and post-partum haemorrhage, will be reduced if we can improve the uptake of midwifery led care. We need to promote midwifery led care where appropriate and have a responsibility to encourage & normalise birth in non-obstetric settings. The default idea of birth in a hospital obstetric unit being safest and homebirth being risky needs challenging by obstetricians as much as, if not more so, than by midwives. The less we interfere with the continuity of care relationship in the antenatal period, the more we can build trust in the woman’s midwife, the more likely the woman is to achieve the good outcome of both physical and psychological safety. In this way whilst obstetricians may not be in forefront of a woman’s care, we are far from obsolete, still an essential component of midwifery led care.

 

How can we facilitate this midwifery led care & not disrupt it? I feel the clue is in the name consultant: The definition of a consultant is “a person who provides expert advice professionally”. This is how a midwife needs to use the consultant obstetrician, by consulting them & the obstetrician providing advice. This leaves the midwife as the key healthcare professional for the care of that woman drawing in obstetric expertise when the situation requires. In practice this can work in several ways. In my role I am link consultant for several midwifery teams; perinatal mental health, homebirth and Emerald (birth after caesarean) teams. Having a specific link consultant obstetrician in this way means midwives from the team can email me for advice or support on a specific issue or give me information on a situation in advance of an appointment. This way of working means I can minimise disruption to the continuity of care pathway by giving the midwife instructions on blood tests to take or helping interpret results so that the midwife can modify care without the woman having an appointment in my clinic.  Some women will obviously need to be seen by me and a small synopsis of the key important points the woman and the midwife wish me to consider can be very helpful, giving me context and enabling me to put a woman immediately at ease by telling them the midwife has been in touch about them. Equally if the midwives can build the woman’s confidence in the link obstetrician ahead of time this results in the woman coming to an appointment more at ease and trusting that she will be given good information and her choices respected. Her midwife has told her about me (the consultant) in advance and reassured her that I will listen, that I will be prepared to think about her as an individual & support personalised care rather than through blanket application of guidance.  The number of women I see who come prepared to ‘do battle’ feeling they need to advocate and fight for their choices is therefore reduced, the trip to consultant clinic become less daunting.

 

 

As obstetricians there can be a temptation to gather women. Once we have seen a woman in our clinic it is all too easy to give her a follow up appointment and more junior members of the team may be more likely to do this as they are less confident & more risk adverse. If a woman is triaged to attend the obstetric clinic at 16 weeks working in partnership with specific midwives also means I can send a woman back to midwifery led care with confidence. Seeing women repeatedly in obstetric clinic can result in more intervention, perhaps things that at face value may seem harmless such as an extra scan can steadily result in medicalisation. Minor factors such as glycosuria or a slightly borderline blood pressure can lead to a woman being labelled as ‘high risk’ and removing choices derailing midwifery led care. In the situation where obstetric review is required, I can work in partnership with the named midwife or consultant midwife co ordinating appointments so that we don’t unnecessarily duplicate but instead share the care. For women who don’t quite fit into the criteria for midwifery led care but who want it we can take practical steps to mitigate risk and help plan ahead; for example, sometimes I prescribe additional medication on a case by case basis for women with a higher chance of post-partum haemorrhage who wish to birth at home.

 

Modern technology such as email and electronic record systems can be used to enable communication. The midwife can clearly see my recommendations and advice, as well as planned appointments on our computer system. This means the women feel that their care is co-ordinated, all members of the team are fully briefed and know how we plan to support her whatever the eventuality. Building trust between members of the team, establishing a relationship between midwife and obstetrician as well as between the midwife and the woman mean that on those occasions when midwifery led care simply is not the best option the team can give consistent advice and support and work on alternative choices.

 

Working in this way inevitably brings its rewards. On an individual basis its lovely to receive feedback that someone has had the birth they wished for. On the occasions when things don’t work out quite as planned, women are less traumatised, having thought through and prepared in advance for a range of options and often comment on this during the post-natal period. As our homebirth rate has climbed and continuity of care rates improve, I can celebrate knowing I have contributed in my small way. As we continue to champion continuity of care, we obstetricians need to adapt and support our midwifery colleagues in a new way. Similarly, the relationship needs to be reciprocal, midwives, need to build relationships with their obstetric colleagues and ensure they are not getting left behind but remain an integral and important part of midwifery teams and maternity care.

 

TheObsPod

I started my podcast TheObsPod to try and demystify obstetrics and help both maternity staff and families going through maternity care understand a bit more about the role of the obstetrician, how we train and why people may be asked to see us during pregnancy or birth. My podcast also suits anyone with curiosity about maternity and birth as well as students thinking about midwifery or medicine as a career. Since I started in March 2020 I have recorded over 90 episodes with a wide range of subjects from clinical topics to stories about my working life. If you have enjoyed reading my blog please do take a look at my websites or wherever you find your podcasts.

The Obs Pod (padlet.com)

The Obs Pod (buzzsprout.com)

 

Florence Wilcock

March 2022

 

This article was provided by Florence Wilcock, Consultant Obstetrician, Lead Obstetrician for PNMH, Kingston Hopsital NHS Foundation Trust. Follow Florence on twitter at @FWmaternity and @TheObsPod and follow the podcast and many other resources here.