Examination of Witnesses (Questions 480-499)
TUESDAY 25 MARCH 2003
MS KAREN
CONNOLLY, DR
TRACY JOHNSTON,
MRS ALEX
SILVERSTONE, MS
ROSEMARY CONNOR,
MR ANTONY
NYSENBAUM AND
MS CLARE
HODGSON
Mr Hinchcliffe
480. Is there a gender issue here? I do not
mean—
(Mr Nysenbaum) No.
(Dr Johnston) I do not think there is. I have male
colleagues that have exactly the same philosophy as their female
colleagues.
Chairman
481. But there is a personality or an attitude
issue that makes a big difference.
(Mr Nysenbaum) Very much. It is an issue of background
and what you consider to be correct. Not all obstetricians around
the country have the same views as others, and that does direct
what happens a great deal.
Dr Taylor
482. So your major interventionists are not
just the old fogeys!
(Mr Nysenbaum) No.
483. We lost our obstetric unit a long time
ago because the births slipped below 1,500. Are you in danger
of losing yours? Are you viable at 1,463?
(Mr Nysenbaum) Yes, unquestionably.
484. You say that, but how can you convince
us that you are viable?
(Mr Nysenbaum) We were delivering 800 a year when
I went to Trafford in 1986, and now we are delivering almost double
that. While a lot of units round the country have seen their births
decline, ours continued to remain static. They rose, and hopefully
they are not plateauing and may well go up again. The difficulties
we are going to have will be issues of staffing. That will be
a very serious issue over the next year and a half.
(Dr Johnston) That is an issue in our area now.
(Mr Nysenbaum) It is a national issue. Viability for
births—unquestionably. We are surrounded by large units,
and patients continue to choose to come to our unit for whatever
reason. You can hear from Clare why they come to us. I think we
are viable.
Mr Hinchcliffe
485. If I could ask the two user reps, Dr Johnston
made the point about work needed in terms of counselling, where
women may want to choose sections because of fear. I always feel
on weak ground, as a man, talking about this area because if men
had babies, we would have 100% sections without any doubt. We
all know that and accept that as fact. Is this an issue that you
have experienced? Do you feel, both of you, that you have been
offered a proper explanation as to what happens, and counselled
on the issues that Dr Johnston was talking about; or do you feel
we still have a long way to go in preparing women for this experience?
(Ms Hodgson) I personally did not have any experience
of caesarean or a caesarean being suggested, but it was covered
in the antenatal classes. Obviously, had it arisen, I would have
been consulted about it. I am quite confident that the options
would have been gone through with me in some detail.
486. Coming from the area you do and the nature
of the population that Trafford serves, what do you feel drives
women to contribute to this higher than average rate—although
it is coming down, as we have heard—in the Trafford area?
(Ms Hodgson) I am not really sure actually.
487. It is not something you have discussed
with the women.
(Ms Hodgson) No, it is not something I have been able
to get a handle on really, not having known very many people who
have had caesarean sections.
(Mrs Silverstone) I work in the unit as well with
the women, and I think a lot of it is that they have easy access
to consultants, and the consultants do sit with them and talk
to them. They explain it. They do not talk them out of it. There
is definitely informed choice. In labour, I have noticed very
much in St Mary's, because there is virtually 24-hour consultant
cover, that the staff are not fighting to phone the consultants
up in the night. That is a very, very important thing. If you
presented with somebody in labour and you are not sure, if you
feel confident to phone the consultant, that must be positive
down the levels. It is explained to the woman and the patients,
and they are listening to them. If she is very worried—she
might have had a very traumatic experience the time before with
a caesarean—they will listen to her and will continue to
listen—it is not just that one point at the beginning; when
she goes back again she is listened to and supported.
488. You are saying it is a one-to-one with
the consultant, as opposed to the preparatory work that might
be done in parent craft classes.
(Mrs Silverstone) Yes. I think this is much more important,
what goes on in the unit—continual support and counselling
from registrars, in-house officers and the midwives themselves.
Andy Burnha
489. Does it depend on everyone in the unit
having a similar philosophy, though—that everyone knows
that is the way it is done?
(Mrs Silverstone) Yes.
490. Obviously, often one person is in charge,
and it is getting that ethos around.
(Mrs Silverstone) Yes.
Chairman
491. Do you get the feeling that there is a
similar ethos at your unit as well with both the midwifery staff
and medical staff about making sure people are informed, trying
to keep the caesarean rate down, et cetera?
(Ms Connolly) I think a lot of the decision-making
about caesarean sections depends on the experience and confidence
of the obstetrician dealing with the case. We do not have the
same consultant cover that St Mary's has, and I think it is extremely
difficult when you have got a crisis. Our elective caesarean section
rate, which is what Tracy was talking about, in clinic when you
are talking to people—ours is 8% but it is not vastly different.
The main difference in ours is the emergency caesarean section
rate, and that of course is a decision taken when the woman is
in labour. That decision is taken by the obstetrician that is
on duty at the time, obviously in consultation with our consultants;
but if you have junior staff or inexperienced staff, or people
who are not even very confident—and we were talking before
about the difference in consultant decisions—it takes a
lot of confidence to stand back and say, "no, we will do
a fetal blood sampling and wait and see how it goes". If
people do not have that confidence, then they are much more likely
to go to section in the first instance.
492. This is a completely lay person's question,
but is it not really fairly formulaic: if the baby's heart rate
is above a certain level, or—
(Ms Connolly) I think that is true.
493. Should it not be more—
(Ms Connolly) There are many cases where there is
no question that it is an emergency situation, where there is
a cord prolapse or you have a persistent bradycardia or something—you
would go to caesarean section. That is what the NICE guidelines
are saying and that is exactly what you do. But there are some
cases where it is a grey area, where it can be managed more expertly
by somebody who has experience and confidence, and they can guide
the more junior members of staff and midwives to manage that case.
It may well end up at caesarean section at the end of it, but
caesarean section would not be the first option.
494. Myself and my wife had two caesarean sections
and we strongly felt the first time round that the decision was
unnecessary—it was "you are not progressing quickly
enough; the baby is getting tired and you might have to think
about it". Once they have said that, that is it; you just
have to say "well, great . . ."
(Ms Connolly) It is very hard to retrieve from that
situation if a more senior person comes in, if that discussion
has taken place. It is that sort of situation that might well
be handled differently by a more experienced obstetrician who
would have a different slant on it, and would inspire confidence
not only in the patient but in the rest of the staff to monitor
the situation. A percentage of those would end up delivering vaginally.
Mr Hinchcliffe
495. Talking about the audit mechanisms, what
exactly do you do to monitor why caesareans have been used, and
how far back might you go on the reasons why you have intervened
in this way? I am thinking in particular of the nature of the
population that you serve, which probably has a more middle-class
population than your colleagues here. What messages could you
possibly get across to future mums-to-be coming in, about the
merits of a vaginal birth?
(Mr Nysenbaum) We audit.
496. Would that be a factor in your audit process,
thinking about going that far back?
(Mr Nysenbaum) Yes, we audit in two different ways.
We have had for probably a few years a regular meeting when we
look at the emergency caesarean sections of the previous week,
where one of the obstetricians—the labour ward lead will
go through them with the middle-grade junior doctors and midwives,
and discuss how appropriate they are. We do formal audits where
we pull 50/100 notes, and break down the reasons and look at them
very carefully. Each time we have done a formal audit, it has
been noticed that our rate of emergency caesarean section falls,
starting the day after the formal audit has been produced. We
know where we are going wrong; it is the ability to change that
that can be very, very difficult. We have relatively junior, middle-grade
doctors. Most people say that they are junior and they do lack
in confidence. As James Walker said earlier, it is getting more
and more noticeable as time goes by.
497. Why are they acting differently from how
they were acting in the past? Maternity units have always been
covered by more junior doctors.
(Mr Nysenbaum) The difference would have been extremely
striking. Twenty-four years ago, I was on a labour ward, and within
three months I was competent at looking after the labour ward,
delivering babies by caesarean section, and with obstetric forceps
in those days. By the end of six months I had vast experience,
due to the number of hours that we worked—which may or may
no have been good. Now, to get equivalent experience, it will
take an SPR probably two or three years to get as much knowledge
as I would have acquired within six months of working. It is very,
very different indeed. The experience you gain by hands-on contact
is very difficult to acquire now. I think that it will get progressively
more troublesome. That is a problem that we are stuck with, and
it is getting worse, and significantly so.
Chairman
498. We have hardly mentioned induction, and
your induction rates are very different as well, and I do not
want to leave this area without pointing that issue out as well.
Again, Dr Johnston, you have the lowest induction rate we have
seen of any unit so far. Do you know why that might be?
(Dr Johnston) We induce for medical indications only.
We do not really have a philosophy of social induction unless
there are very pressing situations for that. If there is a medical
indication for induction in a tertiary unit—and there are
often medical reasons for induction—either antenatal fetal
compromise or a maternal disease—but as far as the post
dates induction, no-one is induced before Term + 10. That is in
tablets of stone: you do not do that, and at Term + 10 everybody
is given a choice. They are presented with the evidence that exists;
they have a cervical assessment done to try and assess how easy
the induction process would be. There is a service put in place
that if they opt to continue with the pregnancy with antenatal
fetal surveillance, and they are reviewed regularly at the hospital,
and if they change their minds and say, "I have had enough;
I am now 14 days over and I am still not going anywhere"—"we
will bring you in". Again, it is informed choice. It is not
a case of, "right, you are ten days over; you must come in".
It is a case of sitting down and giving the options: "This
is what your cervix is like. An induction process will be easy
or it will take two or three days and you have got a 50% risk
of a section." You can leave that a few days and see if that
improves, and quite a lot of women will say: "That is fine.
As long as you are monitoring it, it will be fine and I will carry
on." Again, it is informed choice.
499. How does that fit in with the NICE guidelines
on induction?
(Dr Johnston) Yes, there are NICE guidelines—
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