The Voice of Healthcare

ARK VOL.2

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In this issueWHY CONTROL THEUNCONTROLLABLE?

THE GIFT OF NEW LIFE

THE CHOICES OF THE NEXT GENERATION

CHOICES START WITH WHICH ADVICE YOU TAKE

THE DE-MEDICALISATION OF MIDWIFERY

Caring for people is at the heart ofeverything we do

n our first issue of Ark we dealtwith the difficult but important

topic of palliative care. In this, oursecond issue, we move our focusaway from the end and back to thebeginning – childbirth.

While new life brings great cause tocelebrate, pregnancy, labour andbirth are not without their risks. Andtheir tragedies. All those working inobstetrics and midwifery arededicated to protecting women,giving them options based on what isright for them and their babies whilecontinuously finding ways to reducethe risks associated with childbirth.

Our conversations with women abouttheir experiences of childbirth, aswell as with those whose workfocuses on labour and delivery, haveproved this. From Nicola whoachieved a ‘perfect birth’ for herdaughter with the help of anindependent midwife and doula, toDr Roshan Fernando who isspearheading research into PIEBpumps to care for women usingepidurals.

As you will see from the articles thatfollow, they have also uncovered anopportunity for more communicationbetween the professions. That waywomen may be able to feel more incontrol of their choices for bringingtheir child into the world.

Ali El Moghraby, Editor.Rachel McClelland, Editor in Chief.

2

WHY TRY TO CONTROL THEUNCONTROLLABLE?

My first child was born in a hospital for

expatriates in the Middle East that makes

Call The Midwife look like the leading

edge of 21st century obstetrics. There were

enemas, shaving, your feet up in stirrups

and an episiotomy so dramatic that the

baby shot out across the table and had to

be caught like a rugby ball. When the

congratulatory cards arrived, with their

soft-focus images of new motherhood, I

laughed bleakly: I had survived the

equivalent of a medieval torture chamber.

After that I moved back to Britain, where

the birth plan had become commonplace.

Women were turning up for labour with

sheets of instructions dictating that they

were only to deliver their babies to the

strains of Brahms, by vanilla-scented

candlelight. Not me, though: I was so

traumatised by the first birth that I was in

denial. Not altogether surprisingly, I ended

up having a caesarean. If anyone still thinks

that there is such a thing as ‘too posh to

push,’ think again: it’s major abdominal

surgery. You can’t stand up straight for

days. This turns out to be a real drawback

when looking after a new baby.

By the time I had my third child, I was

taking a much more militant, feminist earth

mother line. I did pregnancy yoga and

arranged a birthing pool. I drank herb teas

and employed a doula, a kind of wise

woman, who was going to rub my back

sympathetically whenever I got out of the

water.

Geraldine Bedell has four children,and four very different birth stories.

If you’d like to share your story, emailarkmagazine@cmemedical.co.uk

I

By Geraldine Bedell

There are about five hundred differentways of giving birth,and rarely are you in

much control

Everything was planned. Unfortunately, my

husband got lost on the way to the hospital.

The maze of a one-way system he chose to

take was littered with speed bumps. Every

time we went over one, I was in agony. I

travelled with my head out of the sun roof,

groaning. It would be a better story if I had

given birth in the back of the car but we

made it eventually, and claimed our pool.

I hated it. I endured three contractions, and

climbed out. The doula helped, though, so I

decided to keep her for the fourth birth –

and she did the best thing anyone has ever

done for me in labour, and suggested to

the midwife that she might hold off an

internal examination for half an hour. Ten

minutes later, I was pushing.

Birth plans are useful for concentrating the

mind beforehand. But the annoying thing

about birth is that it happens when it

happens, takes as long as it takes, and the

pain….

There are about five hundred different ways

of giving birth, and rarely are you in much

control. The bad thing about birth plans is

that they are typical of over-achieving

modern life: the only thing you can truly be

sure of is that in some respect, they’ll set

you up for failure. Of course, in that sense,

they’re excellent training for parenthood.

Even if you do stay in control of the birth,

it’s the last thing you’re going to be fully in

control of for a long while.

THE ROLE OF THE RCOGSo much of medicine is about trying to avoid

loss of life, that the chance to help bring new

life into the world is something all healthcare

professionals cherish.

That’s how it is with obstetrics and

gynaecology, where the overriding objective

of all involved is to ensure the safety and

survival of a mother and her newborn child.

This was one of the driving forces behind Dr

David Richmond’s decision to pursue it as a

clinical specialty when he was starting out as

a hospital doctor back in the late seventies.

Several decades later, it led to him becoming

elected President of the RCOG, a role which

has given him the chance to steer women’s

healthcare in new directions. “I think this

organisation’s greatest achievement has

been becoming a Royal College in its own

right,” says Dr Richmond.

“In 1929, a group of obstetricians and

gynaecologists decided they weren’t getting

a satisfactory deal through the Royal College

of Physicians and Royal College of Surgeons.

Women’s health was probably falling

between the gaps and there was a specific

opportunity to focus particularly on that

aspect of healthcare.

“The RCOG’s royal charter talks about the

remit to enhance and promote the standards

of women’s healthcare. And that remit

extends way beyond Britains shores - the

College has a global influence, particularly

when it comes to raising the bar in standards

and education.”

A GLOBAL REMITOver the last 15 to 20 years, the RCOG has

been spearheading education and training

packages designed to standardise the quality

of new doctors across large parts of the

world. Today, the RCOG exam is sat by over

5,000 hopefuls, not just in the UK but in

22 different countries.

“It has become a global passport in

obstetrics and gynaecology,” says

Dr Richmond.

But testing new recruits is one thing.

A bigger challenge is to uphold the

standards of care amongst all qualified

obstetricians and gynaecologists. This is

where RCOG guidelines come into play.

Dr Richmond says: “At any one time, there

will probably be 60 to 70 guidelines

available. They can be plucked from the shelf

whether you are in Kathmandu, Kuala

Lumpur, Beijing or London. They are

universally acclaimed and respected and are

completely patient focussed.”

4

THE GIFTOFNEW LIFEIt is 86 years since thefoundation of the RoyalCollege of Obstetricians andGynaecologists (RCOG).Here, current President Dr David Richmonddescribes how, despite itsmany achievements over theyears in shaping women’shealthcare, the specialty still faces some difficultchallenges ahead.by Pat Hagan

REDUCING MATERNAL AND INFANT DEATHSUniversal improvements in care take time,

however. And there are still some

frightening statistics around the world on

the numbers of women losing their lives

during childbirth. Dr Richmond says: “It’s

roughly 800 women a day globally – or the

equivalent of two jumbo jets crashing every

single day of the year.”

As far back as 1952, the College led the way

on tackling maternal mortality. Dr Richmond

says a report led by MMBRACE-UK is highly

regarded around the world as a means of

reducing future risks. But he adds: “If you

are in deepest, darkest Africa or other parts

of the world where you haven’t got access

to anaesthetists or surgeons or even blood,

you haven’t a chance.”

Maternal deaths are not the only issue. The

RCOG has recently initiated a project called

‘Each Baby Counts’, which is a national

quality improvement programme which aims

to reduce by 50% the number of stillbirths,

early neonatal deaths and brain injuries

occurring in the UK as a result of incidents

during term labour by 2020.

A crucial part of the project involves

bringing together the lessons learned from

local investigations in order to improve the

quality of care in labour at a national level.

“Around £500m to £600m a year is spent on

obstetric litigation,” he says, “of which 85

per cent will be cerebral palsy.” If we could

reduce that by just ten per cent, then much

of the savings could go on more midwives,

more doctors and better equipment.

“It’s only been running a few months but

already we’ve seen phenomenal enthusiasm

from midwives and doctors around the

country.“ We hope that all maternity

providers will continue to show their support

for this project and engage in reporting and

learning from these tragic incidents, so that

in time we can make it as safe for a baby to

be born as it is for a mother to deliver.”

THE CHALLENGES TOIMPROVING CAREDriving up care standards is laudable but

largely futile without adequate staffing. Dr

Richmond says around 3,000 more midwives

are needed in the UK to properly staff NHS

units. And limits on use of overseas doctors

means finding locums is harder than ever.

As well as top-down management, this

clinical specialty faces other challenges more

to do with the changing nature of

motherhood. Obesity is emerging as a major

factor because it means consultants must

now deal with a whole range of health

issues, such as diabetes and high blood

pressure and the consequences for the baby

and delivery process.

“Obesity is a serious public health problem

and it is our role as healthcare professionals

to inform and encourage women to adopt

healthier lifestyles, and this approach should

be taken throughout a woman’s life. We

must focus on early intervention, rather than

just preventing disease,” says Dr Richmond.

Among obese women, newborn deaths

are higher, Caesarean sections are more

difficult, anaesthetics are harder to manage,

sepsis is more likely and there is an

increased risk of clots.

Rising maternal age is the other major

current issue, as professional women

postpone motherhood. “By your early

forties, the physical function of having a

baby is not as good as in your twenties

and so we have to take account of that,”

Dr Richmond says.

The challenges may change as the years

pass. But the role of the RCOG is clear, he

says. “I would like to see this College as the

voice of women for women, promoting their

rights across the spectrum and promoting

outcomes to improve the health of women

in this country.”

Over the last 15 to 20years, it has been

spearheading educationand training packages

designed to standardisethe quality of new

doctors across largeparts of the world

Tweet us yourthoughts@arkmagazine

THE CHOICES OF THE NEXTGENERATION OF MIDWIVES WILLIMPACT THOSE AVAILABLE TO THENEXT GENERATION OF MOTHERS

6

By Ali El Moghraby

If you’d like to share your story, email arkmagazine@cmemedical.co.uk

ndrea Robertson has just qualified

as a midwife. She sites her journey

from being a staff nurse to becoming an

NHS midwife as ‘a calling’. She continues

to be in awe of the profession she has

spent the last two years studying

towards.

“Every day I admire and respect the

experienced midwives when they are at

work,” she says. “Midwives care so much

for the women and families who come into

their labour wards. They work really hard to

give those women the birth that they

want.”

Andrea is excited about the support she is

going to give to women and she has a plan

for how she wants to achieve that. “I am

looking forward to gaining experience in the

NHS,” she says, “but I think I will become an

independent midwife in the future.”

Her reason for this is that the NHS is not

able to give women one to one care. “For

example, when a woman has queued

behind 40 others to have her baby weighed

and her blood pressure checked, she’s not

likely to be comfortable talking about her

feelings to a stranger,” explains Andrea.

“But if she knows her midwife, it’s easier to

say ‘I’m feeling strange today’ or ‘can I just

sit down and have a chat with you’ if that’s

what she needs.”

For Andrea, the increasingly litigious nature

of midwifery makes her uncomfortable

when she thinks about the effect it has on

the level of medical intervention seen in

labour wards. Having spent six weeks in

Africa where mother and infant mortality

rates are higher than in the UK, she is able

to put the impact of litigation on the

medicalisation of midwifery here into a bit

of perspective.

“In Africa, it is accepted that women and

babies can die in childbirth,” says Andrea.

“While no-one should die in labour, our

culture of needing to blame someone if the

worst does happen means that midwives

are questioning themselves rather than

having faith in their own judgement. So

midwives are more likely to focus on what

could go wrong and send a woman for a

procedure than trust their decisions and

give the woman time to birth her baby

herself,” she says.

As Andrea embarks on what she sees as

her destiny, the future of the profession lies

in her and her peers’ hands. How many

choose to turn their back on the NHS and

become independent midwives remains to

be seen.

A

Give the womantime to birth her

baby herself

‘I see no reason for you not tohave a successful natural birthafter a caesarean section, but asyou are high risk, you will need tobe on the labour ward forcontinuous monitoring.’

These were the words of my consultant,

which felt strangely contradictory. I was in

early pregnancy with my second child,

following a pretty harrowing experience

with my first baby, which ended in an

emergency caesarean section. A heated

exchange of words followed, as I explained

that being forced to lie back strapped to

machines would in no way allow me to birth

my baby naturally. I was told in no

uncertain terms that to do anything other

than this would put my life and that of my

baby at risk.

The thought of this filled me with dread, so

I began to do my own research. The more I

thought about it the more I knew that

hospital was the last place in the world I

wanted to be.

So I asked a good friend who is a midwife,

whether she thought I would be crazy to

have my baby at home. She explained the

risks to me in terms of probabilities and this

enabled my husband Charlie and I to make

what we felt was quite an easy decision.

We felt the benefits of being at home far

outweighed any undue risks.

We decided to pay an independent

midwife to look after us during the

remainder of my pregnancy and the birth.

We wanted to know that the person

present on the day would be experienced

in home birth and would not rush us into

hospital unless there really was a genuine

need. This turned out to be the best

investment we could have made.

Our midwife, Meg, had decades of

experience in natural births, understood all

the risks and totally trusted in her own

abilities and those of the birthing mother to

be able to do it just as nature intended.

She was an incredible support, especially

when I had the hospital pressuring me to

go in for induction because my baby was

‘overdue’. Meg kept saying if I wanted to

birth my baby naturally, I needed to leave it

alone. Do nothing, but chill out, it will come

when it is ready.

I spent a lot of my pregnancy visualising

what my perfect birth would be, and in the

end, it was exactly that! My waters broke

around 11.30pm so Charlie called the

midwife and our doula and began filling

the birthing pool. We had decided to have

a doula for our homebirth to provide extra

support to him and Meg, and this also

proved to be a very worthwhile investment.

Meg arrived soon after, and observed me

quietly and un-intrusively. There were no

internal examinations, just a few whispered

questions and then she quietly told me that

I could get into the pool.

What a wonderful relief warm water is! I

was in my kitchen, with a few candles and

some soft music playing, with Meg, Charlie

and Louise working in whispers around me.

I didn’t hear all the exchanges that

occurred, I was in my own zone, completely

surrendered to the moment. Not once did I

ever allow myself to think anything other

than ‘I can do this’ and I never felt out of

control or overwhelmed.

Our beautiful baby girl, Isabelle Rose, was

born just after 4.30am, peacefully in the

pool. An hour later, her older brother Ben

trotted downstairs, immediately noticed

some chocolate biscuits by the fireplace

and didn’t even realise that he had a new

sister!

What a stark contrast to our first birth

experience, which ended up being filled

with bright lights, pain and fear. Hindsight

is a wonderful thing, but so is the power of

a woman’s body. Given the right

circumstances and being allowed to do

what we all instinctively know, we can all

birth like goddesses. Trust your instincts,

we’ve been doing this for millennia.

CHOICES START WITHWHICH ADVICE TO TAKENicola Nicholson went against her consultant’s advice and chose an independent midwife for her second child.

Professor Lakhani

by Nicola Nicholson

THE DE-MEDICALISATIONOF MIDWIFERY

8

The midwife profession is currently in a state of flux according to SusanBaines, Expert Midwifery Advisor for the Care Quality Commission andlecturer of midwifery at The University of Salford. “It’s a wonderfulprofession to be in”, she says, “but professional confidence and resourceand time restrictions within the NHS are severely impacting on the truebusiness of midwifery.” By Ali El Moghraby

aving spent 40 years as a nurse,

29 of which as a practising

midwife, Susan is concerned about the

future of the profession.

For example, she welcomes the new NICE

guidance (2014) regarding second time

mothers having a choice of home birth if

they are deemed low risk. But she also

believes that this choice is suitable for most

other mothers as well, as long as they have

the right midwifery support and a joined up

team approach to managing any issues.

“If women are to regain control of their

choices for childbirth then the midwifery

profession needs to return to a degree to

its pre-medicalised form,” says Susan.

PAPER OR PERSON?Labour and delivery has been getting more

medicalised for a long time now. The

profession is well aware of it, as are most

women planning for the birth of their child.

But as they research their options and

make choices for how they want to bring

their baby into the world, Susan believes

that too often the midwife pigeon-holes

them into being ‘high risk’ just because of

the forms she has to fill in.

“For example, as soon as a woman turns

40 she is deemed high risk,” says Susan.

“She could be fitter and healthier than the

average 20 year old, but as soon as her

midwife ticks the box that says she’s over

40, she’s flagged up by the computer as

high risk.”

This immediately impacts on her pregnancy

and birthing choices. “Her midwifery care

now takes her down a path that is not

supporting what we know about the

woman and her capabilities,” says Susan.

The woman may be denied the option of a

homebirth or of giving birth in a midwife-

led birthing centre. Straight away, the

chances of medical intervention in her

labour are significantly increased. “We

have to get away from this business of

going to see a woman straight away with a

form,” says Susan.

Susan supports the mindfulness approach as

one of the ways to achieve this, including

when caring for women shortly after the

birth of their baby. “Midwives visiting a

woman in her first days as a mother should

put their notes away, sit and simply watch

and listen to her,” she says. “That way the

woman can better articulate what she is

really feeling and is more likely to benefit

from the interaction. This gives the midwife

a better opportunity to support her more

effectively. The notes can be filled in

afterwards in the car.”

DOUBT HAS CREPT INIt is Susan’s view that midwives are too busy

filling in paperwork and not listening to what

women, their bodies and their babies are

saying. As a result, some midwives have lost

their confidence in being able to support

choice and actually see the woman’s body as

being able to perform naturally.

“We now practice such defensive midwifery

and are so fearful of litigation that we are

doing things for all the wrong reasons,”

explains Susan. “We are taking a woman

down a path and taking away her choices at

each step.”

Susan highlights the rise in the rate of free

birthing as a symptom of women’s lack of

confidence in their midwives. “The women

who are free birthing don’t want any

medical people around them at all,”

explains Susan. “What does it say about us

as a profession when women are actually

moving away from us as midwives? In my

view, they don’t trust us because we are so

medicalised, we are so rigid in our views,

and we are so frightened,” Susan explains.

“That’s a real issue.”

“You cannot give women the choices that

they want in a system that simply doesn’t

allow it,” says Susan. “There needs to be

more awareness of independent

practitioners if only because they offer

women a choice other than hospital. There

are many excellent independent midwives

out there who actively support choice

safely.”

H

TIME FOR ONE TO ONE CAREMany midwife degree courses are

oversubscribed, yet there is a severe

shortage of midwives in the UK (the Royal

College of Midwives says that the NHS

needs 4,800 more).

This has two implications in the context of

trying to make midwifery less medicalised.

The higher volumes of women that have

been labelled as ‘high risk’ go into hospital

as prescribed by their risk assessment. But

as Susan explains, the number of hospital

midwives just doesn’t allow them to always

receive the one-to-one care that they have

apparently gone into hospital for.

“More often than not, the delivery suites

are really busy, the midwives on shift are

stretched and then all of a sudden, it can

become worse when several other women

in labour are admitted,” she says. “They

have all been deemed high risk and so

should be monitored closely by their own

midwife, but it can be impossible – the

midwives may be required to help out in

other delivery rooms thus taking them away

from their woman in labour”. The midwives

are trying their best but there simply isn’t

the time to always provide one to one care.

This is not only unsafe but demoralising and

stressful for all concerned.

While encouraging more home births

should provide the level of one-to-one care

that hospitals struggle to deliver, too often

women who have booked a homebirth are

left severely disappointed when there isn’t

a midwife available when they need them.

“We hear it all the time,” says Susan. “The

woman is in labour but we have no one to

send out because we are really short

staffed and have a full delivery unit. She

ends up in hospital, anxious and fearful

with her choice having been removed. The

bottom line is that for some women,

technology and medicalised care can be a

life saver, however for most women they

need to regain trust in their natural

physiological ability to birth their baby,”

she says.

THE FUTUREThe good news is that the profession is

changing. In March 2015, the Nursing and

Midwife Council launched its new code of

practice for nursing and midwives. “The

new code has been amended to better

support individualised care and promote

professional accountability regarding

choice. It is aimed at placing the women at

the centre of everything we do,” says

Susan. “It is about trying to keep birth

normal, trying to listen to the mother and

allow her to make choices.”

For Susan, the real future of the midwife

profession lies with midwives themselves

and their ability to work closely with

women. Additionally, she sees the

importance of doulas. “Half the time we

midwives are not with the women

anymore, we are with technology,” she

says. “We are often not even in the same

room as the woman when they are in

hospital. So how can we call ourselves

midwives when the term itself means ‘with

woman’? Doulas are normal women who

get to know their mothers well and who

offer continuity and practical and

emotional support.”

“There is evidence to support the fact that

women do better in labour if they have the

continued support of a doula,” concludes

Susan. “At the end of the day, all women

want is a friendly caring person to help

them believe in themselves.”

Tweet us your thoughts@arkmagazine

What does it sayabout us as a

profession whenwomen are actuallymoving away from us as midwives?

10

uring Dr Fernando’s training days at

Queen Charlotte’s Hospital in

London, specialising as a consultant in

obstetric anaesthesia was not as popular as

specialties such as cardiac and paediatric

anaesthesia, even though it is such an

important field. Things have since improved

and many delivery suites within hospitals

are better staffed and equipped than ever

before. But the rising workload means there

are often resource issues, he says.

UNDER-AVAILABILITY OF ANAESTHETISTS“I regard our delivery suite at UCLH as one

of the best. We have very motivated staff

and good resources for certain things. But

we are still under resourced in terms of

obstetric anaesthetists who need to cover

both the emergency and elective workload.

I used to work at the Royal Free Hospital in

London, where annual deliveries are about

3,000 a year.

“Here at UCLH we deliver 6,500 mothers

each year, so double the workload.

We often have three anaesthetists

working extremely hard, sometimes

from 8am to 5pm without a break. The

challenge is obviously obtaining funding

to provide a safe and high quality service

to our mothers.”

However, as every politician, health

professional and member of the public

knows, the NHS does not have enough

funding to deliver the service most patients

expect these days. But in a perfect world,

he says, he would staff all delivery suites

with a consultant obstetric anaesthetist

present 24/7. Many years ago, it was rare to

see any type of consultant outside of

normal daily working hours. Things have

changed and now some of the busy

obstetric hospitals have consultant

obstetricians available up to 10pm and

during weekends or even 24 hours a day.

But anaesthetists are lagging behind in

terms of providing consultant cover, says

Dr Fernando. “We are usually present from

8am to 6pm, but rarely beyond that and

certainly not at weekends. The ideal model

in my opinion would be to have a

consultant obstetrician and consultant

obstetric anaesthetist working together

on the delivery suite throughout the day

and night.”

CUTTING-EDGE EPIDURAL RESEARCHBut while the ideal staffing formula has yet

to be perfected, technological innovation

marches on. Dr Fernando is currently at the

forefront of new research on the use of

epidural pain relief pumps that provide a

programmed intermittent epidural bolus, or

PIEB function, which first came into use at

UCLH a few years ago.

A clinical research trial is planned for this

summer where women opting for an

epidural will be randomised to various PIEB

protocols involving different bolus volumes

and intervals. Dr Fernando says: “I think the

PIEB pumps could be one of the most

important things to have been developed

recently to provide epidural pain relief to

mothers. There are many hospitals in the

UK which are now starting to look at these

new PIEB pumps.”

UCLH has already run a pilot study

involving epidural PCA pumps with a PIEB

protocol capacity. “About a year or so ago

we had a short trial of the PIEB and it

worked quite well,” he adds. The upcoming

trial will be bigger and more in-depth and,

hopefully, shed more light on best practice

for using the PIEB technology.

“At the last UK meeting on obstetric

anaesthesia there were quite a lot of

research abstracts on PIEB. It’s early days to

see if it’s going to reduce motor block in

the mothers legs (a well known side effect

of epidural analgesia) and improve

instrumental delivery rates but it’s an

interesting development.”

In the long-run, says Dr Fernando, these

ground-breaking pumps may all be linked

to Wi-Fi so that consultants can remotely

check how much epidural drug each patient

is receiving. In Singapore this type of

technology has already been in use for

several years. Naturally, these pumps can’t

be seen as a substitute for qualified staff –

especially not in areas such as the delivery

suite or in the high dependency care area.

THE OBSTETRIC ANAESTHETISTWith 20 years’ experience in obstetric anaesthesia behind him,consultant anaesthetist Dr Roshan Fernando from University CollegeHospital London (UCLH) has seen many changes – mostly for thebetter. Here, he talks about progress in pain relief for mothers, on-goingstaffing challenges and the fact that he’s busier than ever. by Pat Hagan

D

Dr Roshan Fernando

HOME BIRTH RISKS FROMTHE ANAESTHETIST’SPERSPECTIVEAgainst the backdrop of hospital-based

treatments, in Dr Fernando’s view, is the

on-going controversy over the safety of

home births.

In December, the National Institute for

Health and Care Excellence (NICE) issued

new guidelines stating births at home or in

midwife-led units were better for certain

mothers and often just as safe for babies as

being born in hospital.

But Dr Fernando believes many women are

not currently properly informed about the

likely risks of home births. “It’s very difficult

to quantify the absolute risks.

“Let’s imagine you live in central London

and your hospital is UCLH. If things do not

go according to plan and you have to get

to the hospital urgently, how quickly can

you get there and how? Patients need to

understand all the potential risks involved.”

Obstetrics and obstetric anaesthesia has

significantly advanced over the course of

Dr Fernando’s career, with major

improvements in caring for mothers,

however perhaps the best is yet to come.

Tweet us your thoughts@arkmagazine

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