When childbirth goes badly wrong: one woman’s account

Nilufer Atik has written a striking account of her experience of PTSD after childbirth. Atik was in labour for 53 hours, after which she was given an emergency caesarean.

But it shouldn’t have happened like that. Atik’s labour started with contractions that were “sharp and hard, beginning four minutes apart and lasting between 50 to 90 seconds each time.” The hospital – St George’s in Tooting – told her not to come in because she wasn’t in active labour. She stayed at home in increasing pain for 19 hours until eventually she could stand it no longer. At hospital:

“I was taken to a pre-delivery bay and more torturous hours passed with the contractions increasing in intensity and frequency. I cried out for pain relief and was given the powerful painkiller pethidine four times (most women are only allowed two injections) but it did little to help. With no sleep, food or water, and feeling so exhausted I could barely speak, I became fearful that, if the baby did come, I wouldn’t have the energy to push him out.”

She was eventually given an epidural, followed by a caesarean section when the baby appeared in distress. But the most remarkable part of her story is this:

“Poor Milo was in a bad birthing position with his back against mine and his head hyperextended. It meant not only that my labour was much more painful than it should have been, but I would never have been able to deliver him vaginally. His head was blocking my cervix from dilating, which was why I was having contractions for so long with no progress.”

The time that Atik spent in labour was wasted – physiologically, she wasn’t able to give birth. Why staff at St George’s didn’t realise this is an interesting question, but it may have been to do with the fact that when Atik arrived at the hospital in labour, the maternity ward was extremely busy.

Two weeks ago an NCT survey found that, in the Guardian’s words, “A chronic shortage of midwives across the UK means women in labour are left feeling unsafe and frightened or as if they are being treated ‘like cattle’ or ‘on a conveyor belt’.” It’s not just lack of midwives, it’s a lack of space: one woman even described giving birth on the antenatal ward, because there was no room on the delivery ward.

It’s been said so often that NHS services are at breaking point that perhaps nobody takes it seriously any more. But cases like Atik’s show that the seriousness and the urgency of the problem. When midwives are overworked, the quality of care for women is never going to be good enough. Women will suffer unnecessarily, as Atik did, and may as a result experience physical trauma or psychological trauma that will need treatment later on. Sometimes, babies will die.

 

 

Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post in response to a comment.

A traumatic vaginal birth involving severe tearing can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Hans Peter Dietz and Liz Skinner.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter.

Dietz and Skinner have done a lot of work in this area, which I’ve written about before. They both feel that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

  • 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
  • 36 said that there was no postnatal assessment of their injuries
  • 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems. And that may lead to an unjustified confidence that obstetric tearing isn’t a significant problem.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.

At last: the NHS acts on maternal mental health

Good news: in the next five years, NHS England will create 20 new specialist treatment centres for women who suffer from mental health problems during pregnancy or after birth.

This has been a long time coming. For years the government has promised to address the poor quality of mental health care for new mothers, and finally it’s putting its money where its mouth is. Admittedly it’s not very much money – the centres will be funded to the tune of £40m, which is unlikely to cope with the scale of the problem: an estimated one in five new mothers (about 120,000 women a year) experience mental health problems.

The majority of these women suffer from postnatal depression, but a substantial minority will have post-traumatic stress disorder (PTSD). The most conservative estimate for PTSD after childbirth is 1.5% (about 10,000 women a year in England and Wales), but researchers now think that the true figure is probably double that. PTSD can’t be cured with a pill: treatment, usually trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) takes several weeks, and is expensive.

Having spoken to many women suffering from postnatal PTSD, I know that it can be hard to find specialist help. It’s not unusual for women to have to wait months for treatment, during which time they suffer the stress of flashbacks, nightmares, anxiety and terror. They are often frightened to leave the house and avoid contact with other new babies, making them isolated on top of everything else. All of these things have an impact on their relationship with their baby and with their partner. It’s not surprising that ­– according to the Guardian report of the NHS’s plans – perinatal mental health problems cost the UK £8.1bn a year.

So while I welcome the new centres as a step in the right direction, much more needs to be done to make sure that women with PTSD and other mental health problems receive the support they require. Even more importantly, I would love the NHS work towards preventing these mental health problems from arising in the first place. Most women with postnatal PTSD believe that it was caused, not solely by a traumatic birth, but by the feelings of helplessness and lack of control during the experience, and by the casual and sometimes even cruel attitude of healthcare professionals looking after them.

Some of this can be addressed by better recruitment and better staff training. But the NHS also needs to adopt rigorous standards of care that hold health professionals accountable: making sure that procedures aren’t carried out on women without their consent, for example, or that women are denied necessary pain relief. In a 21st century health service, in a wealthy democracy these things shouldn’t be difficult, but the stories I hear from traumatised women about poor care show we still have a very long way to go.

Half of maternity units putting mothers and babies at risk

A story in today’s Mail makes for grim reading.

The paper has analysed inspection reports of the maternity services in 150 hospital trusts. Of those, the

Care Quality Commission (CQC) rated the safety aspect of 65 of those as “requiring improvement” and of 13 as “inadequate”. (The Mail’s report focuses on the safety ratings – the figures for the overall ratings are slightly different, with only eight rated inadequate.)

At those 13 hospitals, women and their babies are receiving poor care that may be putting their lives at risk.

Here’s an excerpt from the CQC’s report on the Addenbrookes maternity unit, carried out in September 2015:

“We found serious concerns regarding the safety arrangements in the maternity services which were not replicated in the gynaecology service. These related to the environment, equipment, lack of recording of risk assessments and substantial midwife shortages. There were continued thematic incidents reported, relating to fetal heart rate (FHR) monitoring, with limited evidence of changes in practice to improve safety. We found that the suitability, safety and maintenance of many types of equipment throughout maternity services were unsuitable.”

It goes on, alarmingly:

“In the birthing unit, the environment was also found to be unsafe owing to poor ventilation whereby high Nitrous Oxide (gas and air) levels exceeded the safe “Work Exposure Level” (WEL) which the trust had known about since 2013. In maternity, numerous and essential patient risk assessments including venous thromboembolism (VTE) and early warning score (EWS) assessments were not being completed. Staff raised concerns to us that the maternity record system was potentially unsafe due to a combination of electronic and paper records being in use and being used inconsistently.”

Most of these problems could be put right with proper staffing: the NHS urgently needs more midwives and obstetricians. But we also need to look at the cultural attitudes towards safety in the NHS. There is no good reason for not acting on the poor ventilation at Addenbrooke’s, or for the failure, reported by the CQC, to log incidents correctly at Wexham Park Hospital: “Incidents were not always being reported and there were accusations of improper downgrading of their severity alongside suggestions of defensive practice.”

The recent Cumberlege Review made important recommendations on safety. But this has happened before (not least in the RCOG’s Safer Childbirth report in 2007), and nothing has changed. At Morecambe Bay, 11 babies, and one mother, died unnecessarily over a nine-year period. Judging from the evidence of the CQC, we may be seeing yet more tragedies like Morecambe Bay.