The Consequences of Discontinuing Continuity

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AIMS Journal, 2018, Vol 30, No1

A birth story by Emma Ashworth

It was my booking-in appointment for my second baby, and I didn’t want to be there. I didn’t want to birth with the NHS, but I did want to ensure that I was “in the system”.

“I’m just here to book - I’ll not be seeing you after this”, I said to the midwife.

“Oh OK Why?” She asked, in a genuinely polite and non-intrusive way.

“Because I’m having a home birth, so I’m getting an independent midwife,” I answered, firmly. Her response wasn’t what I’d expected. My decision to birth at home with an independent midwife followed months of fighting for a home birth with my first baby, only to be let down in labour by the attending midwife who really didn’t want to be there, ending up with an unwanted and unpleasant hospital birth. This time I was taking no chances.

“Oh do let us do it - we love homebirths!” replied my lovely, lovely midwife.

It turned out that the independent midwife that I’d wanted was pregnant at the same time as me, due a few weeks earlier I wasn’t aware of others who covered my area (although it turns out that there are many!) so given the enthusiasm of my community midwife, I trusted her and decided to stay under her care.

I subsequently discovered that I had fallen on my feet with a midwife who was well known for being wonderful. Lorraine had a passion for supporting women and babies, and it shone through in everything she did. I had the comfort of being in her care throughout my pregnancy. This continuity of care from a midwife that I knew and trusted allowed me to open up to her about some of the fears that I was experiencing, preparing to birth my second child after the plans for my first birth were taken away by an unsupportive (different) Trust. I was able to explain to her what really mattered to me to achieve a safe and positive birth, and she grew to know me, and to know what went wrong before, so that she could support that without me starting again at every meeting. This continuity saved the NHS’s time as I could go straight in with my new questions without starting my history from scratch with a new midwife, and it meant that when I reached the end of my pregnancy, I felt confident and supported in a way that I’d not felt the first time round.

The best laid plans…

At about 2.30am one night I woke to feel my waters breaking. I woke my husband and scooted to the bathroom where it was clear that it was not just a leak, but all of my waters. I was 36 weeks to my (very accurate) dates, and 37 to my 12 week scan so in anticipation of labour starting soon my husband prepared the birth pool and we went back to bed.

In the morning, nothing further had happened, so we called Lorraine, who came and confirmed - not that confirmation was necessary - that my waters had broken. She did so by checking the pad that I was wearing, as I was now continuously and uncomfortably leaking fluid. She did this by checking my pad rather than by doing a vaginal examination, to reduce the chance of infection. We all hoped that labour would start soon, and she left expecting us to call her back that day.

48 hours passed and still no baby. Lorraine said that the hospital had asked me to come in for my baby to be monitored, which we agreed to, but it turned out that they actually had a different intention for me.

When on the ward I was first seen by a junior doctor who asked me to adopt the well-known heels together position. I asked her what she intended to do, and she replied that she was going to examine me to see if my waters had broken. I explained that they had, but she said that she needed to check. I explained again that my waters had broken, there was no doubt that this is what had happened, and that I didn’t want to have a vaginal examination because of the risk of infection.

“But you have to”, she said.

“No, I don’t”, I replied.

“But we’re going to induce you this afternoon and we need to see whether your waters really have broken”, she said.

“I’m not here to be induced though.”

“But you have to be.”

I made it quite clear that this is not why I’d come into hospital, and that I was not consenting to induction or examination, and she got quite cross and told me that she’d have to get her registrar to see me.

The registrar duly arrived and said, “I understand that you are refusing to be induced. Do you understand that you are putting your baby at risk?”

My husband and I then asked her exactly what that risk was, and how it compared to the risk of induction which was information that she was unable to provide us with other than “you’ll get an infection”, and eventually we were then passed to the consultant.

It was these types of interactions that we had wanted to avoid when we originally decided to hire an independent midwife. We so badly wanted the continuity with someone that we knew, and who knew us. When we get to know someone and build a positive relationship with them they are unlikely to be rude and coercive. When we’ve been able to have discussions about our own wishes, previous experiences and needs for our births, we are starting from a position of understanding and trust when things digress from normality. At the time when my body needed to relax, and my mind needed to believe in the people around me, I was feeling hugely stressed, attacked and isolated and totally lacking in trust of anyone. I could not have needed Continuity of Carer more than at this time, from a person that I trusted. Instead, having to deal with strangers who had led me, by their coercion, not to trust them, was devastating.

We eventually saw the consultant, who was reasonably helpful and worked with us to create a plan which we were reasonably happy with. I asked what happened to women whose waters broke significantly earlier than term, and he explained the normal care plan which would be about combining avoiding risks of infection with monitoring the baby and mother, and considering induction if there was a sign of infection. My husband and I decided to choose this route for our baby despite him being almost at term.

We went home and started to research as hard as we could. We’d started from the position of knowing nothing about premature rupture of membranes (PROM) or its potential consequences, and were now trying to find out enough information to make an informed choice about the care of me and our baby. At the same time, we were trying really hard to ensure that our desire for a natural home birth didn’t result in any decision which could potentially pose a significant risk to our baby. I use the phrase “significant risk” rather than just “risk” as no single choice is risk-free.

I checked my temperature every 3 hours, and kept a very close eye on my waters as they continued to leak (which of course continued, as they get re-made continuously for any sign of infection and there was never any indication of a problem, but any interaction with the hospital meant more coercion, more threats of dead babies from people we didn’t know.

We eventually decided to have a hospital birth with IV antibiotics as at the time we could not find enough information about the antibiotics other than the consultant’s recommendation. We were never advised of their risks. We did not think to ask for the antibiotics to be given at home, although some trusts do now offer this.

Eventually, 5 days after this all started I went into spontaneous labour. We went into hospital quite early as I’d wanted to use the birthing pool, and we arrived armed with a clear birthing plan. This included no continuous fetal monitoring, no vaginal examinations, no drugs, no augmentation, physiological birth of the placenta. The midwife who took us on, who I had not met before that day, read through it and said that she was fairly happy with it all but that she would just like “a baseline reading on the monitor, for baby’s sake”, which didn’t bode well for her actually respecting my needs. What she didn’t know, because I’d not met her before, was my strong dislike of the monitor following an issue with it in my first birth. My own midwife, Lorraine, had been entrusted with my previous story but I had no desire to start telling it to a stranger and again I felt really sad and alone, wishing that I could have had Lorraine caring for me at this most vulnerable time. I agreed to the monitoring because the phrase “for baby’s sake” was one that I was unable to rationally process due to the fact that I was in labour, but I hated it and removed it after 15 minutes.

Several hours later my labour was really getting very strong so I decided to get into the pool, which felt amazing and I commented that I felt that it had “gone back 4 hours”. The midwife replied that in that case we should consider putting up a drip which totally confused me because I was just commenting on how lovely it was! My husband told her that this was all I’d meant, and explained that the drip would not be required, thank you (or words to that effect). Had this midwife been Lorraine, she would have known from our discussions in my pregnancy that of all things, artificial oxytocin was something that I wanted to avoid even if the only alternative was a caesarean birth.

Not much time later my lovely little boy was born gently in the pool. I loved how the pool created a barrier between me and these midwives that I’d never met before, despite my going through one of the most intimate moments of my life. If the midwife that I’d grown to know and trust through my pregnancy had been at the birth, I would never have had to even consider that I didn’t really want to have strangers around me at this time.

In the months following Toby’s birth we did more research, and I am now clear that I would have declined the antibiotics, had a home birth and watched him very carefully for the first few days. Even with the antibiotics, they had asked that my baby and I stay overnight so that he could be checked every 2 hours, but while we did stay, he was not checked at all because the postnatal ward was too understaffed. They didn’t even know that this had been requested. They were yet more new people, yet another break in continuity. When I called the midwife to request that she do Toby’s observations overnight, she laughed at me. She told me that I was worrying over nothing. She didn’t know that we were only there because we had been told that our baby was at risk of dying from an infection if he wasn’t under close observation by hospital staff for 24 hours post birth. She didn’t know that my husband felt, as he put it, “bereft”, after being forced to leave the two of us at the postnatal ward door when he was sent home, and that I was to suffer trauma for which I needed counselling to deal with the incident after incident of contradictory advice and pressure, and my lack of faith from then on in medical staff. A midwife that I’d never met, who had no idea of the terrible stress and anxiety of the past week, and who had no knowledge of the challenging decisions we’d made under appalling pressure, was now telling me that it was all for nothing, and that I was just being silly.

The evidence tells us time after time that a lack of Continuity of Carer through pregnancy, birth and beyond leads to worse outcomes for mothers and their babies. It is not hard to see why women are left thrown from wave to wave of uncertainly and coercion, with no time to build a trusting relationship before being turned upside down by another tidal surge of change. Let’s smooth the waters and ensure that the Better Births vision of Continuity of Carer is available to all women. As they say about doulas, if Continuity was a drug it would be unethical to not offer it.