Writing a book on the medical side of birth - will it be useful?

[DoctorMonty]

Hi MNetters... your reputation precedes you, I'm a bit nervous...!

As briefly as possible: I'm a labour ward doctor (obstetrician) and it seems to me that mums-to-be are well prepped by loads of books/NCT etc. about natural childbirth, how to avoid needing an epidural etc.

But...! Sometimes things don't go to plan, and that's where my job starts. But again and again, it seems like women - particularly with first babies - haven't been told much about the medical side of things, and then you're expected to take it on board within minutes!

Take for instance forceps deliveries. I totally get you'd want to avoid a forcep delivery - believe it or not, so do we as doctors. But there's not much good being told everything about it, the risks and benefits etc, in the few minutes before you end up having one! And sometimes time really isn't on our side. I still see regularly on birth plans "I don't want forceps unless necessary", which I can understand. But at the same time, we don't do it unless it is necessary...! Why is no one putting that information out there pre-birth?!

We had our daughter in 2015, my wife did amazingly, she had a hypnobirth in a pool . So I understand about not wanting to visualise negative things, wanting to picture the perfect birth and all of that... but some people like to know what Plan B is!

So, I'm 4000 words into a book that explains in plain English why we do certain medical things on labour ward and what the risks and benefits are. Some pregnant mums won't want to think about it - I get that. But presumably some would prefer to know as much as possible, so if something starts to go wrong they know what happens and feel more in control...?

Particularly if you're someone with a complication picked up in pregnancy, when a home birth in a pool is just not on the cards.

Anyway, I'd love to know your general opinion on this. Whether you're pregnant and would or wouldn't want such a book, whether it's something you wished you had, what you think should definitely be included... literally, anything. As I said, I've already started it, and if the idea has legs I'd love to enrol some expert help from here to critique it before it's published.

Finally, the format (at least for now) would be an eBook as they're so easy to get out there. I've got a paediatrician and an anaesthetist also writing sections about babies and pain relief/anaesthetics too.

Thanks so much for your time.

Sounds like a great idea. I've not read anything written by a doctor so this book would offer some balance And a different perspective. It will be important u make it clear why an intervention might be needed, what it involves and pros/cons and alternative options (don't ignore non-medical options if there is evidence for them).

I would have been interested in the folllowing topics:

section on vbac which was factual and based on research. So things like stats on the risk of uterine rupture and whether these stats show emergency uterine ruptures where there is an immediate risk to the life of mother and baby or if they include the scar parting but not causing any immediate emergency (think it's called dishesence or something like that). How best to manage the risks. The benefits of elcs. The success rates of vbac for different circumstances. Induction & vbac (what does the research really suggest). FAQ from vbac candidates.

Forceps & ventouse deliveries - why they are needed. What the alternatives are.

Pushing stage - what do doctors think about coaches pushing vs going with your own urges. Why don't they like u to push for too long. What can cause issues at this stage and what are the options for helping baby out.

Low risk births - when would/should a doctor become involved

First births - any differences between first & subsequent births (e.g. Likely length & need for support)

Post birth - what's normal, what's not and when to seek medical attention. Some of the most common birth injuries and treatment options (although maybe advise readers not to read this section until after the birth?)

More thoughts! Lots of work to do!

Re. the last post about changing standards etc - I think you might be surprised by how long it takes for evidence to filter through. One good thing about the NHS is it will be relatively standardised care you receive - yes, sometimes consultant opinion makes the difference, but a lot of it is driven by NICE and college guidelines. These take quite a while to prepare and are only updated every so often. They're usually most heavily based on good meta-analysis like a Cochrane Review or weighted towards the biggest and best trials.

Also, you shouldn't need to keep repeating RCTs to answer the same question if you get a good result - that would be a waste of resources. And the big reviews will by deliberate methodology be weighted towards the biggest and best trials, and little new studies probably won't shift the meta-analysis results that much.

So, it isn't really the case that there are new papers coming out every month or so casting consensus opinion into doubt and changing practice so quickly. It's common for new guidelines to be almost identical to old ones, if there have been no new trials. Local hospital guidelines are set pretty closely to national guidelines unless they have a very good reason not to be, so in the U.K. there really should not be that much variability in the recommendations being made.

That is probably less the case with rarer problems - rare blood disorders, for instance, where smaller trials might affect practice more directly. That would be beyond the scope of the book.

I suspect it's not like this in other countries, where your own doctor's thoughts on the issue might be more important.

Funnily enough, I had that very thought about the shape of forceps a few months ago - when were they last changed?! The answer will be - decades. Some of this stuff is historic. But we're a point where a new trial would be unfeasible, and it would be unethical not to deliver babies by forceps because we know what it would result in (fistula). How long does it take until you're at risk of fistula exactly? We don't know, because it would be unethical to do a trial...!

I realise I've put this idea and therefore myself (in a way) out for critique, and you haven't disappointed But I do hope we can steer clear of "typical for a male ob" kind of comments. I've discussed this idea with female doctors, and midwives. I've met some wonderful male obstetricians and some (IMHO) terrible female ones, and vice versa. And I try to treat every woman I see as an individual - I really hope they feel able to do the same in return.

unethical to do a trial

Nah. What about this dude
www.bbc.co.uk/news/magazine-25137800

If you are seriously saying trials can't be done where there are risks of injury or death I can't see how surgery manages to advance at all.

You must see it's not true. So why isn't research done into birth? Have you really interrogated why that is in your own mind?

Who is making the decisions that the risks of research aren't worth the rewards of vastly improved birth experiences for women?

Have you ever thought deeply about how institutionalised sexism affects the way birth is treated in a medical environment? And just saying 'I'm not sexist' isn't enough I'm afraid. After all it's not just about you. It's about the environment you practise in and the procedures you follow.

I read Lesley Reagan's book which is quite 'medically minded' but then I'm a medic too and wanted to understand about everything that would/could happen. All about finding a way to cope with pregnancy/birth in a way that I felt comfortable with. Realise not for everyone but when things didnt go to plan during labour I found it helpful to have some previous knowledge around the issues.

With a book like this there is a very fine line between empowering women with information and overmedicalisation of birth and having the opposite effect of disempowerment

Personally I think your time would be better spent setting up a program to combat why women are not receiving this information. What a powerful position you are in and able to effect change. Eg. More antenatal visits. Longer than 10min antenatal visits. continuity of caregiver.

Waste of time as the people you want to reach are the people who don't want to hear. You would be more effective spending your time posting on sites like this and a million others to be a voice against the sea of "of course you should have a triplet breech home birth, despite your five previous sections, PPH history and advanced age" and "even if you are fifty weeks gestation, you don't have to consent to induction, babies know when to be born" brigade. Build a credible consistent online persona and meet people where they are at. That is online.

There is research at Liverpool Women's isn't there? Not on forceps per say but on how the uterus works.

www.liverpoolwomens.nhs.uk/News_Centre/news/New_research_centre_aims_to_make_childbirth_safer.aspx

I know this isn't what you're proposing but fwiw what I would really like to see (clearly laid out and easily accessible) are the stats for use of the various interventions and for complications. Preferably broken down into by risk factors too (e.g. age, first baby, obesety). Maybe you could stick that in as an appendix?

While I think it's a great idea I don't think sales will be all that great. It's such a niche market. You'll get a large proportion of Mumsnetters saying that it's a fab idea and they'd love a book like this. Mumsnet however isn't very representative of your average obstetrics clientele. The majority of pregnant women aren't going to read a book like this.

sycamore I think you'll find that those women who wish to avoid interventions are already experiencing huge barriers to realising their hopes and wishes for their birth, they really don't need any more voices added to the chorus.

Almost all mums in the UK in the situations you describe are under the care of the NHS - it's the job of their doctors and midwives to set out the risks and benefits of their birth choices.

Of course labour ward research goes on- but you can't ethically do a trial of forceps vs nothing for example. Or randomise women to induction vs expectant management after 42 weeks. The risks of doing that type of trial are just too high.

"realising their hopes and wishes for their birth". Isn't this precisely the point? Human biology knows nothing of your hopes and wishes. A 42-week old placenta doesn't care if you want a hypnotic water birth.

"One good thing about the NHS is it will be relatively standardised care you receive - yes, sometimes consultant opinion makes the difference, but a lot of it is driven by NICE and college guidelines."

Interesting then that the RCOG maternity indicators show big differences in rates of intervention at different hospitals, even when the outcomes are adjusted to take hospital characteristics and demographics into account: RCOG

Unassisted/normal birth (primips) national average: 42%
Highest rate: St Helen's and Knowlsey Trust - 62.1%
Lowest rate: Wye Valley NHS Trust - 32.9%

Induction of labour (primips) national average: 30.3%
Highest rate: Great Western Hospitals NHS Trust - 42.1%
Lowest rate: Lewisham and Greenwich - 16.1%

Episiotomy (primips) national average: 35.4%
Highest rate: Royal Free - 50.8%
Lowest rate: North Bristol - 16.2%

Would also add, that I'm always amazed at how little concern there is that low risk women labouring in obstetric settings appear to have a very much higher rate of unplanned c/s when compared to similar low risk women labouring in midwife led settings, with no apparent improvement in outcome for their babies.

I think the real demand for the book will be from women who know they are having high risk pregnancies.
A lot of the stuff out there is don't worry you'll probably be fine or more focused on low risk birth. This does make you worry as you are not as informed as other mothers.

MW (low-risk, normality type) opinion.

Bloody good idea.

Although NHS stuff is fairly standard actual practice varies wildly between hospitals and individuals.

Could you please consider language used? Things like 'overdue' versus prolonged, not 'failure' but delay, induction being 'inneficient'. Things like that.

Also midwives aren't deliberately nasty (mostly). To either women or doctors.

"realising their hopes and wishes for their birth". Isn't this precisely the point? Human biology knows nothing of your hopes and wishes. A 42-week old placenta doesn't care if you want a hypnotic water birth."

Women know the general risks at a population level of going past 42 weeks because it's hammered into them by their care-givers.

What they don't know is how these risks apply to them

I take it you are aware that some women and babies naturally have much longer gestations than other women and babies?

I also take it you wouldn't be as sneering and cavalier about women's wishes if they involved planned c/s or lots of diamorphine? It is ok to fear labour and pain want to do everything to avoid it, but it's not ok to fear and want to avoid surgery and interventions?

The attitude you display - the superiority, the sneering, mocking and ridiculing of women's feelings about their births is a massive part of the problem. So disrespectful.

Re. research, yes it goes on, of course. Whether certain blood tests are useful, whether a new plastic pessary stops preterm labour etc but as has been pointed out, you can't do an RCT to see what happens if you don't repair a 3rd degree tear. We know a lot through having learned the hard way, and developing techniques in the bad old days. Same with medication - most of it is old, because who wants to try out a new drug to see if it's safe for an unborn baby?! Sometimes the new use is discovered by accident, like magnesium sulphate.

In terms of forceps - they're actually very good at what they do. Slightly changing their design - the money it would cost to redesign, then trial (if it passed ethics committee - "can we use this to deliver your baby please, we don't know if it's safe...") and what would the hoped for improvement be?

The Odon device is really interesting. I keep hearing about it but it's been in development for a while now. I hope they succeed - but it's the exception more than the rule. Sometimes you need an engineer or at least a different perspective to shake things up! There was another engineer who invented a sort of pipe-cladding style protector for aortic aneurysms. Brilliant.

The research I'd like to see would be research on labour outcomes, and psychological outcomes, comparing women who'd been given an antenatal course where the focus was on communicating information about a very wide range of risks and poor outcomes in birth: PPH, third degree tears, surgery under general anaesthetic, shoulder dystocia, cord prolapse, placental abruption, assisted delivery (including failed forceps where mother then go on to have a c/s), infections following birth, maternal death, puerperal psychosis, severe postnatal depression, unexpectedly poor neonatal outcomes, undiagnosed trisomy etc.

Because if we go by this thread we'd expect to see better psychological outcomes in a group of women who go into labour highly aware of all the terrible things which can go wrong with birth. Maybe better physical outcomes too?

DoctorMonty - why are doctors putting so much effort into designing new gadgets to assist women giving birth and ignoring the fact that what seems to be associated with a large improvement in outcomes for low risk women is staying away from birth environments where they come into contact with medics? ;-)

Maybe doctors could apply their huge brains to analysing what they're doing on labour wards which is resulting in a disproportionate number of healthy women in that setting having dysfunctional labours? And perhaps do less of it?

I'd like you to include some stuff on prolapses. I know so many young women who have issues following childbirth, who all get the "but you're so young?!" from hcps.

Or who are told that peeing yourself for the rest of your life is "normal"

I think that basically, for an information type book/let women want to know why things go tits up and what happens. Why a low-risk normal labour ends up in a transfer to an obstetric setting. Why a baby might need forceps to come out. Why HCPs need to make decisions. Like 'Episiotomy only if necessary'. What happens during induction (difficult as varies so much) but the basics. Induction can take days and might not work.

Good idea
Too many naive people think having a baby is like a spa day where you pick from a menu what you want
Our NHS antenatal class did include a,session on all the different interventions, from induction to sweeps, c section, forceps etc and it was useful.
Way too much focus on delivery with no pain relief in the UK. If you had a headache you would take a paracetamol but having a baby? A badge of honour ylto gave no pain relief. Why ffs? #bonkers

Minifingerz I think that's a really good question.

You could probably say the same about stuff like cancer treatment. For certain cancers, above a certain age, does it even benefit you to know your diagnosis? In other countries I've worked, families have begged not to tell their relative the diagnosis.

We've gone done the route of "more information is better" in this country. In certain situations, there's a genuine case to be made criticising that whole assumption, but we are where we are.

How do you try to get the best outcomes along with the best experience for birthing women when half come out saying "why did no one tell me that..." and the other half say "they gave me all this information and it scared me to death"?! (Exaggeration but you get the idea.)

I would not want to go down the whole "if this happens your baby could die, look, it happened to this woman..." route. Rather say, "if this is the case, this is what your doctor might suggest and why." There is so much stuff that happens that doesn't result in a terrifying or tragic outcome, but that is probably a bit mysterious if you don't work on a labour ward. What is the "clip" they're asking to put on your baby's head? Why does no one seem to be worrying about the heartbeat dipping down? That kind of thing.