The Backlash of ‘tick-box care’ in Maternity Services

A case study detailing my client’s transition from a high-risk pregnancy requiring prescribed LMW heparin injections to ultimately being taken off the treatment and opting for a home birth.

I was contacted by a lovely second-time mum seeking support for her second pregnancy and birth. Unfortunately, I couldn’t provide Doula support as I had no availability during her estimated due date. However, she was very interested in learning HypnoBirthing, so we began working together.

While there is a lot to learn during the 3 sessions of the hypnobirthing course, I like to get to know my clients, their previous birth stories and how their current pregnancy is going. Unfortunately, her previous birth experience was a traumatic one hence she was seeking support, wanting to be sure it wouldn’t happen again.

The majority of my clients are second-time mums. This could be for an array of reasons such as previous traumatic birth, or they felt let down and not supported during their first birth by the medical team, or being pushed into treatments they didn’t want to have but felt like they had no other options.

 

The care pathway

When this lady got in touch with me, she was already 33 weeks pregnant and her pregnancy was classed as high-risk.

Her risk factors were:

– raised BMI (30)

– advanced maternal age (40)

– previous varicose vein surgery

– family history of stroke

Due to the boxes her case ticked,

– she was prescribed a routine blood clot preventative treatment in the form of daily blood thinning injections (Inhixa) to be self-administered from 28 weeks of pregnancy

– she was given three extra growth scans

– she was scheduled to be induced at 40 weeks of her pregnancy

– she was told she could not have an epidural or spinal due to having the blood thinning injections.

This would mean that if she needed to have an emergency caesarean section, it could only be done under general anaesthetics.

Risk factors are extensively debate-worthy especially when it comes to maternal BMI and its fallacies as well as the questionable risk involved with ‘advanced’ maternal age and the ‘aging placenta’.

 

Hot topics and debatable risk factors

Induction carries many risks as all interventions do.

I will only mention just the birth outcomes of induced labour here. On average 15 out of 100 women will be delivered by ventouse or forceps and 22 out of 100 women’s birth will end up with a caesarean section. To see it from a different angle, those women whose labour was induced are twice as likely to give birth via caesarean than those whose labour started naturally (Kjerulff et al 2017).

When it comes to raised BMI and age it is relatively easy to refuse induction and many do so without doubt. Generally speaking, well-informed and educated women especially those who have already experienced induction won’t want to experience induced labour and birth again and are a lot stronger to stand up for themselves and motivated to seek support.

However, if someone is truly at high risk of developing blood clots it is not something to take light-heartedly.

Safety is always first but let’s take a deeper look at the boxes her case ticked, especially the blood thinning injections.

Childbirth following LMW (low molecular weight) heparin treatment

When someone receives blood thinners, they must stop them before the onset of labour. The duration of the treatment differs uniquely for everyone depending on their diagnosis.

My client was told to stop it 48 hours before labour started and she was scheduled for induction.

What we need to know about physiological changes during pregnancy is that women’s blood volume increases by 1 – 2 L, and the total blood volume is more diluted however the capacity for clot formation increases to safeguard us from bleeding after the baby’s birth (postpartum haemorrhage)

Adverse effects of LMW heparin:

– low platelet count

– bleeding (antenatal and postnatal too)

– Anticoagulant-related postpartum haemorrhage

The risk of bleeding and having a haemorrhage is not low in women receiving prophylactic treatments of LMW. In 57 pregnancies where low-dose heparin was administered 1 woman had antepartum, and 4 women experienced postpartum haemorrhages. (Ellison et al., 2000). In another report, 4 out of 14 women had anticoagulant-related postpartum haemorrhage following a section. (Sadler et.a.l, 2000b)

As you can see the risks of excessive blood loss due to the treatment and the intervention in the form of an induced birth, that can potentially end up in instrumental or operative delivery.

This put her at high risk on top of her high-risk pregnancy.

When a care pathway is chosen for an expecting person, the benefits of the treatment or procedure should outweigh the risks or at least even it out but not put them at even more risks. Especially, if appropriate assessment or monitoring is not present.

Missing information

As I mentioned above, the risk of developing a blood clot is not something to play with. It can be dangerous hence appropriate management, prescribing, monitoring and care are required.

As a hypnobirthing therapist, my aim and role were to empower her no matter what treatment she was going through, teach her coping strategies and so on.

As a birth professional when I see a client with a complex medical background, I initiate extensive conversation about it. I want to make sure that they are looked after well and have all the information required. Whether they know what certain medical expressions mean and the possible negative and positive consequences of treatments that they will potentially undergo.

This time was no different.

One might think that as her medical history ticked the boxes for the risk factors, decisions should not be questioned.

One of the biggest problems is that expecting women don’t receive enough information from their care providers and this was no different in my client’s case either. Many unanswered questions were waiting to be answered.

Since she is my client, I had the duty to bring her as much information as I could. Even though the medical side should not be my responsibility, as I am only her hypnobirthing therapist. Hands up, I say the same, questions and answers regarding her medical conditions are the responsibility of the medical team. However, I have seen enough during my practice to think otherwise.

The point of no return

I have shown my client the medical guidelines relevant to her case. I advised her to read them after which she began to question her doctor’s decisions. The very same guidelines that her care was determined, were not applied appropriately by her doctors.

Generally speaking, it is a normal practice to determine the care pathway based on medical history assessment should be carried out.

The major problem was one simple action, more accurately, lack of action.

My client was never assessed appropriately.

Meaning, no doctor had a look at her legs to see the very veins that reasoned her to receive Inhixa (LMW heparin injections).

At her next appointment, it turned out that she was not at high risk of developing blood clots!

During this appointment, her doctor carried out a physical assessment instead of ticking the boxes. This was the third doctor she had seen and only this doctor took a look at her legs.

 As a result, at her 36th week of pregnancy after being on Inhixa for two months she was taken off them.

She told me there was another person present in the room who stated that “You are a very well-informed mum”. To which my client answered, “I am informed now because I wasn’t informed the first time.”

She is currently enjoying her maternity leave and practicing her hypnobirthing and is looking forward to her home birth, supported by community midwives.

It is all about balance

Understanding that any decision you or your care provider make for you has negative and positive consequences, is important. No treatment is without side effects and consequences. You need to ask the right questions, think and think again and not be afraid of asking more to find out.

It may turn out that they have made a mistake or missed something.

I wish to congratulate my client for questioning and standing up for herself. It is not easy to speak up for oneself in a consultant’s room but doing just that can save you from pain, worry and often from an array of unnecessary treatments.

This case perfectly represents everything that is wrong with tick-box assessments.

If you are unsure where to find relevant information for your case or you are seeking support, reach out to me.

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