Amma, consultant obstetrician and gynaecologist

0.00 My name’s Amma. I’m a consultant obstetrician and gynaecologist. I’ve been a consultant for 16 years now. I’m dual qualified: I’m a physician as well as an obstetrician. And my area of special interest is really medically complicated pregnancies. So that takes in women who… whose medical condition can either put them, or their baby, or both at risk. So.. I qualified back in 1986 and, as I say, trained in medicine and obstetrics and… yeah, that’s, that’s what I do.

0.40 What initially attracted you to obstetrics?

0.44 Ah, now that’s an interesting question because I… back in the day, I went to… I did my medical training in Cambridge. And you could at… at that time finish the Tripos – which was the medical degree – in two years and then do something else in the third year. And in those days, you know, the course was paid for by your Local Education Authority, and I actually wanted to do anthropology. So I duly finished my course in two years and then the Education Authority said I couldn’t do that; I had to do a much more science related further topic – and I was quite upset about that. And the topic I then chose was a physiology module and it was human reproduction. And I felt, you know… I was rather disgruntled at having to do it. But then I actually found it really fascinating and that first put the idea of, you know, childbirth and reproduction into my mind. And then when I qualified, I thought, you know, I would, you know, certainly try a junior job in that specialty and that’s how I got into it. You know, and then, I, you know… I found it very… very stimulating and rewarding, and that’s how I got into it – slightly oblique.

1.57 Do you remember what you were taught about stillbirth during your training?

2.04 Well, very little, actually. I think the way we were taught about stillbirth was in the context of… other conditions that could affect the fetus. I don’t think we were taught about it in any way that prepared us to manage women who suffered it. We learnt it that it was consequence of the placenta separating or the placenta failing to feed the baby. It… it was very much as a consequence of other pathology – as opposed to a subject that we were taught about in itself.

2.44 Can you remember before your training what your attitude towards stillbirth was – your personal attitude?

2.54 I think before my training I had very… very, very little experience of that. I’m… I’m… Ghanaian by origin, so in… in West Africa the attitude to stillbirth is… it’s different to Europe. When a baby is lost, it’s almost forgotten straight away. The woman is meant to get on and look ahead to the next baby: to look forward and not look back. So, that’s probably part of the reason that I was unaware of it. I certainly didn’t have, you know, an older sister or female relatives who were having babies at the time, but even culturally it wouldn’t be mentioned.

3.40 And do you remember the first time that you cared for a mother who’d experienced a stillbirth?

3.55 Yes… I mean… I was a junior, so I wasn’t directly responsible and… we were looking after a lady who’d been having recurrent bleeding. And we feared that that bleeding was related to her placenta. We were concerned about the growth of her baby. And we were managing her initially as an inpatient – and she really didn’t like hospitals. She found it very… destabilizing. She was lonely; she wanted to go home. But we were concerned about the baby. And we came to an agreement with her that she would come for monitoring and we asked her obviously to present to us if she got any heavier bleeding. And, you know, that arrangement went well – we were nervous, really, with her at home. And what happened with… what we feared, did happen – that she returned… one morning and when we scanned her and when we listened for the baby we didn’t hear the baby.

5.02 And, you know, that was… I remember the moment when, you know… because my consultant obviously came to scan her once the ultrasound technician couldn’t find the baby’s heart. And I was in the room when… my consultant told her, I’m sorry your baby has gone. And I remember that was a shock. I hadn’t seen anything like that before, and of course I… I knew her because she’d been coming each day. And you know… it… it was really heartbreaking to see the grief. She didn’t have her husband with her and of course she wanted her husband straight away. And I was sort of sent out to… you know… well, not make the phone call, but just tell the ward sister to make that phone call. And I remember being really devastated; I’d never seen it happen before and I couldn’t quite believe that it had happened, really. Because we always give the warnings, in a way you hope they never, never come to pass, but it did in that case. So yeah, well, that was very affecting. I was a Senior House Officer at that stage – so quite junior. Yeah, it was… very affecting.

6.07 Do you remember how you dealt with that at the time? How did you… you know… how did you deal with that?

6.14 Well, I think at first, you know, I was just sort of busy practically – because there are things that have to be done for a lady who’s lost a baby and as… as the most junior member of the team most of those were my tasks. And so in a way it’s a case of being kept busy. So I was busy really. I had to get certain blood tests done. I had to ensure that people were told: that her GP was told; that her health visitor was told – because the worst thing would be that someone would call her and expect to see her for a follow up and there wasn’t going to be follow up.

6.46 So actually I didn’t really get a chance to, in a way process my feelings until I was off call, till the end of my working day. And I… obviously she was on the ward and while she was waiting for her husband, I spent a bit of time with her. And, you know, the first thing I could tell was that she felt guilty and that it was her fault. And I just said to her, I’m very, very sorry this has happened. There’s nothing that you’ve done. And I remember she was blinking through the tears and I remember… it was a look that, sort of, said thank you but I don’t believe you. And I remember trying to say that. I remember feeling really helpless to say anything – so I didn’t say much.

7.33 I just… I was in the room with her for a little while waiting for her husband and I was lucky I didn’t have much else to do. And I was able to… I was there, when her husband came in.  And I stood up and told I him, I said, I’m really very sorry, your baby’s… your baby’s gone. And… I said obviously, I said her name and I said, she, she obviously just needs you now. We’ll be outside if you need anything. I said, we’re going to… I’ve taken some blood tests and we just have to just see that there hasn’t been any [cough] major upset in her body systems and so I’ll be looking at those blood tests but, you know, we’ll leave you alone… now and I’ll come and see you a bit later.

8.13 And then of course he was devastated and we left them. Usually we… they… we put a little… there’s a little emblem that we put on the door… of rooms where people have been bereaved, so that people are not rushing in and out; so that they’re given a bit of privacy. So, yeah, I left them and… we put the little emblem up and then towards the end of my shift, I… I went home and then… only then I really thought about it. So devastating because it’s all about life, the job usually. It’s all about life and you know that there can be losses… but it hadn’t happened to me yet and I was, you know, a young doctor, and that was the first time.  And then you realise there’s loss as well. So it was… it was quite… yeah, quite an impact it had on me… Mmm.

9.05 And you mentioned that that was… you were the most junior person at that point, do you remember the first time you were the most senior person on labour ward when it happened?

9.17 Well, whenever… if there is a loss… staff will always look at the notes and see who is the named consultant. So, yeah, I think the first time I’d been… I became a consultant in 1999 and then I… no, it was probably late 2000, because I had my son and then came back. So yeah, I think… I think I was called in… in one of my clinics – and I don’t think I’d met the lady who had unfortunately lost her baby, because in those days all ladies had a named consultant, but you know, they may be very low risk ladies – very low risk indeed: no discernible risk factors. And so it would be quite possible for them never to meet their consultant. And so it had been with this lady, she’d been totally low risk. Nothing, going wrong; come along for a routine appointment – hadn’t even really noticed a reduced fetal movement. And then the midwife had been unable to find the fetal heart. And then the natural thing is to obviously get somebody senior to scan, and it was my colleague on the… who was covering the wards that day, who scanned her and confirmed unfortunately, you know, the baby’s heart was gone. So I… I got a call in my clinic.

10.41 You’ve had this, you know…  one of your patients. And I thought, oh my goodness. And I asked how pregnant she was. And she was term… and no discernible problems at that time. And usually what happens is, you know staff know what to do when there’s been a loss. And so they… they’d begun to do their jobs. The midwife had taken her somewhere quiet, started… contacted her partner and said that they would call me. It was the middle of my clinic. And… they told her that I would come as soon as I had finished that. And I remember thinking, oh, what am I going to say? What I am going to say now? And I… obviously wanted to know a little bit more about her.

11.28 So when I finished my clinic I went down to the… she was given a room off the labour ward. And of course, I look at the notes and the notes were just full of nothing; she was a healthy woman. And… she had had… two children before – so this was her third child. No obvious problems. And I remember… well, actually I didn’t sort of fret too much before I went into the room. I mean that’s my job; that’s the job, and… the look around the room is, I’m glad you’ve got that job and I haven’t got it. And that’s where… that’s what I call a consultant day, that kind of day, where you have to… you know… deal with patients and give them that kind of news.

12.11 So, I went in to see her and of course, distraught. And the first thing I did was give my condolences. I said, I’m very sorry for what has happened. I briefly asked her if… if she had been unwell or if she had noticed anything, and of course nothing, had been the case. And of course she said, is there something I’ve done? What have I done? I said, I don’t think you’ve done anything. I said, I said, I think our first act needs to be to make sure you’re… be safe. We’re going to do a few blood tests and just see. And for you to wait for your husband to come and then we can talk about what we should do. I want to get you delivered safely and then there’s… there’ll be time to talk about the other things. And you know, she was obviously distraught. She called her husband and I just… I think the point was that she could see that… the affect it had on everybody.

13.05 Everybody was very sad. But there’s only so much you can do, because it hasn’t happened to you. But I… as I say, you try and instinctively… instinctively comfort them. But ladies who’ve had that kind of loss have said to me in later life, you know, thank you for what you did, but you can’t get close to how I was feeling. But I appreciate any… women, I think, they appreciate any attempt at empathy. But it’s such a deep grief. I think that most of us can’t touch that. So yeah, once I, once I had met her and I had… I said, when your husband comes I will come and see you. I think it’s important because, I think again what women have said to me is they feel alone. They feel like in that busy unit, they are the only one who’s child is gone and that no one will understand. That no one will look at them. And I think it’s very important to engage and at least not have that feeling.

14.09 So that’s what I did and I came back out and I thought, oh god, there you are, that’s my first patient… my first patient that I’ve lost. And… then the juniors, you know – as I had been all those years before – there’s a junior who’s doing the basics and making sure the right people are knowing about it; make sure the right tests are being done. And then… and then usually we have some very good midwives and usually it’s an experienced midwife. Again it’s the same thing for a midwife – a student midwife would be overwhelmed – usually quite experienced midwives will be allocated to these ladies.

14.48 And I think the really difficult thing – the really difficult thing – that I’ve learnt over the years is that even in that awful moment of grief, you have to suggest… suggest… the idea of examining the baby when the baby comes. Suggest the idea of post-mortem. And I think that’s… one of the hardest learning events… learning steps of my career – to find the right time to suggest that. I’ve left it too late with certain patients and had terrible difficulty broaching it. And, I think at the very beginning, I almost actively didn’t mention it. But, because there’s such a feeling of why? Overwhelmingly, why has this happened? Then sometimes we may get an answer from examining a baby. I have to say many times we don’t, but I think when there’s a chance then it’s… it’s incumbent on me, to at least suggest it. But I think that’s one of the hardest things to do.

16.01 And it is usually the most senior person who… who will do that, because it’s quite a painful thing to do. You know, one’s come in, in that morning, and the baby was alive – or you know, she felt the baby was alive – and suddenly we’re talking about an examination on her baby. And… so yeah, asking for… but I’ve learnt it must… it must be done early, must be done right in the early moments because after that a woman closes down. She’s emotionally closed down to survive. And it’s harder to suggest those things. It’s harder to penetrate that… that coat that she’s created for herself. So I think I’ve learnt that over the years. In amongst the grief you have to suggest that.

16.50 And you know, there have been ladies of different faiths, and people of different faiths and different cultures have different attitudes. Certain cultures will want their baby to be buried very, very quickly. And they’re just the same as other women in a way, they want answers, but they have a cultural approach that sometimes might prevent even, them getting the right answers. And again, I’ve learned over the years that, you know, there are things you can offer: babies can be photographed; they can be x-rayed; little portions of skin can be taken that can be examined. And actually now, coming to the modern day, there are, you know, quite subtle things that can be done that give a lot of information without disturbing, you know, the appearance of their baby. So that you can give some more information, because after the grief, after the baby is even buried, people have questions. I wonder if? And you want to have tried to answer as much of those things as possible.

18.00 You don’t want them to – in amongst their grieving – to have regrets that something wasn’t done. But I think one of the hardest things for a consultant is to ask for that at the right time. Ensure that they have had full knowledge, whilst they’re coping with this awful grief. I certainly find that has been one of the biggest challenges of my career.

18.30 How do you talk to parents in that situation? I mean, what words do you use?

18.37 I think a lot of it depends on how they are at the time. So if someone is just distraught, I think mainly I just work on trying to calm them. Because if they’re distraught it is usually that they feel they have done something – and I really… I think even if we are going to find something – so many times you don’t find of course – but 99.99 percent recurring it will not be anything that anybody’s done. So I usually feel confident in saying, it’s nothing you’ve done. It’s nothing you’ve done. I know you’re feeling that, because I know that a really common feeling is that women go, I was his mother. I didn’t do my job. I didn’t protect him. I’ve let him down. And I try… I can imagine that feeling – that’s maternal feelings. But I usually do try and say, listen, it’s nothing you’ve done.

19.36 But, if we can find any answers, we will try. And there are some ways that we might try and look at that. And sometimes depending on… you know, sometimes women go, I don’t want him examined and I don’t want him cut. I don’t want him touched. And I go that’s fine.  And what I’ve learned now – and really over the last few years – is to call a consultant paediatric colleague, to just come in, take a look. They look at babies and children all the time, and there can be certain appearances that give them clues that wouldn’t give us clues. Now, I didn’t do that at the beginning of my consultant career. It’s something I’ve learned to do, and… so there’s always something. So, the… the way I’ve broach it is, this has happened. I’m so sorry it’s happened. We may not find anything, but there are a few things we could do – depending on their culture and their religion, and their… their emotional state, that could just be a naked eye looking at the baby, might be x-raying the baby, might be taking samples, might be a full post-mortem exam.

20.52 But you can start that discussion. And I think it’s quite hard because… sometimes if you start talking that way, you’ve got to be careful not to cause distress because people feel, oh, it’s all over already! You are just objectifying. And so it’s very, very… I think I’ve just… I’ve learned to just gauge it by their responses. How engaged they’re able to be. If they’re too grief stricken you have to leave people for a while. But I’ve learned not to leave them for too long. I’ve made that mistake in the past, when… I had a lady that was very, very grief stricken. Really, nobody could even come near her. And we left her for too long, in the sense that she called me some weeks later wanting an examination of her baby and it was very, very late to institute that. It was possible, yah, but it was very late and that I… I felt… that that would not give her as much information as an earlier examination might have, but I hadn’t felt able to approach her.

22.03 And that’s what I mean about the learning curve for professionals. I learnt how you have to maybe just get in there and give the idea of it; because if then later when people feel able, they ask for it, then it might not be as effective if it’s occurring too late. So, I learnt from that. So, it’s… it’s always… I would say, I learn from every patient. Every patient is different in how they respond. And then I learn something about how to deal with this from every patient. Because people are different. I’ve had patients call me later, ask me to really… try and reassuring them again that there was nothing that they did. I think that’s the overwhelming feeling women have: of guilt. You know, the baby was growing inside them, what was wrong with the baby’s house – that the baby couldn’t grow? It’s primal, isn’t it? It’s just very basic. And, so I would say that’s the overwhelming thing, I am usually just trying to just reassure them there was nothing that they did wrong – because after all I hope they’re going to grow another baby.

23.19 They need the confidence. And that’s what I think. I’ve got such an immense respect for women who’ve lost babies because they can’t have another one without going through nine months. And so it’s about restoring their faith in their bodies, that they can do it. You know that will be a long nine months, and you have to get them through it. They can’t have another baby without nine months and that’s what… I’m hugely respectful of women who take the plunge and do it again.

23.51 So, part of what I say when they have… when they’re right in the eye of the storm and they’ve lost the baby… is there is nothing that they did wrong and let’s see if we can find out why it happened. Let’s get them delivered safely. And let them begin to start to heal. There’s only so much healing I think that a woman will do – there’ll always be some kind of wound there, but… that they achieve enough in their journey to feel able to try again.

24.28 I think the other thing that I notice is that, another response when a baby is lost is, to want to try again straight away; to want to soothe the pain, with another baby, straight away. And I think what I would say – having seen many women in that situation – is that… yeah, another baby… soothes some sort of pain, but it doesn’t soothe the pain of the loss of the first one. And I’m always very keen that these mums don’t try again too quickly, because I just feel that they’re still grieving. And then there’s the anxiety of the new pregnancy. And there’s the very real possibility of sharing the birthday. If you try again so quickly and then the whole emotional significance of those days, in that month, and when your new baby may come that time – so that’s a birthday of joy and there’s a birthday of grief. I think that’s very hard. So, I like my ladies to wait. I wouldn’t say they rarely do. Some do and some don’t.

25.50 Women will always do what they feel they need. But I always want to say, from my experience, what that last bit may be like. Because I… as I say, I think people just want a new baby; they want another baby; they want to get on; they want to start – or add to – their family. And I just want… and I want that for them too, but I’ve managed so many ladies in the second pregnancy after a loss, so I can see… I’ve seen different responses as the due date approaches. And I think it’s enough of an emotional… challenge to be approaching that due date without that being also the birthday of the baby they lost.

26.38 And some ladies, may bear that in mind and others may bear it in mind and go, I’ll be alright; my need to have a baby is greater than worrying about sharing the birthday. And I think all that is fine. In the end, it’s them not me going through it, but I think, I just want to give them the value of my experience. But it’s… nothing’s sacrosanct. When they come to me pregnant so quickly, I just say, hello. Come on. Let’s… let’s go through this one, you know… I think its fine. I am so hugely admiring of the strength of women who’ve lost babies. So you know, it’s a… it’s a pleasure to manage them again. I understand when they don’t want to come: when that… that unit, or that room, or that clinic is associated with such raw emotion for them. And I always do say, you know, wherever you’re looked after, you know, I think you’re going to do well. And I wish them luck. And sometimes women will come back to me. Some people… sometimes women will come back to the hospital and not to the same consultant – and I’m never at all offended by that. You know, I really like it when my colleagues go, you know that lady who had… she’s had twins. They’ve come out fine. And that’s great.

27.58 I think one of the most affecting things I remember was a woman who… who I hadn’t managed, she wasn’t my patient. She lost her baby and unfortunately she had some you know post-delivery complications. The placenta hadn’t come out completely and she’d… she’d bled and she kept coming back and poor woman, you know, I scanned her in my… my gynaecology session. I do scans. And there was a little piece of placenta still there and I just thought she really needs that removed. Because she’s going to carry on bleeding and you know, this whole nightmare for her was not going to end.

28.40 And I told her and her husband and you know she sort of just shut her eyes and just thought this is just a nightmare that’s not ending.  And I wanted her to have antibiotics before – and they needed to be intravenous, and we would normally admit someone for that. And she just looked at me. She said, I cannot come into this hospital again. I cannot. I cannot. And… you know, it’s quite interesting – as with a junior doc – and you know we have so many protocols and things that guide our practice. And I believe in protocols, they keep people safe, but sometimes you’ve got look at the individuals. And I knew this woman really couldn’t bare to spend a night in the hospital but she had to have antibiotics because that fragment had been there a long time and it put her uterus at risk really, because it would be very soft if it was infected.

29.23 And then, so we made a plan for her. She had a really good community midwife, and we put the drip in her arm, we gave her the antibiotics, and she went home. And she would come in and the midwife gave her the antibiotics. She needed three doses. And then she was going to come in and her named consultant – who she knew and trusted – came in specially to just take out that fragment. And, you know, I think she was eternally grateful for that. She didn’t want to come into the hospital and I think she knew that it wasn’t the norm, what was happening. But we just needed to do that for her. You know, just because protocol says this that and the other – we knew she wasn’t at risk. The midwife went to her house. We knew she was sensible. We knew that the drip was in, it wasn’t… and we managed that for her.

30.07 And I remember she told me the name of her child that she had lost and it was – I remember all this was probably late November. It was probably late November. And… I talked to… we’ve got a bereavement midwife here – a really good one – and she was seeing her and I asked how she was and she told me that she was doing well considering. That she was really grateful that she hadn’t been made to stay back in the hospital. And I… so I sent her a card for Christmas. And I said, I know it’s not the Christmas you envisaged, but I hope that either I, or one of my colleagues, will manage you into having a brother or sister, for the child you’ve lost – and I named the child you’ve lost – and I hope that you will have happier times. And the bereavement midwife told me that that card meant an awful lot; and it meant a lot because I’d named the child that she’d lost.

31.13 Because that’s the other thing: that this child that you think about and you plan for, never gets that chance to be recognised. And just naming that child in the card, made that woman very happy. You know, and I was pleased for that. And I… I don’t always do that, but sometimes I’ll do that. I’ve done it a couple of times. And, I think for certain women, that is… it’s a… It’s a big thing. It’s giving the child the oxygen it hasn’t got, because it is not alive anymore, but just an acknowledgment – because it should have been mentioned in cards that Christmas shouldn’t it? But it didn’t come. So I… I was pleased to have done that.

31.52 Again, something I’ve learned. I don’t use it with everybody, but sometimes though, it’s just the acknowledgement. It’s just the acknowledgement. Because I do think, it is very hard for everybody else around someone who’s lost a baby. People don’t want to… rub it in; lets say, if you were pregnant at the same time, what do you say? People at work who’ve seen you off, you went off at 36 weeks and you had a baby shower. People don’t know what to say. So with the best will in the world, they choose silence. And that silence can isolate the woman. And, she’ll… I think most women know that actually people don’t know what to say either, but she’s got her grief, and she’s feeling alone, and she doesn’t want to be alone, and she’s not sure how to… how to change that. The people around are not sure how to do it, and so what you get is a load of silence.

32.50 And I think that’s why it’s very important that women can talk to other families and individuals who’ve been through what they’ve been through – which is why Sands is such a good organisation. Which is why skilled bereavement midwives are such marvelous assets. I think bereaved families need to talk to other bereaved families to really feel… to be able to relax and say what’s on their mind. I always acknowledge that to my patients. I haven’t lost a baby. You probably need to talk to someone else who’s been through what you’ve been through. Not all women want to do that, but I always will give them the choice and make sure they’re aware of how they can access that. I personally think that it’s very helpful, because in the end it hasn’t happened to me. In the end even the bereavement midwife, unless it’s happened to her. So we’re… I think we’re all aware of the value of our experience, but we… it hasn’t happened to us. And so it’s really important to make sure that they… ladies can see and talk to people.

34.06 And the men, the fathers; I think it’s really hard on fathers. They can talk to people who’ve been through it like they have. And I think we have to accept that we can’t… we can’t do that part. We can’t aid their healing in that area and I think that other people can who have been through it and I think it’s a great source of support. One of my senior colleagues here is, very… still… she’s retired now, but she’s still very much involved with that. And so I’m sure in her practice learnt an awful lot, because that’s even more contact with families remote from the loss. And I think again, if I talk to my younger colleagues – either trainee doctors or young consultants – it’s that feeling that it never goes away. I’ve been to several… you know, I do high-risk obstetrics, so I go to conferences where we’re talking about problems, and increasingly over the last couple of years we have women who’ve experienced loss. And the loss can have been 20 years ago. And the feeling is as raw as it was then – but they’ve moved on. But the feeling is as raw as it was. And I think that’s something that we have to recognise. Yeah, definitely so…

35.30 You’ve talked about the difficult… you’ve talked about the difficulty of talking to parents about broaching the subject of post-mortems, but when you’ve told a family that their baby has died, how do you talk to them about delivering the baby?

35.53 Well, how a baby is delivered will depend a lot on… what has gone on for the mother before. Because if you have a mother whose had several caesarian sections, then ordinarily we suggest that women have caesarians if they’ve had two deliveries, and it may be the safest way to deliver a baby. If the baby is in a mal position: if it’s lying transverse. Then we must deliver the baby by caesarian – that’s the only way. But in the vast majority of cases – when there isn’t an issue like that: the uterus is unscarred and the baby is head down and the woman is essentially well – I would always encourage a normal delivery. And I would suggest it in the context of keeping the mum safe, delivering her in the safest way, and in a way that allows her to recover, and not affect her future childbearing. Because to do a caesarean – we do it many times obviously; we do it when it’s necessary – but it does affect your future childbearing. Future labours have to be managed with an… with an eye on the scar, so they aren’t… they’re not … they’re labours that need monitoring. And depending on the mother’s attitude to that, she may feel constrained, so I’d rather avoid caesarean delivery. And the other thing is the risks of caesarean are worth – in my opinion – worth running for the sake of a healthy baby.

37.55 But those risks become – well, for me – unacceptable when you can’t give a woman a live child, after putting her through those risks. The risks will be the same – of bleeding, making clots, possibly getting infections – but you balance those risks with, you know, your baby’s distressed, but if get the baby out now, baby should do well. Well, you don’t have that in a stillbirth. The baby’s gone and you would expose your patient to those risks. Now as I have said, if there is some reason why she has to have a caesarean then fine, but ordinarily I would always encourage my ladies to deliver normally. I think they have the same worries as they would if the baby was alive: of being in pain and of having complications. So, I would really assure them, that we’ll make sure they’re pain free. Talk to them about the conduct of the labour. That we essentially induce them, and that when the uterus contracts, we make sure that they are pain free. We try and keep the same midwife with them so that they can develop a one-to-one relationship with an experienced midwife.

38.08 And during that time, they can talk to the midwife about what they want to do when the baby comes. Women are different, some want to be just totally involved in every aspect. Some want to even see the baby come out; they want to hold the baby straight away. And others are different. They feel they don’t want to see the baby straight away; they’d like the midwife to take the baby, wrap it up, and they’d like to just – in their own time – ask to see the baby. That might be some hours after the delivery – it might be minutes. But when you’re planning a labour, that’s why you have an experienced midwife, and the couple can talk about what they want to do when the baby comes.

39.57 It’s also important that we try and make sure that… when I say the labour is complete: we make sure that the placenta is out and complete, because the worst thing is to have a complication of the third stage – which is the placenta coming – that may bring the woman back to hospital. So you want to really be sure that the placenta is out. And sometimes if a loss has happened earlier in a pregnancy – let’s say, 26 weeks, 30 weeks – sometimes the placenta won’t separate as easily as it would at term, you know at 40 weeks. And part of the preparing of a woman for a labour at that gestation would be – well, certainly would be my advice – that she consent to a little procedure after the delivery to ensure all the placenta has been removed. Because it is quite common for it to fail to separate well and if little fragments are left they… you know, she could bleed and come back with problems and retained products.

41.16 And as I’ve said, to have a complication after such a sad event anyway, I think is doubly devastating, because you still have to then come back to hospital and engage again with the services and maybe have a procedure. And now all that’s so unacceptable, so that… the aim is safe delivery; good pain relief; ensure that everything is delivered – that the placenta is completely removed. So for earlier gestations to have that extra procedure – it’s a short one – just to ensure that when they go home, they don’t have to come back.

41.54 So I…  the way I put it is about, you know, this has happened and I’m so sorry it’s happened, let’s get you delivered safely, with as little pain as possible so that you can begin to… start to recover. And I must say that most couples are happy to consider that. I mean a lot of them… as I say, a lot of my ladies are not the high, high-risk patients: are not the ones in whom I’m looking for it. They’re my… the small population that I have who are totally well, for whom my name is just on their notes and they don’t expect to meet me. And so it is a… it’s a double shock because they’ve been totally well and it has come out… it’s come out of the blue. So… that group of ladies, were contemplating normal delivery anyway, and so the idea of delivering – even though their shocked they’ve lost their baby – they understand and would want to deliver normally.

42.59 I have had, on occasion, a lady who was planning a normal delivery totally, actually – hopefully without doctors around – who received the devastating news that she had a stillbirth and then absolutely in a way lost faith in her body and just wanted the baby to be taken out. And I remember of course all the staff were, sort of, dismayed that she would want a caesarean for a baby that wasn’t alive, and were trying to persuade her, but I felt in the wrong way: highlighting the side effects of the operation, bleeding and infection and blood clots. And, you know, she… she wasn’t to be persuaded that way and she was adamant that she wanted the caesarean. And… I was her main consultant, so they came to find me, and, you know, my colleagues were quite upset, that they would have to do an operative delivery for a baby that wasn’t alive, for a lady in her first pregnancy.

44.04 So they asked me to see her, and, you know – I think several groups of doctors had been in and tried to dissuade her – and I remember going in and her, you know, her husband was asleep on a little futon beside her and the room was, you know, low lighting. And I could feel that… this sort of weariness. I felt they thought, oh, another doctor coming in to try and persuade us. And I think the first thing I said was, you can deliver the way you want. I said, I want to say that. The first thing I want to tell you, you can deliver the way you want, but I want to tell you my thoughts about delivery. And I told her that, you know, she’s quite right, she… caesarians are done all the time… and the risks of caesarian – which had been talked to… talked to her about. I wasn’t going to say them again – she was well aware of them. I said to her, those risks are worth running when the health of a baby is… is on the other side of the balance, but for me as your consultant, none of those risks are worth having if I can’t hand you a live baby. None of those risks are what I, as a doctor, would want for my patient because I can’t hand you a live baby. And if you have a caesarean for that reason, like every woman you have to heal – you have to take some time – it will delay you trying again. You have to heal.

45.52 And it was interesting because, you know, clearly when you’ve had that news, you couldn’t care if you lived or died. So I can imagine being told about the risks of cesarean, you’ve lost your baby, you probably just want to die. So that would have no effect – it would have had no effect on me to tell me side effects if I had lost a child. But what was affecting was to be told that I might have to wait to try for the next one. And I think that that just opened a chink, which allowed us to communicate, and that she… started to consider normal delivery. And she told me that she wouldn’t push, if she did decide, because her baby was gone and she wasn’t going to do that. And I was able to say, that’s alright. Ladies with bad hearts, we don’t let them push. And nature will bring the baby down the birth canal. And you will have a midwife, and if necessary, we’ll lift the baby out, so you don’t have to push.

47.04 But it would be good to deliver and not run the risk that you would be delayed in trying again. I expressly did not talk about those other risks, because she didn’t care about that. But she did care about waiting and being unable to try. And eventually she decided to have a normal delivery. She had a marvelous midwife looking after her. The pain relief was perfect. And she was able to just really talk to her midwife and her husband. And the midwife told her when she was ready to push, she was unaware, the pain relief was good. She was a healthy woman, the labour progressed and it was the midwife who told her that she was virtually ready to deliver. And she didn’t need to push – the baby came. And she was able to meet him and say goodbye to him and take mementos. And I think that was very, very important for her – and for her husband. And I think she was glad in the end that she hadn’t… abdicated the chance of having a normal delivery.

48.20 So I think that was important. I learnt something there: that we’re concerned with the medical side effects, but the emotional injury of losing a baby, makes women oblivious to side effects. So that you couldn’t persuade a woman to do something because she might die, in the moment that she’s lost her baby. She’d probably say, oh, fine. Because the grief of losing the baby is so much. So, I think I learnt – and I think the doctors who were counselling her, I would hope – learnt that that’s not the way to get people to have an operative delivery in that situation. The way to… empower a woman is to say, to give her the chance to be able to try again as soon as she can. And of course, having a caesarean to deliver, when you don’t need it, would interfere with that. And that is why she chose – not because of all the scaremongering of the doctors. So I learnt something from that that. I think it’s important.

49.38 How, as a professional, do you balance what uses the most positive professional… you know, the most positive decision as a professional, with the wants of a family in that emotional state?

50.01 I mean, I think… as a… as a health professional looking after people who are in such a terrible situation, my allegiance is always to the baby… to the mum. Even when the baby’s alive – my allegiance is always to the mother. And when the baby’s not alive, my allegiance is to the mother and her future. And, you know, in the end, women must have what they want. And I would hope that I would have the skills to show them what they can have, what each choice would mean for them. And I think I’ve learnt that they want a future. You know, their future as a mother, in that moment, has been dashed. So the way to empower them to act would be to offer them the choice that brings that future closer. And so that is how I usually… I mean, women can have what they want in the end. My job would be to make sure they knew what… each path would bring. And you understand they just want to be mothers; they want to add to their family if they’ve already had a child, or they want to be a mother if they haven’t got a child. And so that… I… I counsel them with that in mind and… with that positivity. I don’t counsel negatively. I don’t say you’re going to lose this if you do that, because in that moment they don’t care. In that moment women do not care about any of that. But they do care about the future. They could care about being able to hold a baby that’s alive and so I think I try and… I try work from that viewpoint. I work from that viewpoint.

52.01 Can I ask you about your… how you separate your personal and professional responses to stillbirth? As a professional how do you, how do you do that?

52.15 Yeah, well… well it’s interesting because, you know, I had my children late in life – mid-forties. So I spent much more of my life not as a mother, than… as a mother. I think my attitude to stillbirth… what? Deepened… I mean I was always affected by it, but deepened once I’d had a child. I don’t find it difficult to separate and… advise women, because… I’m there to ensure their safety. And I’m clear what they need to be safe. Women have so many different ways of expressing their grief. They have cultural overlay, religious overlay, their own personal experience, but I don’t… I don’t have a difficulty in just… just separating off the personal.

53.22 Of course, I have not had a stillbirth myself. I’ve seen a lot. I’ve seen different ways of handling… the situation. I think I would always go – if I had lost a child – I would want to deliver normally. I’d want to get on. I would not be… be wanting to forget. You know, culturally, in some cultures – West African culture – you’re just meant to look forward; you’re not meant to look back. I think it’s important to grieve and let something go. So… sometimes, if I’m talking to someone who is of that culture, I will say, I know you’re meant to look forward but it’s alright. Its alright to think about this child – for now. It’s alright to do that.

54.14 And so in a way, that’s a personal thing that I’ve brought in, because I understand the culture that is… uppermost for those ladies. And I will sometimes say look, it’s alright. Okay? And I think sometimes, you know, some of my patients are grateful for that. But generally I’m able to separate because, you know, I’m there for the women, so I want to make sure that they’re safe. They don’t need me to be… overly emotional. They don’t need to be… need me to be dabbing tears away. That’s… that’s not the empathy they need.  They need me to be… steady and sympathetic, but not overly. There’s no point for me to weep with them. That’s not going to help them; they’ve got people that’ll to do that for them. My job is to keep them safe and show them the future. Show them that it wasn’t their fault, that the baby went and tat they can have another. And let’s try and keep you safe, and get you well, so you can begin to think about that. That’s my job. I usually find… I don’t find a difficulty with doing that.

55.24 You mentioned that having your own children did affect you as a professional. Can you tell me a little bit more about that?

55.34 Yeah, well I think, you know, I’ve always done… complex obstetrics and so we have this sort of, you know, that sort of rather trite phrase: precious babies. When of course all babies are precious. But I look after women for whom the… delivering of a baby really is a very special event. I… I always say a lot of my patients have got no business being pregnant, you know, they’re not very well! But if you… you know, women are… women are strong, strong individuals and as soon as many women get over a serious illness, you know, they go back to the same aspirations as every other woman: they want a baby – whether or not there’s been something awful gone on with their heart, or their kidneys, or their brain – and they, you know… A lot of people say, oh, isn’t she just happy to be alive? Why is she trying to be pregnant? And so, you know, I do have ladies who put themselves at risk but they… they usually do very well.

56.29 So I’m very used to the concept of, you know, babies that because of their mother’s illnesses are very tiny. And we’re nurturing them along and we’re looking to try and just let the pregnancy last long enough to get the baby grown without the mother’s illness taking over.  So I was used to that concept of these, you know, sort of precious babies. And of course I have my low-risk population who are having their babies and it’s all going very well. So I’m used to that concept and I kind of just thought, well, you know, my baby will be special because it’s mine, yeah? But I was really unprepared for the rush of emotion that you get with your own baby.

57.07 So having been in so many delivery rooms with babies that really shouldn’t have been there, that, you know, the mums were not meant to be well enough to have them and then they came.  I thought I was kind of used to it. And then I would be having mine, and I was an older mum, so that was a gift as well. But I was unprepared for the real rush of emotion when you have your own child. I had my own child in my own unit – delivered by the same midwife for both babies. And it was a… a thrill; a great thrill. And I think… I think a lot of people say this don’t they? You look at the world differently once your children are in it. You know, the news has more impact on you because you think, oh well, my kids have got to deal with that. And so I think in that… in that sense, I didn’t change, I think, the way I behave to my ladies – I hope I was… I’ve always been empathic and professional and kind.

58.01 So I don’t think I changed in that way, but I think the enormity, I kind of understood the real enormity of it. Whether or not it’s a high-risk or whether it’s just a totally low-risk and you’re beginning your life as a parent. So I think that struck me even more – because I suppose I was in that way of it where I deal with high-risk and so, you know, there we are – and everybody’s just having their babies. And then I had mine, and I realised… how… how seismic it is for everybody. I think maybe I just thought it’s my patients – the high-risk ones – but it’s seismic for everybody. It was seismic for me. And… so it added, I would say added a different… another dimension. I don’t think … I hope I’ve always treated my patients well. So, I don’t think I changed, but I think I understood more what a seismic event it is for everybody. Not just people who have come through medical adversity to become pregnant. I think that’s what I learned.

58.58 Can I ask if being a high-risk obstetric professional, affected your actual pregnancies in any way?

59.07 Well, it’s funny because, of course I’m used to looking at pregnancies that could have problems. I mean I was an older mum, so I kind of knew about risk and things like that. I think… I tell you what, I don’t think it did because I was actually… I think the one thing, if you’re a medical professional, being looked after within your specialty – so, if I’d had, let’s say, some kind of gut problem and I was under a gastroenterologist – and in this case I was pregnant and under an obstetrician – I’m actually a good patient. I don’t start… I wasn’t being an obstetrician for myself through my pregnancy. I chose an obstetrician I trusted, a midwife I trusted, and I let them look after me. I let them look after me.

59.54 And… so…  that made a lot of difference. That made a lot of difference because I wasn’t so… you know, when I had my blood tests, I let them look, I knew they would tell me. I tried as much as possible to be a normal patient.  I joined a yoga group, locally. I asked the teacher not to say that I was an obstetrician at the local hospital.  And I just was like everyone else, trying to focus on my baby and have a normal delivery. It was quite interesting when I would hear other mother’s views of the hospital; the hospital that I worked at; the hospital at which I was a consultant – because they would talk about whether this consultant or that one would let you go overdue or their views and things like that and…

1.00.42 I think the difference for me was that I didn’t have a fear of the hospital. Some of them were a little bit frightened because they felt they’d lose control. They had their plans. And I still had my plans – I wanted a normal delivery – but I wasn’t fearful if I wasn’t progressing, because I kind of knew what would happen, and I knew that the doctors were not… not knife happy, not forceps happy – whereas some of the other women felt that they might be.

1.01.04 And I, you know, thoroughly enjoyed trying to be just a normal patient and focus on my baby and try for normal delivery. And the really interesting thing was that we were all encouraged to come back and talk about our experience. And I had a very normal delivery and… quite lucky at my age. I had a really good midwife and I was able to go back and say that. And some… some of the girls in our group who were really, really intent on it utterly natural had – for various reasons, you know, baby development complications – ended up with quite a lot of intervention. And we kind of… when, you know, they came back we were like, oh, how did you feel about that? And they always brought their babies. And they went, you know what? He was in trouble and it was great that I could have help. So, you know I wanted a water birth? But, you know, I couldn’t. The doctors were great, and here he is. And, you know, that more than anything, was just very, very helpful, to other women in the group.

1.01.58 Because you know, you’d seen women who were very, very, very focused on non-intervention; nothing should go wrong; I’ve got my birth plan. And for some of us it went well – others it didn’t – and it was really important to see them come back and say, look I’ve got this wonderful baby and I’m happy. So, I really enjoyed a bit of anonymity when I was pregnant. And as I say, chose doctors and midwives I trusted and I actually had a pretty, pretty normal time. And I was very lucky to get a normal delivery. And… that was great. Actually I had him on my own unit … so they were very… the midwives were saying, see it’s quite good isn’t it, normal delivery? And I was really pleased to have achieved that actually. So you know, I say to my patients sometimes, I’ve been a consumer and a provider – sometimes say that.

1.02.48 I’m interested, going back to your role … as a… as you say as a provider and a consumer. As a provider, as a professional,if you do… do you ever think that it’s helpful to have an emotional response to your work?

1.03.07 Oh yeah, I think you do have an emotional response, but it doesn’t have to be overt. Yeah, you’ve got to be. You’ve got to… yeah, you’ve got to be affected by your patients, but not in a way that makes you unable to work. Not in a way that overtakes you. Of course you’re got to respond – I mean, it’s one of the most emotional specialties. Interestingly, as I say, I deal with high-risk – but I mean, I deal with a lot of normality – I say to medical students it’s the one… firm that you may do where nobody’s ill. I mean, it’s not an illness pregnancy, but it can have complications – but it’s not an illness. And that is why women must have such a say in what goes on. Because there’s nothing wrong with them, so they’ve got a right to say, I want this that and the other.

1.03.52 Our job is – for really healthy women – is to just say… to show them their options. If there are actions that we want to take that they’re not keen on, to explain why we… why we suggest it – but it’s a suggestion; they don’t have to take it. So you do have be, still be an emotional being, but it mustn’t overtake you. It mustn’t prevent you being a good doctor for your patients. So I still feel all the emotions that we’ve discussed. I feel devastated if someone’s lost a baby. I feel thrilled if someone’s conceived after years of infertility. You see what I mean? But… not to the extent, that I can’t look after them my ladies. Not to the extent… I mean, you know, they don’t need that from me. It’s not helpful.

1.04.43 Is there support available for you or your colleagues or your trainees, you know, should that emotion become overwhelming?

1.04.52 Yeah, I think you’ve… you’ve touched on something there. I think, certainly when I was training, there was very little training in how to break the news to a mother that the baby had gone: very, very little training. But ,over the years, the medical profession in general, yeah? – and we’ll talk about in obstetrics in particular – the medical profession in general has recognised the need for communication skills. And they are being taught. I’m one of those people, I didn’t believe that you can teach empathy. I think I still have a bit of skepticism about that – but there are empathic skills that can be taught, and they are being taught to this new generation of trainees.

1.05.38 Coming to obstetrics in particular, I’ve said, it’s a basically normal healthy women going through a normal healthy process, so when it goes wrong… it’s devastating. So, when there is a near miss or a disaster, it’s devastating for everybody involved. And I think, it’s getting better, but there hasn’t been enough support for staff involved in losses of babies or mothers. And I think the unit I’m working in, is… is pretty far-sighted in that it has counsellors now for the health professionals. Chances to debrief and talk in confidence – if necessary – to somebody about those feelings.

1.06.37 Alongside that, there’s the official requirements of dealing with tragedy – that there will be reports; there will be reviews, but even actually within those very sort of set, official procedures there are what we call round table discussions now. And they’re… they’re quite good, because round table is everybody who was involved comes and they can just talk and actually a report is fashioned from their discussions. And it’s a chance for people to say, I saw her temperature go up. I gave the paracetamol and it still went up.  You know, people feeling, I wish I’d done this, I wish I’d done that. And it’s a chance for people to speak. It’s called a  Round Table One. And then the official review process will occur and, you know, causes and root causes are examined and a report is made. And then there’s a Round Table Two when the report comes out. The report findings are shared with the people who were involved and there’s another chance to talk and do things.

1.07.56 So that’s the official process, but outside that, certainly, I think increasingly in units, they’re trying to create support groups because some people are affected years later by these losses. You know if you’re a busy midwife you may look after several women who have a tragedy and… this is what we talk about resilience. You know, how do you pick yourself up from that? Just as a mother feels there’s something they may have done, if something happens in labour, the doctor thinks, oh, if only I’d delivered her then or a midwife: if I’d done that.

1.08.31 It’s natural, it’s human nature to feel, could I have done something else? And health professionals need an outlet for those feelings, because they have to go back on the labour ward and deliver somebody else and look after somebody else. I think it’s been woeful… previously and I think it’s starting to get better… to support the professionals involved, when there are losses. There’s no doubt that it’s devastating for all. There’s no doubt it’s devastating for all. And that people need support and debriefing. I think it is a bit better developed for midwives because their… their way of working involves supervision. So a midwife is naturally sort of linked to a supervisor and they are there for all aspects of their practice: for good practice; for practice that could be improved; for events that may upset them, So, its actually… their structure has a leeway for debriefing.

1.09.41 Medicine’s always been terrible like that. We’re not meant to have any problems. We’re meant to just come to work and be great. But… all of us are affected. Consultants – right down to the most junior, junior. I think it’s been woeful. But I think the powers that be and those of us who now, you know, when we meet in our departmental groups, are crying out for a resource for our own debriefing. And so there are, you know, there are counselors who are either brought in or who are part of units – different units have different ways – but I think all of them are starting to realise that if you’re going to ask this workforce to just come out and keep delivering women, then you have to support them when things have gone wrong.

1.10.34 What advice would you give to a sort or… a junior doctor encountering a family who’ve experienced a stillbirth for the first time?

1.10.47 Well I think, if I remember my own experience, I think the first thing is to support them, in they’ll… they’ll feel devastated. And acknowledge their grief and say to them, that’s alright. Because just as you were talking to me earlier, about whether you should let emotions show, when you’re younger and you’re less experienced, I think it would be very hard to stay focused and able to do your best for the patient. You know, when you’re a young doctor and it’s the first time or you may have been involved with a patient, it might be very, very hard not to cry when you’re working… when you’re with them, and it might be very hard to keep focused and to do your job. And I think I would certainly say to a junior doctor, I understand that. Don’t feel bad for that. It’s very difficult. And so I would certainly support them for that.

1.11.42 But I would say that a woman needs you to be able to do the right things for her, so despite your grief you still need to make sure that her tests have been done, that the other people have… you have to do the other things around it – because those jobs, fall to the most junior doctor. They’re actually very important jobs. So, I would support them in their grief and I would actually make sure… who is your educational supervisor – these are the people who supervise them. Go and tell them. If you’re having a hard time; if you really feel that you can’t come to work tomorrow – that’s alright. Let us know if you need some more help. I think I definitely… I would offer that, because there’s no way that they would say they need it. Medicine’s a difficult thing. We all have to look like we cope. That is changing, this new generation of doctors, I think, are far more supported. My generation was stiff upper lip. But I think I would just encourage them to seek help if they’re suffering; to acknowledge that it is devastating; to remind them though that they’re doctors, they still… the patient needs them to do a job. So that’s how I’d do it.

1.13.06 You’re talking about the changes in attitudes to the emotions that… that clinical professionals may feel. What other specific changes have you seen – in terms of the care – over your career for people going through a stillbirth… or families experiencing stillbirth?

1.13.28 Yeah, I think it’s improved a lot. I mean… some things haven’t changed in that, you know, everyone finds it hard to look after a patient who is not happy. Now whether that is unhappy with the food, unhappy with a long wait for an operation, or they’ve had something awful like a stillbirth. People naturally would hope that someone else is dealing with that. Okay? And I think that was… I think the system allowed that and I think that certainly in the past, you know, let’s say a woman comes for her routine scan and the baby is not alive. Often, you know, the ultrasonographer wouldn’t even communicate that to the woman, she’d… they’d… she’d just say, err, you need to just wait. Someone else has got to scan you. Wouldn’t even sort of say why that is; you’re sitting in a corridor waiting and eventually, you know, somebody senior comes, and they scan you, and they tell you your baby’s gone.

1.14.28 So, because that ultrasonographer didn’t want that responsibility – it’s not her job – and so, you know, in amongst that there’s so… that’s so harsh isn’t it? You come for a scan and somebody’s not telling you, you’ve got to wait for somebody else… you might wait ages. You might wait ages. And nobody’s going to, sort of, come near you because… that’s a difficult thing to say. So it was always left to the most senior person and that could take ages for the senior person to come. Now I think that kind of thing has changed.

1.14.55 I think there’s… Stillbirth has always unfortunately been part of obstetrics; it’s a… it’s a living process. It’s loss going on at the beginning; middle; end. But it hasn’t ever been acknowledged. It’s kind of… we hope that that never happens, and so we get on with the living, don’t we?  But I think that attitude is changing and I think – particularly over the last couple of years and with current campaigns – because it’s always been something that’s not talked about. Because you know, obstetrics is happy, isn’t it? It’s all about babies and you know we don’t talk about losses. But I think, you know, women are… feeling able, I think, to start talking about it. We start to see programmes about it; we start to hear women speaking about it. And it is though it’s like some dirty secret – and it mustn’t be, mustn’t be.

1.15.51 So I do think the profession – and society. It is not just… it’s not… you know, hospitals are part of societies. I think that society is a little more open. Not way open, yeah? A little more open to acknowledging these losses. And I think, as I say, the presence of bereavement counsellors, the existence of Sands, and the acknowledgement by doctors of loss is all a step in the right direction. Can it be better? Yes. It could be better. But, I think it’s a bit like mental illness. People don’t… it’s a bit like a dirty secret; people don’t want to acknowledge; don’t want to accept that it’s there; don’t want to discuss it. It’s as if you… you haven’t got to give it space.  If you don’t give it space, we can pretend it’s not there. So it’s better than it was and it can get better still. It can get better still.

1.16.55 I mean I always have great admiration for the midwives who are the bereavement midwives because the majority of their work then is with women who have a bad outcome. And they create good relationships and can be very supportive and I often… I mean those… those health professionals are really resilient – really resilient – because what they’re doing is always seeing the rare events that lead to tragedy – but that’s their work. So that’s their… their daily work. And I think it’s quite hard to keep a sunny outlook, but they do. Because they’re usually so… enthused by their patients. The positivity. Trying to get over it and helping them to do that, and helping them to the next stage – which is usually conceiving again and supporting them.

1.17.55 So, it’s better than it was, because we have professionals now focused on that. And because now all… all of us are really, really focused on asking about fetal movements and encouraging women to say, it’s not good today. The baby’s not moved well. Get up and come see us that day. Don’t leave it till tomorrow. That feeling that you’re not going to be wasting our time. Because I really hate that – in a way about the NHS, people hear so much about it being under pressure – I really hate it when a pregnant woman goes, I’m sorry I don’t want to waste your time. I just thought… And, I go, you’re not wasting our time! You come in if you don’t think that baby’s moving – day or night. You’re not wasting our time.

1.18.36 I’ve said, I’d rather you come in and your tummy looks like a bag of ferrets, than you don’t come in. I’ve said, please don’t feel you’re wasting our time. And I think those little things that… women must feel that they can access. Because we’re worried that the baby may die. And I think, you know, we’re sort of saying, please come in. Don’t wait. Those things we never said before. And so people didn’t feel that they should… didn’t want to waste our time. Oh, I’ll come in the morning. He hasn’t moved, but I’ll go in the morning. Too late. Come straight away. They must feel that they can come. So you know, lots of little changes that are going to make it easier for people and… to be encouraged to, to vocalise their worries. It’s important because we’re going to pick up a woman who’s baby might have died overnight, but if she comes then we might catch it. And it’s really important.

1.19.35 We’ve… you’ve talked a lot about the women – the mothers. What about the fathers in… in this situation?

1.19.43 It’s awful for fathers. So awful for fathers. Often the fathers are not there when the diagnosis is made because often it’s the mum who’s come to the clinic. And I often think, oh my God, to get that telephone call. And to come in and… you know… I think… expectant fathers are in a funny… there in a funny kind of role because they, they still want to be protectors and they still want to – depends on their relationship with their wife actually – they still want to run… run things! And they want it to be alright. Sometimes… it’s… it’s very different. Sometimes, you know, they’re just devastated in the corner. Other times they’re just desperately trying to support their wife – but they’re devastated. I feel for them because of course our focus is on the mum; our focus, it has to be on the mum.

1.20.37 But, certainly, you know, I think in most units we certainly try and always accommodate the fathers so that they can stay and that… encourage them to say what they want, as well. I think it’s hard though. I think our focus is very much on mums. I think it’s very… I will always ask my ladies… whether their husband will be able to have time off? Does he have close friends? Does he have someone he could cry with if he’s not here with you? I usually ask that kind of question. And, I think, of course, it depends on different people’s relationships… how the devastation shows itself.

1.21.24 Again, culturally it will be different. Different religions it’s different. I often find sometimes though the husbands busy themselves with the practicalities. They go and ring people; they see about funeral arrangements – and I see them as displacement activity. They’ve got to do something. They feel so helpless they can’t help their wives. They’re usually very worried about their wives feeling pain during the delivery and that’s why, you know, I always try and reassure them. I say, we’re going to make her comfortable as possible, and you can… you know, if there are other children they’ve got to go and look after the other children – they often have to juggle that. So it’s difficult.

1.22.11 I think we could probably do more for fathers. But I think we have to do more for mothers first. It’s difficult. I will usually ask about dads when I see my ladies. I usually see my ladies six to eight weeks later. And just get a handle on how they’re coping and you get a little idea of their social set up. I will usually ask, who knows what’s happened? If people’s parents are alive and in the country, often there’s a lot of parental support, but, you know, increasingly now in London you’ve got people who are really displaced; they’ve got no other relatives in the country. And they’re isolated. And I… I will ask about, you know, whether… has your husband gone back to work? How’s he coping? Do you talk about it? And sometimes couples don’t talk about it.

1.23.07 Men sometimes find it very hard to express themselves. Again it depends on the relationships. I’ve seen couples where the husband goes back to work straight away. And that’s how he’s coping, burying himself in work. But then she’s at home alone and… and wanting her mother who’s not in the country. You know, it’s… it’s very difficult. So what I would say to you is that personally, I try not to forget the dads. And I will always ask about how they’re coping, but we’re still, I think, focused on mums and it’s difficult. Like I’m sure we could do more for dads. But we probably need to do more for mums before that. It’s tricky. Its very difficult – very difficult.

1.23.52 If they come to that second… that visit, then I will talk to them. I’ll give them a little bit of the consult that is about them: and how about you? How are you coping? Are you sleeping? Have you gone back to work? Can you tell anybody about it? And then I ask the couple usually, have you told your social circle? Do your friends know? Do you talk about – and usually they’ve named their child – do you talk about…? It depends on again their mindset and their culture as to whether they’ve done that. Because I’ve had couples saying, no one wants to hear about that. No, we don’t talk… no one wants to hear about that.

1.24.30 And I always feel slightly… I feel sorry… I feel sorry for couples where the culture has made that. Certainly, in West African culture’s a bit like that. Because in the end, I think it has to come out some time. It has to come out – grief – some time. You have to deal with it.  But… yeah, so I try and… I will always try and involve a father if he comes to that visit and I will always ask the mother about her partner. But, yah… difficult, difficult for fathers. Sometimes they feel they’ve failed too. They feel… they’ll come and ask things like should I have got different food? Should… there was too much noise. I was working nights. She was by herself. And I said, you didn’t do anything wrong. Just like for the mums, there’s always something that they think, I could have done something different. Was it because we had that row? And I just have to try and say, no. It’s nothing like that. Its nothing like that… so that they can feel confident.

1.25.30 Is there anything you feel we haven’t touched upon or you’d like to add?

1.25.38 I think I want to, you know – if any woman is listening to this – I want… I know that many women have had an experience where they feel that they haven’t been cared for and I would… you know, as a doc that saddens me. I think that it’s a hard situation for doctors. I think they try and I think just like all the millions of types of people there are in the world, there are a lot of different people who are health professionals, and it’s a challenge. It’s a challenge to face that devastation and I think different doctors handle it differently. And I… want to say to women who’ve lost babies that… I think somewhere, in… in all the doctors who’ve looked after them, is a great wish to comfort.

1.26.42 But not all of people have those communication skills or the emotional ability to connect. Now, I think that we should… people who do this line of work, people who are in obstetrics, people who are in most of those face-to-face specialties, should have some help to gain those skills. I’m sorry for women who’ve been cared for by doctors who don’t. But I’d like to reassure anyone listening that… the way I train my juniors, the way I would talk to anyone coming into this line of work, would be to highlight the need for that; highlight the need for that. We’re moving away from being so scientific in our approach to being a little bit more holistic. And I think that’s… that’s, that’s what women deserve, but it will always be hard. It will always be hard and some people, with the best will in the world, some professionals find it hard to cope.