Seniority - midwife or consultant?

[digsydel]

I recently changed hospitals from Epsom to Kingston over an ELCS (I have a separate thread about it). I had my first consultant appointment on Friday and he was so great - complete opposite to the consultant I saw at Epsom. He listened to my history, reasons for wanting the ELCS, talked me through some things and then approved it. Told me to wait outside and a midwife would call me to book a couple of other appointments and a date for the ELCS.
Eventually got called in and first thing midwife tells me is that the consultant midwife has stepped in and won't book my ELCS until I talk to her. Apparently as I've changed hospitals I haven't followed their due process and she wants to make sure all the boxes are ticked (she did actually use the words "box ticking exercise").
It's a faff and frustrating and stressful for me that this is still dragging on but if ticking boxes is all it is, then I'm ok with going through it to get where I need to be.
My concern is that she's going use this exercise as a chance to block my request and I'm wondering if she's allowed to do that having already been given approval by a consultant.

Does anyone know who gets final say here - I would have presumed a consultant obstetrician would have seniority over a consultant midwife but I'm not sure?

Thanks in advance.

[Essexgirlupnorth]

I would say the consultant would be more senior

[Liss85]

I would have thought the consultant given that they're more senior.

[hippydippybaloney]

Consultant definitely.

[LillianFullStop]

Definitely consultant but I think midwives can insist on following hospital policy/process and even consultants have to follow those.

[Slothlikesundays]

I actually disagree. He consultant is high up in the speciality of obstetrics but a consultant midwives oversees all pregnancies in the trust/hospital. The consultant midwife is more senior.

[digsydel]

Thanks for all your replies.
I'm hoping the majority is right although I'm terrified Slothlikesundays is in fact correct.

Having war with the consultant midwife - she basically told me the hospital does not in fact give me a choice of an ELCS And that iits something they decide whether I'm allowed. She also said that as the consultant I saw was a locum and, through no fault of his own, was unaware process hadn't been followed, that he's not in a position to approve my ELCS request (which begs the question, what exactly is the point of hiring him!). She originally offered me an appointment to see her when I was over 37 weeks but I refused and just been offered one for this Thursday (35 weeks). I'm terrified, it seems so unfair that individual staff members can out this much stress and anxiety on mums to be!
I don't know what to do if she flat out refuses - NHS and NICE guidelines both say that I'm allowed to choose and she's obliged to offer me one or refer me to someone who will, but I'm worried she's just going to stone wall me and I'm running out of time to fight this.

[YoungGirlGrowingOld]

That's awful OP. My ELCS was agreed at 15 weeks with no arguments. It's nuts that there is much regional variation.

I think the NICE guidelines are your friends here. Take them to the appointment with you, refer to them and request a written explanation from the clinical director if they refuse because you need to know why they are declining to comply with best practice as recommended by NICE. There is a poster on here called Redtoothbrush who is very knowedgeable in this area - maybe PM her.

I would be appalled if a midwife could overrule a consultant like this - it seems all kinds of wrong.

[YoungGirlGrowingOld]

I have no idea if this will be effective but the 2 things I had in my mind for my consultant appointment (if she had refused me ELCS) were:

• informing her that I would not be willing to consent to forceps, induction or episiotomy (which would increase the likelihood of EMCS)
  

• insisting that she refer me to another consultant who would be willing to carry out ELCS. As a PP points out, you do have this right.
  

I think in your case you also have to make a fuss about how you have been massively messed around and it's causing stress and anxiety.

[theredjellybean]

My advice would be to put calmly in writing your reasons for wanting an ELCS , and the details of the conversation you had with the consultant ( locum or not the senior midwife should NOT have said what she did to you) and then send it to

1. PALS
   
2. The chief executive of the Trust
   
3. The medical director of the Trust
   
4. The director of obs and gynae ( this is the head consultant)
   

add in that you are not complaining but that receiving conflicting advice from health care professionals is extreamly distressing to you at this stage in your pregnancy, and that as far as you are aware you fit the NICE criteria for a section. That you are extremely disappointed with the attitude of the senior midwife who was unprofessional in commenting on her colleague the consultant and you do not wish your delivery to be compromised by what appears to be conflict within the department.

I am a doctor and work in area of dealing with complaints.
I dont usually encourage mumsnetters to complain / make a fuss but in this case you need to !!!

[HaPPy8]

In the hospital I work in neither would be senior to the other as such but the consultant obstetrician would have final say over an elcs

[OydNeverDeclinesGin]

The advice of Theredjellybean is spot on, make a very big, but calm, fuss.
Good luck.

[digsydel]

THanks for additional replies - I've already sent an email to PALS and will probably call the consultant whose care I'm officially under tomorrow (even though she didn't see me on the day) to get her opinion (she's permanent).
I've already put my ELCS reasons on paper and midwife has a copy already - told me over the phone that there's plenty she wants to discuss with me on there so no doubt she's going to argue each point with me.
I am definitely going to make further complaints too - thanks theredjellybean for telling me who to direct those too - although I may wait until I see her on Thursday first.

The stress and anxiety isn't fair - I got off the phone with her yesterday and had my 3 year old patting me saying "mummy, please don't cry". Feel like I'm taking my stress out on her too, it's a horrible place to be

[digsydel]

Will take redjellybeans advice too and not "complain" as such.
Thank you so much for all that information

[Hedgeh0g]

If it's anything like my hospital (and it sounds like it is), it really is just a box ticking exercise. I also had to see the consultant midwife before they would approve my elcs (birth injuries from last time). She did try to persuade me that it would all be better this time (on the basis that 'second births are usually much easier') but did say it was ultimately my decision. My consultant, who had insisted I see her and has up until then been quite negative about having a c section, signed it off straight away once I said I hadn't had my mind changed by the consultant midwife. I can see why they do it - they want to persuade those that don't have firm grounds for an elcs or aren't convinced. But in my experience at least, if you have good reasons, check their boxes, and still haven't changed your mind, they sign it off with relatively little fuss.

For what it's worth, and I don't know your reasons for wanting an elcs, but I did actually find seeing the consultant midwife and going through my notes from last time a useful exercise. There is a chance I will go into spontaneous labour, and had I not seen her, I think my reaction to that would have been blind panic. As it is, I'm now more comfortable with what I will and will not accept in those circumstances and will feel more in control of the situation.

Good luck!

[NoJudgingPlease]

Consultant by a long shot.

[CatchingBabies]

I'm a midwife and work in hospitals. There is no senior between a consultant midwife and a consultant obstetrician, they are BOTH consultants and therefore equal in seniority. However a obstetrician specialises in high risk pregnancies only whereas a midwife specialises in ALL pregnancies I can therefore understand why she would want to see you herself. I very much doubt she would overrule you wish however as NICE guidelines give women the right to choose their mode of birth.

[hopeful31yrs]

Seniority doesn't matter and as pp says you have a right to choose. I was told in last pregnancy I couldn't choose by a consultant midwife who then back tracked massively when I got so frustrated I cried. She then tried to show me her numbers of how many normal births ended up in instrumented deliveries (a no no for me) and emcs and essentially made me feel rediculous for asking. I stood my ground but the pressure was high from both midwives and medical staff to not follow my gut instinct and ended up with normal labour, but as feared long second stage with baby getting stuck and needing forceps. I now have a lot of damage down below (not from forceps but from pushing for too long) and the same risks I was worried about last time. I am pushing for elcs this time for definite!

[livinginabox]

The hospital I'm with don't routinely offer sections and are up front about it pretty early on. Unless there is a compelling medical reason, getting an elective section is almost impossible. NICE guidelines are just that- guidelines and hospitals are not obliged to follow them.

I'm not sure how I feel about that but it's the reality unfortunately. I'm guessing you changed hospitals for similar reasons?

[YoungGirlGrowingOld]

livingnot true in my experience. I have no compelling medical reason and my section was agreed with no quibbles at all. I simply told her I wasn't willing to take the risk of tearing and incontinence with a vaginal birth.

I would have challenged based on the NICE guidelines had it not been so easy. Of course they are only guidelines but I understand they reflect best practice and that a woman is entitled to be referred to another consultant if they are not followed. (Sounds like poor OP has already done this).

My DH is a consultant in the same group of hospitals and confirmed this. We would definitely have pushed it if necessary but luckily it wasn't.

[digsydel]

A couple of people have said NICE guidelines are just that, guidelines, and not obliged to be followed, however the NHS itself says the following:

"Asking for a caesarean

Some women choose to have a caesarean for non-medical reasons. If you ask your midwife or doctor for a caesarean when there aren't medical reasons, they will explain the overall benefits and risks of a caesarean compared with a vaginal birth.
If you're anxious about giving birth, you should be offered the chance to discuss your anxiety with a healthcare professional who can offer support during your pregnancy and labour.
If after discussion and support you still feel that a vaginal birth isn't an acceptable option, you're entitled to have a planned caesarean."

www.nhs.uk/Conditions/Caesarean-section/Pages/Introduction.aspx

The last sentence being the key there. Surely they're obliged to follow NHS information. Ironically this come from a page called "NHS choices - YOUR Heath, YOUR choices"!

I'm also frustrated that I have in fact already been given approval by a consultant and she's intervened. While I understand where she's coming from in that Kingston feel they need to make sure I have all the information from them, it's not my fault that they cocked up somewhere along the way, while frankly at 36 weeks it feels a bit late to start trying to correct that now at my expense. And when I told her that I was happy to go through all of this anyway as long as she still respected my choice at the end of it, she told me I didn't have a choice!
Anyway, I have letters to write and I have my appointment tomorrow so fingers crossed there's some improvement in the situation.

[livinginabox]

They are not obliged, although lots of people feel they should be. Hospitals generally have their own policies on best practice and will follow those based in the latest clinical evidence.

NHS choices although useful is just a website. Clinical decisions are made by clinicians based on a whole range of factors, including hospital policies.

Kingston have some info on their website about planned sections that may be useful. Hopefully all will be well at the appointment tomorrow and all the boxes get ticked.

https://www.kingstonmaternity.org.uk/giving-birth/your-questions-about/caesarean-section-(planned).aspx

[LillianFullStop]

Hope your appointment went well OP and you get approval (again) for the birth you want.

[Blackpoollassy]

Can you get hold of the Hospital's policy/procedure on elective c-sections?
It may help explain the process. At mine, i had to see the consultant midwife and follow due process before getting the agreement from the consultant.
It's all an auditing exercise, especially as they are supposed to be reducing the number of electives.
Just don't give up. It is absolutely horrible to have to go through this.

[RedToothBrush]

Actually, I would say that it doesn't matter who is more senior in this case.

I think who is more senior can actually depend on the hospital rather than the position, since a consultant midwife role can differ between hospitals, and although normally a consultant would have a more senior role, it would depend on the remit of the consultant midwife.

In my case, it was a consultant midwife that made the decision, and effectively told the consultant. I didn't even see the consultant until the pre-op to go through the risk. The consultant midwife was in effect the decision maker and the one that wielded the actual power administratively, whilst the consultant was the clinically more senior. I don't believe that is the case everywhere though.

But as I say, I think its a mute point in this case.

Someone who is senior enough to make the decision, has done so and has informed you about this, and its on your notes. They are medically qualified to make this decision. As far as you the patient is concerned, you had been relived and that the pressure and much of your anxiety removed by that.

You have ALREADY changed hospitals over the issue and this in itself should show your intent and how serious about the matter you are. You clearly have done so on the basis on your mental health.

If the consultant has not acted within the proper structure of the hospital, then that is frankly a staffing and potentially a disciplinary matter, which you should not get caught in the middle of to the detriment of your mental health. Their turf war, if there issue not yours. That is HUGELY unprofessional and against the ethics of 'doing no harm'. This has obviously pulled the rug from underneath you, led to unnecessary anxiety and distress.

If the 'box ticking' is about your physical health then this is fair enough, but this should be properly and clearly explained sensitively and it stressed that, unless there is a serious issue this is a formality. Again it should be stressed that their ONLY concern is your health, and not their procedures. Box ticking is not a sufficient excuse under the circumstances to change your care plan at this stage. You categorically should not be left hanging - the process of hoop jumping, is actually one of the things that is actively creating your anxiety. Their actions are part of the problem.

With regard to your rights. You do NOT have a right to a CS on the NHS under the NICE guidelines. Previous posters are completely correct in saying the guidelines are just guidelines. However you DO have a right to the most appropriate care for your health circumstances. This means that if your mental health is a serious case, you may well have good grounds to stake a claim for a right for a CS on those grounds. As in, the best way to care for you and preserve your mental health is to perform a CS and you therefore have a 'right' to a CS.

The difference is subtle but important. If you are going to make a case, you need to stress this and you need to stress that the handling of the handover has been detrimental to your health.

If you can frame any case in these terms it makes it a lot harder for them to reverse the decision. Do not rely on the NICE guidelines alone as frankly they are insufficient under the current political climate, and sadly, the availability of CS is being determined by politics and budget rather than clinical need (which contrary to popular belief DOES include mental health).

Good luck, I hope you can bang the appropriate heads together and get it sorted soon enough.

[Blackpoollassy]

What an excellent post pp.
OP just read your other post. Didn't realise you were vbac. That's even more weighting for them to a free to an Elcs for you. Why on earth are they making your lie so difficult