Royal Society of Medicine Forum: Coping with the impact of an obstetric emergency on the mother and her carers.
Report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, Thursday 16 June 2005.

This report is to be published in part in the Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

Chair: Dr Anita Holdcroft, reader in anaesthesia and consultant anaesthetist, Chelsea and Westminster Hospital, London

Is maternal preparation for emergency obstetric anaesthesia adequate?
Dr Surbi Malhotra (SM), specialist registrar in anaesthesia, Chelsea and Westminster Hospital, London

Operative intervention during an emergency may interfere with a mother's original birth plan; emergencies may have maternal causes - cephalopelvic disproportion, haemorrhage, pre-eclampsia, or fetal - malpresentation or indications from cardiotocography are examples. The NICE 2004 guideline. Chapter 6. Proceduralaspects of CS:6.2 on decision-to-delivery time stipulates that from the time of the decision the baby should be delivered within 30 minutes; however the College of Anaesthetists relies on the Guidelines for Obstetric Anaesthesia Services of the Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists' Association of 2005, that there should be a clear line of communication between the duty anaesthetist, theatre staff and Operating Department Practioner once a decision is made to undertake an emergency caesarean section (CS). The urgency of CS should be categorised by a system agreed locally by obstetricians, anaesthetists, theatre staff and midwives, and the anaesthetist should be informed about the category of CS. The 7th Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report (1998-2000) stated that there is a generally agreed recommendation that emergency CS should be achieved within 30 minutes of the decision to operate. 'However, this is a pragmatic rather than evidence based rule'.

In practice the degree of urgency is agreed between midwife, obstetrician and anaesthetist and discussed with the mother, although the inevitable haste may interfere with communication with the mother and result in anxiety for her and her partner, whose main concerns are with the baby. The professional team is concerned with the safety of both mother and baby, and would wish to involve the mother in the decision-making process; mothers feel out of control if they are given inadequate information at the time of an emergency (Brown & Lumley 1994). This can result in their feeling dissatisfied with their labour and birth, and they may come to see the experience as a traumatic event, with long term effects (Ryding et al. 1998).

At the Chelsea and Westminster Hospital and with our colleagues in Poole, Dorset, after written informed consents we undertook a survey of the quantity and quality of information given to mothers about their anaesthetics at the time of obstetric emergencies, with a view to effecting improvements in these. The mean age of the 101 participants was 30 years; 60% were primiparous, and 69% had epidural analgesia at the time of the emergency. 67% required immediate caesarean section (CS) although there was no life threatening compromise to mother or baby; for 20% the threat to life was immediate. The remainder required their anaesthetics either for assisted delivery or for manual removal of placenta.

13% had general anaesthesia, 86% regional anaesthesia , epidural or spinal or a combination of the two. More than half of the women were given information during labour; almost half said that the obstetrician had provided the information, while only 11% said that it had been the anaesthetist. Some women had been given leaflets or had educated themselves from the internet, but the great majority received their information verbally.

Anxiety about the efficacy of a regional block was common, almost one third, and anxieties were expressed about insertion of the needle, the condition of the baby, and possible side effects. Women found prior information and the constant presence of the anaesthetist reassuring, or they reported getting comfort from an effective regional block or from the professionalism of the staff. 87% reported a high level of satisfaction with their anaesthesia, and the remainder agreed that they were satisfied. Information given prior to or during labour was generally appreciated, but some women said that they were made anxious when information was given at the time of an emergency, and particularly when presented with possible ill effects. The majority would have preferred the anaesthetist to be the information giver, with the midwife with whom they had made a relationship the second choice. The verbal method was preferred by most, as this provided the opportunity for discussion, and it would be most welcome antenatally or on admission to the labour ward.

Emergencies are difficult for both mothers and professionals. Information given in haste is often incomplete, with mothers feeling that they are excluded from the decision process; as clinicians we must respect the individuality of the women we serve. Ideally more information could be provided antenatally or during labour.

References.

Ryding et al, Wijma K, Wijma B. Experiences of emergency caesarean section: a phenomenological study of 53 women. Birth 1998; 25:246-51

Brown S, Lumley J. Satisfaction with care in labour and birth: a survey of 790 Australian women. Birth 1994; 21:4-13

National Collaborating Centre for Women's and Children's Health: NICE Clinical Guideline CG13 on caesarian section. April 2004

Discussion.

SM, replying to an expressed anxiety that the provision of information about emergencies prior to a birth will medicalise the experience, pointed out that women have the option to read written material or not, but agreed that it might be preferable to give the information at an earlier stage. However, it remains the case that events in the labour ward are often unpredictable.

SM: The selection of cases for this research was not random, but consecutive, with half coming from London and the other half from Poole. More of the London group had epidural analgesia in place, and my figure for this is an average of the two. As the questionnaire survey (based on surveys devised elsewhere) was four pages in length women who do not speak English or understand it well enough were excluded.

The chair reflected that little work has been done to improve information giving when an emergency occurs. SM: Research into labour will always pose difficulties, but we must persevere in order to improve care. Questioning women after births is particularly difficult, as they are fully occupied, especially when it has been a first birth.

Emergencies: the impact on staff.
Sarah Davidson (SD),clinical psychologist, Chelsea and Westminster Hospital, London, and senior lecturer, University of East London (Co-author)

There is an urgent need for support for staff when the emergencies have occurred, with lives lost or lives saved. Interpretation by those involved will determine how emergencies are experienced; those of us working with the cognitive model will be aware that negative interpretations can lead to blame and stress, while the positive can be positively reinforcing.

In the cognitive model beliefs and assumptions about ourselves and the world exist outside our awareness; they influence what we attend to, remember, and how we respond. The belief that we are well prepared enables us to be more effective in action and less likely to be devastated if the outcome is not good. Emergencies themselves can challenge the sense of our own efficacy or that of the team, and if we feel out of control this can lead to powerlessness. Hence the connection between self-reported stress and low staffing levels.

Our experiences and relationships affect our unconscious beliefs, and these in their turn mediate our appraisal of events and emergencies as they occur; our behaviour facing an emergency is modified accordingly, and this in its turn is added to our pool of experiences. An individual's possession of an internal locus of control is likely to aid coping in the face of emergencies; this is made more difficult when the dimensions of an emergency increase - when it is very sudden, unanticipated or uncontrollable; when loss of life is actual or threatened, or when moral or ethical dilemmas are involved. If the support of colleagues or clear lines of responsibility are lacking and if communication is poor the possibility of coping is likely to be reduced. "Who is the patient? Whose is the responsibility?" Doubts such as these are rife in labour wards and neonatal units.

Staff may face further difficulty following an emergency. Their role may go unacknowledged, and they may feel isolated or in conflict with colleagues; they may perceive support offered as unhelpful, for example if confidentiality is not respected. Poor resources or lack of staff are ongoing stresses, as are critical responses such as targeting an individual or team for blame, or adverse reports in the media. The lack of opportunities to demonstrate efficacy and coping can lead to self fulfilling prophecies of poor management. The ritual of marking an event and moving on is known to be important; examples are debriefing and memorials.

The personal relationships of involved individuals may be affected; they may express anger or distress, and feel shame and guilt, emotions which can be difficult to deal with. Syndromes of burnout, anxiety, depression or post-traumatic stress disorder (PTSD) and its manifold symptoms may result. In an environment of failure and depletion of staff the team may experience escalating communication difficulties, with distrust, power struggles and contradictions. Errors increase in frequency, morale is low, scapegoating - where a person's discomfort is split off and located in another - common; absenteeism and high sickness and turnover rates aggravate the situation.

To help us understand these responses we have the concept of the socialised carer (Dartington 1994); having entered a health service full of hope he or she can easily be led into despair and shame by a perceived failure. Routine occupations such as temperature or bedpan rounds act for them as institutionalised defences (Menzies-Lyth 1967). Today's litigious culture leads to distrust and suspicion as the population becomes better and worse informed from sources such as the internet, and the former idealised picture of the service crumbles. With staff shortages the pressure is on to put in that extra hour.

A woman was admitted in a state of great distress with some psychotic symptoms and there were concerns about her safety and that of her baby. For lack of planning there was poor clarity around responsibility, and poor communication between a number of involved teams; the anxieties this generated were not well contained by the staff and the emergency was poorly handled.

If we are clear about our roles and responsibilities in a multidisciplinary setting, and if we know how to access additional resources in a cash strapped situation and how to prioritise them, we will feel in control and will be prepared to cope with emergencies. It is important and valuable for the team to share a narrative around positive outcomes, ability and recognition; they also need signposts to other sources of support. They should value the reflective space and always think before acting. The *good enough" concept (Winnicott 1960) might well be our watchword - to be a good enough staff member of a good enough team, and so prevent our rushing into denial or by over-identification and so asking for stress and burnout, which can result from the unwise management of a perceived need to provide holistic care, one-to-one.

Faced with research implying that psychological debriefing after an emergency can do more harm than good, how are we to address individual and team needs after such an event? Can we find the time and the thought, as we must, to care for the carers?

References.

Dartington, A. “Where angels fear to tread: Idealism, despondency and inhibition of thought in hospital nursing.” In Obholzer, A. and Zagier Roberts, V. (eds.) “The unconscious at work.” 1994; London: Routledge.

Hodgkinson, P. E. & Stewart, M. “Coping with catastrophe: A handbook of disaster management.” 1991; London: Routledge.

Menzies Lyth, I. E. P. “The functioning of social systems as a defence against anxiety: An empirical study of the nursing service of a general hospital.” 1967; London: Tavistock Institute.

Roberts, N. “Integrating staff support into an NHS Trust.” Clinical Psychology Forum 2000; 135: 23 – 24.

Winnicott, D. (1960). The theory of the parent-child relationship. Int. J. Psychoanal., 41:585-595.

Discussion.

A delegate reflected on the harm that can be done if the story told at debriefing is inaccurate; this may leave staff believing that they are responsible for a failure and plagued with guilt. SD: This is particularly true when they hear the perspective of people with whom they do not normally work and which conflict with their own view of an event.

SD: Attachment between a mother and her midwife can be mutually beneficial and so protect the midwife from burnout, as Jane Sandall has reported. But attachment develops over time, and cannot be hurried; it does not come cheap.

Wendy Savage deplored the pressure put on junior doctors at perinatal mortality meetings, and criticised the government's policy of targets. SD thinks that the Government is projecting its own anxiety on to its employees, and needs them to soothe this anxiety with an unattainable excellence.

Are those babies really mine?
Diane Akin, mother of twins

It has taken quite a while for me to believe that my twins are really mine. I had skipped the birth plan bit in the book, as my caesarean section was planned - to fall on my husband's birthday, in fact. Natural birth was not to be for me.

Placenta praevia was diagnosed at 28 weeks; five weeks later I started to bleed and I admitted myself to hospital. I became aware that the staff were concerned for the babies; the bleeding had stopped, but it began again and more heavily the following day, and my private obstetrician was with me within ten minutes. He advised immediate delivery, and the anaesthetist started to tell me about the procedure while I was being wheeled to the operating theatre; he was reassuring, I was fatalistic, but confident that I was in good hands. I felt that I wasn't dressed properly for the introductions to all the strange people there; it was peculiar, lying there with blood everywhere but free of pain. The anaesthetist told me that I was about to have my epidural, when suddenly the obstetrician decided that it was too late for that - I must have a general anaesthetic.

Recovering consciousness I knew that my babies must have been delivered, but somehow couldn't know or accept that they had been born; I don't feel that I have ever been through birth. Michael and Daniel were healthy and well; my husband took them to the neonatal unit. But I was still bleeding, and the obstetrician realised that I had a placenta accreta. The anaesthetic had to be renewed, and later I felt lucky not to have undergone a hysterectomy there and then. My husband sat outside the operating theatre worrying, and it was more than four hours after the babies were delivered that he felt able to telephone the good news to the rest of the family; he hasn't said much, but I think it was a time of great stress for him; his anxiety then was greater than my own.

The gentle care and morphine in the intensive care unit was like heaven for me, an unforgettable experience. By the time that I was moved into my single room at the end of that day I had seen little of my husband and nothing of the babies; when I made this known I got to hold Daniel, but not at that time Michael. After a night overhearing the birth of a baby in the next room I couldn't feel that I was a mother. There were no babies in my room.

After waiting a while for a wheelchair I could meet Michael for the first time, and was glad to be encouraged to hold the babies, but by now they were part of someone else's routine, and it felt odd. Of course I hadn't expected premature babies, and was quite unprepared for motherhood. It was two weeks before I saw the boys naked (their first bath), and 17 days before they were ready to come home, which was a much shorter stay than many of the babies there would have; but we had no private time with them during those days, and a neonatal unit is anything but a homely environment.

It has taken longer than I expected to come to terms with that feeling of distance from the babies, but they are healthy and I am grateful for the treatment I received; I love them, and cherish their first words.

Discussion.

Asked whether she understood the meaning of placenta accreta, DA showed a good understanding of it and of the management. She understood that a substantial part of her placenta would be left in place to be absorbed over months, and she had been able to live with that without anxiety.

DA: I feel that I was adequately prepared during pregnancy, and when I was admitted to hospital neonatal staff offered to show me their unit. I declined this, denying to myself the possibility of premature delivery, but now I wish that I had visited the unit.

The chair, reflecting and that fathers are often in the operating theatre during caesarean sections, wondered what DA's husband, left outside while his wife was in the theatre and bleeding, would say if he were present at this meeting. DA: He was as well informed as I, and I think that he was more anxious for being excluded than he would have been had he been with me.

DA: The only debriefing I got was a useful half hour with a midwife soon after the babies were delivered. Most of my adjustment has taken place in the subsequent months, and mostly after the babies came home.

After her baby had been taken from her to be resuscitated following a normal birth a mother felt disconnected from him until he began to look like his parents. DA: If I feel disconnected there are more reasons than one: I missed labour, and I missed birth.

Aware of the loss of the birth experience caused by general anaesthesia, an anaesthetist described skin-to-skin caesarean section, in the which mothers with epidural analgesia are handed their babies immediately at delivery for them to hold.

One midwife's practice was described: she writes detailed accounts of deliveries under general anaesthesia and gives these to the mothers after delivery, in the hope that this will at least in part fill the gap in the experience which the mothers feel.

Wendy Savage: Does a detailed antenatal preparation for mothers medicalise birth? Although the great majority of pregnancies and births will be normal if left without interference, there is today a great emphasis on risk. I believe that there is a difficult balance to be struck between frightening a woman and leaving her with the belief, which I am sure is very important, that the birth of her baby will be normal.

A delegate suggested that there is evidence that full information given antenatally does not frighten women. SM agreed, but finds that women frequently reject the notion that they could, in the circumstances of an emergency, require caesarean section.

SD: Knowledge tends to become idealised; it is best imparted within a trusting relationship within which issues can be explored. A midwife emphasised the importance of continuous care, which enables her to be aware of any gaps in a mother's knowledge.

Wendy Savage: There is evidence that relatives do not get in the way or behave inappropriately if in the operating theatre when general anaesthesia is used. It enables them when suitable to hold the baby at an early stage, and later to give a detailed description of the procedure.

The profound fetal bradycardia sometimes seen independently of a fall in maternal blood pressure may be due to catecholamine activity after the sudden relief of pain. It is always important to check the fetal heart rate again before proceeding to caesarean section, in case it has recovered. The chair mentioned the not insignificant effect of drugs errors, particularly with oxytocin, when epidural analgesia is in place.

Wendy Savage agreed that there are no clear differences in emotional responses between male and female staff members. She recalled the benefit obstetricians in training got from weekly supportive sessions with psychotherapists; this was evident in their subsequent handling of parents of stillborn babies. Obstetricians, whether men or women, deal poorly with the emotions generated by their work.

SD: Women working in this field frequently adopt masculine attitudes, turning from the emotions to the science. One must sympathise with fathers in neonatal units, permeated as they are by womanly feelings and activities, and where male staff are a rarity. Fathers are attending my weekly parent groups more readily now that I have a male colleague.
Professionals go to some lengths to avoid engaging in the pain of emotional self-discovery. They have difficulty understanding mothers dissatisfied by birth experiences which have appeared to be good from the professional perspective; the necessary ticking of boxes leaves them little space for feeling, except for the guilt which comes with errors and omissions. The chair asked how she should deal with staff in tears. SD would have them involved in some impersonal task, or given the opportunity to talk through the emotive situation with a sympathetic ear. We must at times face and overcome our fear of entering the emotional space in which another is suffering.
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