 Felly, mae'n meddwl i'ch gweithio floraeus yn gweld ddechrau. Floraeus yn ffordd o'r cyffredinol yw 30 gadw, yn ymgyrch yn ymgyrch. Mae'n cyffredinol i gael ei ffordd ac yn ymgyrch â'r cyffredinol yw'r cyffredinol sy'n gweithio'r ffordd o'r cyffredinol i'w gweithio'r gweithiau. Florence is the lead obstetrician for perinatal mental health and has a joint clinic with the perinatal mental health colleagues. She's also the link consultant for the trust's home birth team and has a joint clinic with their consultant midwife. Florence is also a member of her local maternity voices partnership. She has co-founded hashtag mat EXP with Jill Phillips, a grassroots movement of women, families and staff caring for them working together to improve maternity services. The workshops have been a tremendous success being used by more than 50 maternity services and still being used today. Florence is also a clinical representative on the RCOG women's network and has her own podcast called the OBS pod. Florence, I don't know if you're able to turn your camera on and we'll turn ours off and then I'll give you presenter role. Hello, can you see me? We can. Welcome. Perfect. Thank you very, very much for the introduction. I'm just going to shut my blind because I'm going to be a bit stripy otherwise. You've got rain. I've got a bit of sun. So I'm very excited to be here. And I'm going to talk about collaborative working and I'm just going to give you some ideas the sorts of things that I do in my day to day work and the midwives I work with do. And I'm very happy to be interrupted and ask questions as we go along. If there's something that you want me to expand on, just put it in the chat and hopefully Ali and Leticia can just draw my attention to it. So a little bit about who I am. So I've been working in obstetrics and gynaecology in the NHS in the UK for about 30 years now. And actually, when I became a consultant, I decided to subspecialise just in obstetrics, which at the time was relatively unusual. But maternity care had always been my absolute passion. Labour ward was where I felt happy. It was my happy place and I really wanted to focus on that and improving maternity care. Along the way, I had two daughters of my own and I had very different birth experiences in terms of experience but identical birth experiences in terms of clinical outcome. So with both my daughters, I had an emergency cesarean for what people would describe as failure to progress. This made me realise even more than I had before how the language we use, the way we talk to women, the way women experience their birth and the care they're given has a massive impact. Because although on paper, my births were identical, to me, they were very, very different. One was a very negative experience and the other a very positive experience. So, as Allie mentioned, I've done lots of work on trying to improve women's experience of maternity care. And in lockdown, I decided to start a podcast to try and demystify the role of the obstetrician, make us a bit less scary, a bit more approachable, and to try and let midwives and pregnant women using maternity services kind of understand our thinking and a bit about us and what it's like to be us. One thing always leads to another with me and I ended up giving a TEDx NHS talk in August of last year, which is called Birth Should Be Special, about the idea that a birth experience is a woman's unique experience. And given I work in a high income country, women are often only having maybe two, three children in their lifetime. And those experiences are the profound moment for them when their child is born and that stays with them forever. And that's not to say if you have more children, it's less important, absolutely not. But we need to understand that birth is a pivotal moment in that woman's life. And indeed, I heard some time ago some recollections of women. It was interviews taken in a hospice at the end of life. And one of the key things that women wanted to recount about their lives was their birth experience. So it's important to the day they die. In my job, I'm teaching, training and supporting not only junior doctor colleagues, but also midwives, student midwives. And in their turn over the course of my career, midwives have taught me an immense amount. I'm sometimes labelled an honorary midwife and I'm really proud of that title. And so when it was suggested to me, I might like to come and talk at Virtual International Day of the Midwife. I absolutely jumped at the chance. So why am I here? I'm here because I strongly believe in midwifery. So access to a midwife and good midwifery care is crucial to outcomes for mothers and babies. We know the evidence is absolutely abundant. But midwives are only part of the system, as it's sometimes called. A maternity service is composed of all sorts of other health professionals. And it's important that we work together if we're truly going to put a woman at the centre of the care we give. As professionals, how do we make that happen? If that midwife is that key contact, that key continuity, hopefully, and key person, then midwives are advocating for women as well as caring for women. And how we interact as obstetricians, anesthetists, nursing staff and other health professionals can have an impact on that relationship and support of that relationship. So I'm here to share my ideas and improve collaboration, hopefully provide some ideas about respectful, safe women-centred care, wherever in the world you are, and hopefully make some connections. It's exciting to see people from across the world. And I'm interested that there's quite a few people from the United States because that's quite a different sort of maternity care provision. So I'm going to explore four basic things. I'm going to talk about relationships, leadership, information and communication. So before I start, I'm going to talk a little bit in relationships about teamwork. Who do you see as part of your team? I did some work on experience in the operating theatre and I took Jill Phillips, who I collaborate with, who's not a medical professional, to look around the operating theatre. And it was really fascinating because the sister-in-charge of operating theatres very proudly displayed this beautiful display of staff photographs. And when we looked at the photographs, we noticed there were nursing staff and operating department assistants, but there were no anesthetists and no surgeons. And we asked her, this is the operating theatre, where are the anesthetists and surgeons? They're not up on your board, surely they're part of your team. And she said, no, they're not part of our team, they're just visitors. So thinking about who actually belongs in your team, who do you see as being in your team is an interesting question because what you might think of as your team might be completely different from what other people think of as your team. So I'd like you to say, if you can, by taking the poll, which I'm going to give you, who do you think might be part of your team when you're on duty? I'm just giving it a moment. So we've got 15 responses to see if anyone else wants to do it. So when I'm on duty, I definitely feel it's the whole team. So I've been on Labour Ward today and I'm working with my colleagues, anesthetists, midwives, nurses, midwife in charge, students, a whole range of different people, pediatricians. So I'm going to publish the results. So we've got most people saying that every member of staff on duty, they consider to be part of their team, which is heartening. We've got a few who feel one or two that are just the midwives or just other junior people. And that picture I put up about flattening the hierarchy is really important. How approachable are the other people on duty? Do you feel able to go and talk to other people? So sometimes we work alongside people, but we may not be a genuine team. Do we actually really work together? Professor Michael West has done a lot of work on teamwork and he talks about su day teams where people aren't actually working as a team and really coming together, understanding each other, having a common purpose, a shared goal and then reviewing things. But they just happen to be people that are working together. It's a bit like when you have toddlers at a play group and they're kind of playing, but they're playing alongside each other rather than with each other. So do we really get to know each other? Some suggestions and things I've participated in to try and get to know and understand my colleagues a bit better are rather than a randomized controlled trial, a randomized coffee trial. So that could be that you put your names in a hat and you pull someone else out that works on your team and you just go and have a coffee together or have lunch together or just meet up and have a chat together. It could be that you decide to do that with a specific person that you perhaps work with but occasionally but don't know very much about. How do you get to know another human being as a person, understanding the whole of them, not just their work or their grade? What's going on for them? What are they interested in? What do they feel is important in their day-to-day work? So trying to get to actually know each other and I've done this both within the maternity unit but also we've done it across maternity units. So an initiative a few years ago was to have a randomized coffee trial of people interested in Matex improving maternity experience across the UK and we matched people up so that actually someone who was working in perhaps Devon could talk to someone who was working in Scotland for half an hour and now with the advent of Teams and Zoom and these virtual platforms it's really easy so you could have a randomized coffee trial with someone on the other side of the world doesn't necessarily have to be someone in your team but getting to know your team and understanding their roles. Another way of looking at people's roles and understanding what they really do is shadowing. So our admin team are really critical in improving continuity of care and making sure a woman sees the same midwife throughout her pregnancy and hopefully also being looked after by that same team in Labour. So they have a really critical role but how much do we understand about what they do and how much do they understand about what we do? So one of our admin team who works in the maternity back office and organizes all the appointments and sits on reception came to shadow me on Labour wards so that she could understand what the final outcome is and what that woman's experience of birth is and I went and I shadowed her in the office and understood the complexity of how to get the woman an appointment at a time that she could go to that was with the correct midwife in the correct place so that she would get continuity of care and sat on reception to see the sorts of worries women come in with, what appointments might need adjusting do they need interpreting services and all sorts of things that I haven't thought about. One of our consultant obstetricians had one of the home birth midwives come in and shadow her on Labour ward because she was very used to looking after uncomplicated births and women laboring physiologically at home but didn't have a lot of experience of women in an obstetric environment and one of our consultant obstetricians shadowed one of our theatre runners so we may do a case, do a cesarean perhaps walk out of theatre but do we know what the runners are doing to tidy up after us clean the theatre, sterilize things make sure the equipment goes back to be re-sterilized, account correct the floor mopped and then all the equipment, where does it all live and what do we need to do to prepare for the next case so understanding the crucial role that we each play in the team and how that team comes together and starting to try and get to know the rest of your team a bit helps build understanding so coming back to roles and responsibilities I'm a consultant what does that actually mean? well if you go back to the origin of the word consult the definition is to get information or advice from a person or book etc with specialist knowledge on a particular subject so that doesn't mean I have to do absolutely everything but it means I can be consulted so what does this mean in practice? I am the link consultant so many of the women under my care will never meet me I don't necessarily need to meet them I work closely with a number of midwifery teams and we can decide who needs to see me who can see them and how best to make sure that that woman gets the right care from the right professional within the team the picture I've put up is actually the perinatal mental health team so we've got specialist midwives that you can see on the left and myself and then on the right we've got psychiatric and psychiatric mental health nursing support so we will see women in a joint clinic but it might be that they need to see the specialist mental health midwife it might be that they need to see the psychiatrist or they might need to see me and the psychiatrist and we'll have a lot of conversations going on behind the scenes perhaps emails back and forth or sharing information on our electronic record or they'll come and say to me this woman does actually need to be seen by you I'm seeing her today but actually this problem is cropped up can you see her? so a consultant is a critical part of the team but doesn't have to see every single woman we can delegate and share out tasks depending on what the relevant expertise is and this works with a number of teams that I work with not just the perinatal mental health team the other key team that I work with is the perinatal mental health team the other key team that I am part of is the home birth team what does an obstetrician have to do with home birth you might say home birth is uncomplicated pregnancy and birth at home it's nothing to do with an obstetrician but actually being the support behind the scenes being there when a woman perhaps develops a complication or even just a slight deviation or change in her risk factors that means maybe she needs a little bit of obstetric input sometimes the midwives will email me or contact me or the women will come and see me for an appointment for us to discuss is home birth still a sensible option maybe it is maybe it isn't strictly speaking according to guidance but balancing up the risks and discussing things together we can come up with an approach that's individualised for that woman maybe it means having a bit of extra treatment available at home or explaining to her she's got a slightly higher chance of being transferred in in labour so there's a lot one can do as a consultant to support the midwives and a lot of those women having a home birth I will never see but I'm there if something crops up and it's important to have that relationship of trust so I've worked with the team for a long time I know the midwives are extremely experienced in home birth so when I'm talking to a woman about the chance of complications or problems at home I'm very confident that I know that that team are very experienced and I will tell her if the team say that you need to come in then you need to come in you will need to be transferred and you need to listen to that team because they're very competent someone had their hand up Just from Linda you tell her the advantages of home birth too Oh absolutely yes and often so a lot of the women that are asking for something that's a little bit more out of guidance shall we say I will often say to them actually yes I think you're quite right that home birth actually could be a really good option for you for example I wouldn't necessarily encourage a vaginal birth after cesarean at home but actually for some of the women that have had intervention and you think they didn't have an obstructed labour there isn't a reason maybe they've had a cesarean for breach birth for breach presentation then actually if they go into spontaneous labour being away from our doctors could actually increase their chance of a successful it's about balancing up the risks because we know that the outcomes are better for midwifery led care and home birth and because I've got that trust with the team and I know they're used to doing home vaginal birth after cesarean I know that if anything starts to deviate from normal that they're going to recommend the woman comes in and have a low threshold so I can say yes I can't officially recommend this but I can understand the pros and cons and why and yes there could be some benefits of this and the same with perhaps a woman who's got a normally grained baby but she's gestational diabetes but well controlled on diet officially she shouldn't be having a home birth but actually we can have a rational conversation about risks if your baby's not macrosamic and your blood sugar control is good and your labour starts spontaneously so we can have sensible conversations because yes there's a lot of benefit so I want to think a little bit about hierarchy now so I showed that slide with the midwife at the bottom and the doctor at the top and this idea of hierarchy and that's really important within relationships how flat or guess high would be the opposite is the hierarchy so I want you to just take this poll now and tell me how easy you feel it is to raise questions or concerns at work so I don't know if you're aware of the each baby counts work from the RCOG and one of the things they looked at was the fact that when there's a CTG concern how easy is it for people to escalate and can they escalate clearly and a lot of problems come about with decision making because people don't escalate or feel apprehensive about escalating and this is a really important safety question going back to what I said about getting to know your team if you know your team then you're much more likely to feel safe letting the midwife in charge know or letting the doctor know that you're worried about things so I'm interested to see here that there's a bit of a mixture and that actually a third of people on the call are feeling sometimes they feel a bit apprehensive about raising concerns and that is a worry and it's difficult to get a good culture where it's very easy to escalate and I'm going to talk a little bit about some of the things that may make that easier so one example is what we've done with fetal monitoring training so as I mentioned fetal heart monitoring can be a big issue in terms of escalation and risk of action not being taken or people not feeling happy to escalate and at my trust we are all educated to the same level so we all midwives, junior doctors, consultants senior team we all do the identical fetal monitoring training I do apologise my dog has just arrived we all do the same fetal monitoring training we're all identically trained we all go to the same master class once a year three or four hours of mandatory training we all take a competency assessment we all do the same one we're all marked in the same way and therefore we have a common language and shared understanding and everyone can recognise an act so rather than the old system where it might be that the junior midwife in the room would escalate the midwife in charge and then she might tell one of the junior doctors and then the junior doctor might tell the consultant and then a decision might be made everyone has the same understanding so I can have a midwife come and say to me Florence there's a chronic hypoxia there's a lady with chronic hypoxia or Florence there's a lady with subacute hypoxia on her CTG and I don't need to go and check I mean obviously I will go and see the women so I will check but I immediately know what I need to do and that midwife will immediately tell me this woman needs delivery this woman, this baby is in trouble so that need for escalation is taken away because everybody's on the same level everyone's got a shared understanding and everyone's view is respected I've also started as Allie mentioned in her introduction doing a joint clinic so doing a joint clinic with my consultant midwife colleague we found that a lot of women who were slightly having alternative care plans were having to come and see her and then come and see myself and there was a lot of duplication of appointments and it wasn't very helpful and we decided to bring things together so that we see the women usually once and then we can have some email back and forth or I might follow her up if needed but we will then make a written care plan and share with her via email it will go on our computer system at the hospital so that everyone is aware of what the care is that we're hoping to provide but it just means that we're not giving inconsistent advice it isn't that the midwives are saying one thing and the doctors are saying another thing and the pediatricians are saying another thing we can just bring everything together into one appointment and that's been really helpful and recently it was just so lovely to receive this feedback from a woman and hear how much she felt that having that joint appointment had really helped her then I wanted to talk a bit about leadership so I want to know where you're working and it's interesting we've got lots of people from the States because I think my understanding is a lot of women give birth in anithotomy in the States so let's take this poll how do most women giving birth vaginally so this is excluding cesareans give birth in what position just giving a bit of a time warning Florence it's 22 so we've got about 5-10 minutes ok I'm going too slowly aren't I ok in that case I'm going to publish this poll that's not as bad as I thought it was going to be actually so we've got 50% in whatever position they want so in this country it's around 20-25% depending on the year that give birth in anithotomy regardless of whether it's an assisted vaginal birth which is really quite worrying and this led me to do the anithotomy challenge which was trying to put myself in that women's position because as I mentioned I'd had emergency cesareans so I wanted to understand what it was like in anithotomy and I did a anithotomy challenge for NHS Change Day and if you look on Twitter at hashtag anithotomy challenge you'll find lots of different people have followed suit and done really interesting reflections with their teams on what it feels like, how vulnerable and exposed even though I was wearing clothes building understanding of what it's like as that woman as people come in and out of the door or come and talk to you between your legs what that actually feels like and how difficult that is and I've done this with student midwives and I've done this with midwives and I've done it with doctors and I'll practice development midwives do it with all our new starters now so that they get from the beginning and also sense of ok if I put a sheet and cover her up and give her a bit more bit less exposure a bit more modesty that makes a small difference, if I put her in anithotomy for the minimum possible time that makes a small difference and this week I've been really gratified to see some people doing the anithotomy challenge in Southampton, Isle of Wight and I'm really sorry for maternal mental health awareness week. It's also important how you role model and I try and role model quite a personalised caesarian experience so giving the baby direct to mum if baby can come on your chest with a vaginal birth, why can't it for a caesarian birth you can just pass the baby across the drape for skin to skin with the umbilical cord intact while you're waiting for optimal cord clamping of course with the uterus open I can't leave the umbilical cord waiting for white sadly although sometimes I can because sometimes the whole placenta is delivered and I can pass baby placenta the whole shebang to the midwife to sort it out. I put on here about different anaesthetics because I've also had issues where both parents are excluded from the birth of their child because the woman is having a general anaesthetic. We don't generally have partners in theatre at that point and I have on occasion managed to bring the partner into theatre to see the baby born even though the woman is under a general anaesthetic because why should that baby arrive completely surrounded by strangers How good are you at discussing names or do you talk about women as diagnoses so we've got people mostly using a woman's name which is great you know some of us get into bad habits and I do it myself sometimes where it's the placenta previa or room 24 and that's really bad we need to remember these are women we need to remember these are human beings and I usually on the wardrobe go into a room and say hello my name is Florence and I will say hello Latisha hello Allie whatever their name is address them by name and it helps implant them in my mind as that person as a specific person rather than a diagnosis or the same with the staff it's important to consider that your fellow staff you know are not just we have a real bad habit of talking about the peed as in the peed attrition rather than using their name their people and they deserve to be known by name language is really important I mentioned my births were failure to progress the use of failure is very negative and also using language women can't understand like IOL that means induction of labour to me but to an ophthalmologist means intraocular lens so not only can it cause confusion but women don't understand what we're talking about so we need to be transparent and clear with the language we use knowledge is power so it's really important to give women good information if we're going to hope to give them good women centre care and we're very much trying to treat women autonomously we're moving away from this paternalistic idea of medicine where I tell you what you should do because I'm the doctor I give you information on which you can then make your decision is the way forward so that's why I started my podcast and it was partly from maternity staff to try and help them understand the things that I'm thinking about but also to try and get my thoughts out to pregnant women and often the midwives will recommend to a woman a particular episode related to whatever problem they have in pregnancy and I try and signpost to nice guidance or RCOG guidance so that there's some good quality information because let's face it these days women they may use the internet they look stuff up so at least then they get some good standardised quality but also I try and be open and honest and discuss the fact that some things we're not very clear what the evidence is we're making recommendations but how good quality is that evidence so to bring it to an end and I'm sorry for rushing through things a little bit I think what I'd like to leave you with is that anyone can make a difference these are just my thoughts and ideas there are little things that you might be able to change in your day to day work with the team that you work with that might help you collaborate a bit better with the rest of your team with your obstetricians or anesthes or fellow midwives so there are little things that each and every one of us can do that don't cost anything using a woman's name and introducing yourself properly or thinking about minimising the time in lithotomy or having a coffee with one of the team doesn't cost anything but it may improve things improve your teamwork improve your culture and ultimately improve things for the women and babies under your care thank you thank you Florence I'm sure you've inspired a lot of us to build that relationship in our team with the neonatal doctors the obstetricians, the midwives, the team leaders and really have that openness and mutual respect of each other an agreement in the chat regarding some of your suggestions every maternity unit needs a Florence can you clone yourself Florence an amazing comment actually from Laetitia where every woman every woman in Ghana gives birth in lithotomy and Linda who was a midwife in England and lives in Scotland now has seen a woman giving birth in lithotomy which astounds me Linda that's amazing I don't know if anybody does have any questions we are running very short of time our massive facilitator Halima has already pasted some links but I'm just going to repeat them there again and I'm just going to grab presenter just to remind myself just a quick one Florence yes everything we are discussing is how to improve the experience of the woman's birth but in other parts of the world for example where I am we are still holding on to making sure that every woman goes home safe so that is where emphasis is on emphasis is not on how we write a good story about the woman's experience even in the classrooms the way we teach students and all that and not emphasise it on the birth experience how nice it was and all those things so in an era like this where we are promoting writing a good birth experience how do we incorporate this into our old primitive ways of doing things yes so this is a common thing in terms of people thinking that we just need to focus on the safety and when I started doing this work people were saying no that is just fluff we need to focus on the safety but there is a lot of correlation between safety and experience so listening to women really listening to them and understanding what they are telling you and what is happening to them is critical for safety and communicating with them properly is crucial for safety so I think sometimes people think well we have to do the safety first but actually the two come together so being able to raise concerns a woman being able to tell you what she is feeling and then for her to be listened to and not women talk about not being believed in the UK and I can't imagine that that is necessarily different in other parts of the world so people not listening not believing them when they talk about what symptoms is not moving or they have bled and people saying it wasn't that much so I think my advice would be communication and listening is a critical component of that safety I don't know if that answers your question I think it is fine Thank you Florence I think we all need more time with you because we haven't had much for questions and I think there's a thirst for that but I'm sure people can head to your OBS pod and get some more insights into the work that you do and a big big thank you from the VIDM for presenting today