I’m the Lead Obstetrician for postnatal care at Chelsea and Westminster Hospital NHS Foundation Trust, London. Such roles are relatively new in the National Health Service (NHS) and I have been working specifically in this field for nearly four years. These roles offer obstetricians an opportunity to actively engage with the wider team in delivering care beyond pregnancy and labour to our mums.
Our initial project included developing a mum and baby app to provide our new parents with information to support them in the immediate postnatal period, and more recently the creation of digital storytelling modules where new mothers have kindly shared their postnatal experiences to support reflection and learning amongst health professionals and other mothers. Both projects are supported by our hospital charity CW+ and have enabled us to explore newer ways of empowering mothers and staff.
We have also undertaken other pieces of work aimed at enhancing the experience on the postnatal ward. It was only at the Royal Society of Medicine Conference on medical innovation in 2016 that I came across the concept of design thinking in healthcare - truly my lightbulb moment in terms of realising how our operational efforts could translate into a really positive difference for our mothers. This methodology encourages a human-centered approach, which goes beyond clinical outcomes, and requires professionals to truly understand the emotional experience (feelings, pains, anxiety, concerns) of those who use and deliver our service. This discovery stage (i), is then followed by stages of defining the need (ii), brainstorming and developing (iii) empathetic models of care and finally delivering (iv) care. Further reading revealed that this methodology had also successfully informed the Better Births report, the NHS 5-Year Forward View for maternity care.
In October 2016, we adopted this design thinking approach to postnatal care in our hospital and have started to gain new insights into the real-life experiences of the new mothers and the team providing care. Part of this work involved running a Whose Shoes? workshop, bringing together a range of staff and mothers/ partners and babies (see above image) to start a journey of healthcare improvement. We are now working on a number of the identified themes through the NHS Early Adopters Maternity Transformation Programme in Northwest London.
A Fellowship in Quality Improvement - Collaboration for Leadership in Applied Health Research and Care (CLAHRC) - in 2017, offered me the opportunity to focus on improving experiences associated with pain in the postnatal period. This is a theme that repeatedly came up in my postnatal clinics, an observation in keeping with the Mumsnet survey's findings of postnatal care. My own low pain threshold and clear recollection of my first childbirth (before I chose a career in maternity!) motivated me further. This was when the overriding clinical need was to get me out of the bed and mobilised ahead of the day 1 obstetric ward round, irrespective of my pain management. Beyond my personal account, several studies report that poor management of acute or persistent pain after childbirth can be associated with symptoms of postnatal depression at three, six and 12 months, and can negatively impact breastfeeding and mother-baby bonding. Therefore getting correct pain management after childbirth is so important.
To understand why the pain management strategies were not translating into good experiences, we undertook surveys of mothers and staff on the postnatal ward. We found that mothers sought regular reassurance about the safety of painkillers whilst breastfeeding, but that this reassurance didn’t always materialise in a busy ward setting. On the other hand, staff were genuinely surprised that this should even be a concern to a mother when a health professional was prescribing and dispensing medications. In addition, having gone through most of the pregnancy avoiding medications, the sudden transition to being offered a range of them really worried some mothers.
With time, I noted further preconceptions, biases and opinions unique to the postnatal period. This led me to explore how pain is assessed postnatally compared to other areas of healthcare. The expectation of pain or discomfort after childbirth means that mothers did not always seek support or pain relief medications, even at times when it may have been needed. It was not routine midwifery practice to use an objective tool like a visual analogue score (0-10 pain intensity scale at rest and on moving), where women assess their pain’s intensity to guide staff as to their needs. Using quality improvement methodology, our team has started to incorporate this into our routine clinical care, with positive feedback from staff who have started using it. The local teaching programme now emphasises the need to treat and manage pain after childbirth with the same significance as one would outside of maternity settings like in gynaecology or surgery.
Two years ago, I naively believed an operational approach would have long fixed this problem but as I’ve delved deeper, the intricacies of managing pain after childbirth are now becoming clearer. Working with a design approach and with the support of our maternity voices partnership team, we have started the journey towards optimising pain management in our service.
Through this blog (my first ever) I want to achieve two aims:
- To empower new mothers and mothers-to-be to work with their local Maternity Voices group to have their knowledge and insights help design how healthcare is delivered; and
- To raise awareness that poorly managed pain after childbirth is an avoidable outcome with possibly significant negative consequences for the mother and her baby. Mothers should feel confident to assess the intensity of their pain after childbirth and work jointly with their health professional to address this. Defining this pain as part of the ‘normal’ experience after childbirth cannot be right and this must change.
I would welcome suggestions on how mothers feel that hospital postnatal services should be designed to optimise pain management. You can contact me via Twitter or email at [email protected].
Image: Parents and Chelwest Maternity Voices co-chairs (back row - extreme left and right) who took part in the Whose Shoes event on postnatal care in July 2017.
You can find out more about the Mumsnet Better Postnatal Care campaign here.
and still upsets me to think of it ten years later. 
Night 2 was even worse!