Delivery didn't go according to plan (but feel there were some things done poorly by midwifery team, should we say anything?)

[HSlant]

Not sure if right forum, we didn't have the best birth experience (partner posting on behalf of mum). Much of this was baby/mum related (progressed rapidly, and delivered within 3 hours of getting to hospital), things like birth plan therefore went out the window, tried to convey that one of the biggest concerns was of getting a 3rd-4th degree tear (trumped only by something like a hypoxic brain injury to baby), and if there was anything we could do to avoid this, would be keen to try. Ended up delivering in Lithotomy and (we think) instructions for pushing may have been incorrect - told to push hard, continuously throughout contractions. Left now with a 3rd degree tear, needed stitching in theatre. Wasn't all down to midwife, she needed help and used call bell twice (for Dr and then 2nd midwife but no one was available - it was a really busy night). Also this was 3rd midwife 3 hours (they were just too busy and hadn't accounted for us, and now rapidly we'd progressed, so had to be passed from one to the other), so not much continuity. Ofc very relieved baby is safe and hoping mum doesn't have any long term effects. I don't know if we should say anything? Is this normal? We have no frame of reference. The doctors said they'd explain things but they didn't really know why things happened the way they did and just left things at that.

They will always try to avoid 3rd/4th degree tear as nobody wants this as an outcome - not nice. I don't think it's weird to be concerned about that as an outcome, but I do think it's unhelpful to frame it as though it's an option in a birth plan (not criticising you/partner OP).

Unfortunately it is often the case that you get taught a load of stuff in birth prep courses (like never push on your back as it causes tears!) but the reality is that it ends up happening anyway. It didn't necessarily cause the tear - I had the same worry about delivering on my back, but 3 babies, all on my back, I got a small tear/graze with first baby and none with the other two. It is useful to know about how gravity and positioning can affect labour but do bear in mind that this is all probability, not necessarily direct causation. It's true that hospitals probably shouldn't encourage women onto their backs purely out of habit/policy, but on the other hand that might well be the best position for some other reason - comfort/[lack of] ability to move, or yes, visibility/access for the midwife in an emergency or concerning situation.

Do ask about the debrief. It's a really helpful/important step in processing any traumatic experience to be able to understand what happened when, and why. My own experiences of birth were very fragmented, and being able to piece together what had happened with DH offering what he knew from his side was hugely helpful.

It's really important that your wife is not simply stitched up and sent home. Is there a programme of supported recovery for third degree tears? Can your wife see a specialist physio for pelvic floor through the hospital (or privately if you absolutely have to)?

No I haven’t name changed. We are separate posters.

Birth has never been and never will be a painless, 100% safe activity which you walk away from with no physical long term effects.

On paper the care wasn’t gold star, no. But most people don’t get that - like every other area of our health service. It wouldn’t occur to me to complain unless I felt something was clearly mismanaged resulting in harm to me or the baby.

The OP’s language gives me the impression they went into this (or rather, she did) with a very specific plan which they expected to be followed to the letter, which simply isn’t realistic nor possible in most cases. Op also seemed to feel entitled to an ‘experience’ which again is pie in the sky. A third of first time mums have a CS, a third have an instrumental and a third have a ‘normal’ birth. You’re more likely to need intervention than not.

I think ask for a debrief and take it from there.

I’m a healthcare professional and it’s amazing what people do/do not remember or take in and how the HCP/patient can come away with a completely different take on what happened. Especially when decisions or actions are viewed with the benefit of hindsight. This isn’t meant to come across as critical of the patient in any way - I’ve been the patient enough times myself and had those experiences myself. But when you’re in a high stress situation in an unfamiliar environment the brain processes things differently. I’ve had patients swear blind that they were never consented or told x, y and z when they definitely were - humans are incredibly complex cognitive creatures and how our memory or cognition works (especially at times of stress) is no straightforward thing.

Having a debrief will hopefully be a helpful experience in going through how and why things happened as they did. It may be there were suboptimal aspects of care, the staffing sounds stressful and confusing for one (though this is more likely to be a systemic issue than the hospital doing anything deliberately, none of us like working on understaffed departments and it’s easy to say that there should always be x people around but that becomes more difficult once you’re not starting with a full rota to begin with and then emergencies all happen at once). It may be that having somebody go through and talk through exactly what happened and the likely reasoning behind it will help answer all your nagging questions and help you move on. Or it may identify that there were issues or things that did go wrong and enable you to address those. Equally it might highlight that the care and actions of the staff stopped a bad situation from deteriorating further and you’ll know that whilst not the ideal birthing experience the choices made were the ‘right ones’ for the situation you all found yourself in. The important thing is you’ll (hopefully) have the information and some agency.

Yes childbirth is unpredictable and dangerous and can be fatal etc - but it’s because of all that, because it can never 100% be planned for, that empowering patients to seek information and be able to talk about what happened to them is so important. Especially as the birth of your child is such a significant emotional and cultural event (whilst you can be traumatised in all areas of medical practice I’d argue that the framework is very different in birth - you don’t go to classes ahead of having your appendix out for example and you’re not going to have an ongoing relationship with your gallbladder once it’s been removed).

When it was apparent Dr wasn't coming, she called for 2nd midwife but they could only pop their head in to say they had an emergency next door and poor midwife had to deal with any problems herself (think our midwife had been pulled down from the community unit due to short staffing and hadn't done labour ward in a while, which she disclosed to us quite openly)

This sounds scary. My anxiety would have skyrocketed if this happened to me.

Sounds like understaffing was the main reason all of it happened.
Do get a birth debrief, like PPs suggested.

You can disagree all you want. I’m not a midwife or a consultant and I honestly don’t think that matters - do you really think there is some sort of an agenda against women from the medical staff??

I’m a woman with a lot of experience with birth and I can say that in my experience the women who went in with high expeditions specifically in terms of calmness and pain were the ones left with the most trauma post birth. I find it had to deny that there is a link between the two.
People very close to me have literally said if they had gone in with a different mindset they don’t think they would have experienced the same shock.

If anything I want women to come out of their birth feeling better! But I do not believe that telling them it’s all rainbows does that.

Soem births are calm, magical experiences so it's not unreasonable for people to hope for that
I genuinely think it is unreasonable to hope for that and I think it does damage to women.
From 2 nct experiences and many close friends having babies at the same time I would say less than 5% had a ‘calm and magical birth’.
The reality is it’s scary, and stressful and messy and painful and to me knowing that and managing those things is what leads to the best possible outcome.

To me it’s the equivalent of asking for a calm and magical heart bypass. It’s unrealistic and not helpful.

No wonder maternity care in the UK is so crappy at the moment. Why are people blaming sub-optimal care on women's expectations of having decent, safe care in labour?

So if you expected the care to be crap you wouldn't feel so bad when it is crap. Great message. The OP and his partner were not asking for magical but they should have had safe and supportive. There is research that shows that women feel positive about their birth experience when they feel listened to and cared about and when they feel they have some control, no matter how much the birth differs from their birth plan or how much pain they feel. This women and the OP obviously felt that they didn't feel listed to and cared about or that they had any control and the hospital needs to hear that.

But you can’t have ‘control’ in labour, that’s a total illusion. Medical staff can’t win - if they strongly encourage something they’re called ‘coercive’ and everything they recommend ‘unnecessary’, meanwhile there was a thread on here not too long ago by a woman who wants to sue the NHS because she was given a choice and made the wrong one and now ‘feels they should’ve made the decision for me as I was in no place to make it after giving birth’.

I think some women feel privately disappointed by their birth and their body not doing what they want it to do, and find it easier to blame the medical staff.

I had a third degree tear, following fetal distress on the ctg monitor. However I am a midwife and I knew they were directing my pushing as they were concerned about what state my DS was going to be born in. Luckily it was a good outcome for him. I certainly felt traumatised afterwards but 22 months later I had another vaginal delivery with just a 2nd degree tear.

Re a c section- it may have been too late for that. If the baby is already down in the birth canal the only options are pushing it out or ventouse or forceps.

This is why birth plans are totally pointless, and shouldn't be encouraged. Tearing is also very common, it's a part of birth.

No, I absolutely do not for a second think there is an agenda against women from medical staff. That wasn't what I was getting at, my point was you referred to your experience without contextualising it, which didnt really add much beyond an opinion. I can only speak to my own birthing experience for example and I know its not representative of everyone's.

FWIW I went into my birth with the mindset you are outlining. I wrote down my ideal set of "birthing hopes" as I called them. Then I had a chat with my midwife (several chats actually) about the potential actual outcomes and things that could go "wrong". This was indeed a great approach as I had wanted a water birth or a vaginal delivery where I was free to move about and labour down So i wasnt pushing for ages. I was induced, it took 14 hours from starting the drip, i pushed for nearly 3 hours, baby turned the wrong way during labour and it was agony. Birth "plan" straight out the window and one epidural and an emergency c section later I had my lovely baby in my arms. I was prepared for the fact I might have a drastically different birth than is hoped for and while I did still have a few "wtf just happened" moments I wouldn't say I'd experience any trauma.

I responded to you and cuppasoup as I have done because I don't read OPs post as complaining they didn't get what they wanted but they were concerned that what had happened didn't need to happen as it did or that they were potentially unsafe. They've got questions, they have the right to ask and have answered without people chiming in that birth is difficult and dangerous and they just need to get on with it. Especially not after the fact - its happened and they need a bit of closure, if you don't want to reassure or encourage them to have a debrief or ask questions about their own personal experience then you don't need to support that. But you also don't need to rock up and patronise someone who is already struggling to process what happened and how they feel about it. A little bit of empathy goes a long way, but as you said to me... you can disagree all you want.

It's not about controlling the labour it's about feeling in control whatever happens. Having things explained and taking part in the decision making process. About being treated with respect and with empathy. Even the midwife described in the OP sounds like she felt out of control of the situation as she didn't have the support she needed.

1.Ask for a copy of your maternity notes. You can apply for this through the hospital website, can't remember the exact term "patient notes" or something similar. They should be able to email this over to you. When I got my notes I then went through and highlighted any areas of the birth I wanted explaining or questioned.

1. THEN organise a birth reflection call with a midwife. When this happens have the notes in front of you, they will go through each of those notes so you can then read along and raise questions as you go.

1. If you are unhappy with a particular part of your birth and believe they were negligent then raise a complaint to PALS specifying what happened and why you are complaining.

1. If you aren't happy with their response then contact Birth Rights and seek their advice, you can even copy them into your correspondence with PALS.

I just wanted to add that you sound like a very caring and supportive partner. It sounds like you really tried to advocate for your wife during the birth and continue to do so afterwards.
That will be a massive help to her.

If you feel like it was traumatic, then it was.

Please get your wife to speak to her GP and see if there’s any therapy available (for you as well if you need it). Birth trauma can lead to PND.

Ask for a debrief but do remember that the number one priority is to deliver your baby safely, plans can have to change and they prioritise safety over explaining why

I’m a midwife and I agree, definitely ask for a debrief.

routine lithotomy should not be used. Constant pushing should not routinely be used. However there may have been a need for it if concerns about heartrate, etc. but also were other things tried first , change in position, clip on the baby’s head if struggling to get a good trace abdominally? If not was that because it was a midwife who wasn’t up to speed on Labour ward? Certainly sounds like she should have been getting more support if she normally worked in clinic. And that maybe needs raising.

Just to close the loop on this, the CMW who checked in with us the day after d/c was v.helpful and sign posted us to the debriefing service.

Whether this means anything or not, she said it was a bit eyebrow raising (for her professionally) to encounter a third degree tear following a non-instrumental vaginal delivery (she said the rates for this specific presentation are lower than the quoted 6%, more like 1%). She said the other bits around staffing were of concern too. However without reading the notes to understand some of the decision making it's difficult to be certain, their were some paradoxes (if delivering Lithotomy and active pushing due to concerns about fetal distress, why not pull alarm bell etc). She advised us to request the notes.

One further question, for anyone who might have direct knowledge: NHS can't book us in for Physio for a further 2-3 weeks, is it worth seeing someone privately sooner? (ie can the recommended exercises be started asap or do they tend to suggest waiting a few weeks to recover before doing so anyway, in which case we'll wait for NHS care).

If you can afford a private women's physio I would go down that route.

You said your wife's midwife didn't work on delivery ward for a long time. Might be the case her knowledge is out of date/not willing to keep up with new standards? I'm wondering if she had reasons other than convenience/old school knowledge to lithotomy and directed pushing. Sounds like nightmare.

Congratulations anyway and sending your wife best wishes. Hopefully you can find answers about what happened and kind of make your closure with the whole thing.

Sounds like your midwife was anticipating a doctor review with a forceps or ventouse expediated delivery, hence the lithotomy & episiotomy kit.

She probably panicked if she couldn't pick up the FH, then panicked some more when informed she was on her own. She will have encouraged valsalva pushing because she (the midwife) couldn't reassure herself that baby was fine.

Nah mate.
A midwife who isn’t normally a midwife and is inexperienced and everyone else too busy to help even though there is a poor CTG trace is utterly appalling practice. You were lucky to get away with a 3rd degree tear. If you have the energy to do so, please complain but make sure you have as many facts as possible. Be polite but firm and be very clear about what you want - a meeting with the head of Obstetrics? Changes in practice/hospital policy? Compensation? There should be a patient complaint/feedback process that you can access to help you to formalise your complaint/concerns. Congratulations on your baby!

Private physio isn't that expensive. If you can afford it, definitely go for it. In my area it's around 65 quid. I think 2-4 weeks PP is too soon though. More like 6 -8 weeks? You might die of boredom waiting for NHS physio.

Personally I’d move on and enjoy your healthy baby. Not sure why dwelling on the birth will help

Births often don't go to any plan. Babies can't read manuals and plans. All you need, at the end of it, is a healthy baby and a healthy mum.😉