With a weariness I read today yet another story about midwifery staffing levels falling short of the number required  for the government to meet it's own declared standard of care.

BBC: Midwife numbers 'to fall short'

I've said it before, and I expect I'll say it again; please look after our mums properly. The fact that the government thinks that this is one of the safest countries in the world to give birth (actually, it's one of the worst in Europe) is no reason to spread maternity care too thinly.

When I spoke in Basingstoke, at the SE Regional conference a little while ago, one of the highlights was this video, shown by one of the other speakers.

Concentrate hard and follow the instructions.

When we watched it there was a big cheer as everyone got the correct answer, and then a gasp!

I had a letter today, from CEMACH, with some of the comments made by the (mainly midwife) delegates at the South East Regional CEMACH conference in Basingstoke Jan 2009, in their evaluation forms. To underline the purpose of Jessica's Trust, the campaign and our petition, I thought I'd share a few:

• Jessica's story highlighted the need for MEOWS on the postnatal wards
• Jessica's story of tragedy shows the importance of how not to miss the bear moon-walking amidst the data.
• High quality communication, referral & follow ups is vital to good provision of care - information should be provided to all women in a way that they can understand it + make choices about their care. - I will always remember Jessica's story.
• Importance of observation! To re-emphasis use of MEOWS.
• Higher awareness in units regarding newly introduced MEOWS.
• Considering how to take forward Ben's message in practice.
• Copy of MEOWS chart of postnatal women's observations to community midwives.
• Jessica's story increasingly moving.
• The presentation from Ben was extremely poignant and completely sums up the purpose of CEMACH - Very powerful and real life experience should be portrayed to many more maternity staff - it keeps the reality in the midst of statistics and risk.
• There is a need for an early warning system to be implemented in trusts. We need to ensure that women are aware of risks & that there are guidelines for e.g. sepsis in pregnancy.

Thank you to CEMACH for inviting me to speak, and for permission to use these comments.

[It has to be said, it's more of a surprise if the video isn't titled before you watch it!]

I was very glad to attend the South East Regional CEMACH conference in Basingstoke today. I was asked  to speak a few months ago, and as anyone who knows me will testify, I hate public speaking. As a result I blanked it until the last minute and just revised my last speech at the eleventh hour.

As yesterday approached, CEMACH offered me a corner of their table for my leaflets and books, then a table of my own. By the entrance/exit.

I was made to feel so special I forgot to be nervous this morning, especially as the chair of the conference handed me some Bachs Rescue Remedy. By the time my slot arrived I was feeling comfortable in the lecture theatre, knew what I had to say and launched in.

I knew to expect the rustle of tissues, but I was overwhelmed by the support shown afterwards, and the number of requests for a repeat performance in other parts of the country, and the speed at which copies of Friday's Child flew off the table later.

As promised to a number of delegates, here is the link to the text of my speech in Birmingham last year - largely unchanged today. And yes, I will consider recording it and putting it on YouTube. The more (student) midwives that hear it the better.

Things will change, thanks to Jessica.

Modified Early Obstetric Warning Score charts are instantly clear and they can save a life. What are they, though?

They are a single sheet chart, with time tracked across the top, where observations - pulse, blood pressure, temperature and a whole host of others - can be marked in the columns below.

Normal readings: fine.
Borderline readings: the box is shaded in yellow.
Dangerous readings: the box is shaded red.

One red or two yellows at one time and a doctor is required for 'early intervention'.

It is so graphically obvious, and a mother's history so clearly charted that, the idea is, a mother who is developing a critical condition will be treated before it is too late.

Sepsis (for example) is often already life threatening by the time it is clinically obvious. Therefore the best opportunity to intervene is based on the early warnings.

These charts are not routinely used, though. Some units do use them, others are looking at using them, and I believe there may be a national pilot some time.

I filled in Jessica's observations on such a chart a while ago and it is so obvious. You can see that she was very ill, long before she was showing the more advanced symptoms of sepsis.

When I was in Birmingham the other day I showed the chart to the conference. A midwife came up to me after I had spoken and said that her hospital had had MEOWS on the agenda for a while but that no-one had yet got around to implementing them.

She told me she was on the panel and was going to go back to work to get them implemented. Now.

I want these charts to be used routinely, as in other disciplines, and they should follow a mum home to the community midwife as well. How else is she supposed to know her patient's full history so definitively?

You can see an example MEOWS chart here.

This is the text of the speech I gave to The Sixth National Conference on Current Issues in Midwifery organised by the British Journal of Midwifery yesterday. I have reproduced it here by popular request. I am not going to include the photographs of my family that I refer to, nor the medical charts, but the important information from these is in the text. The full version of the story is, of course, told in Friday's Child.

Good morning. My name is Ben Palmer, I am a father of two children, and a widower. I am also founding trustee and chairman of Jessica's Trust – a charity focused on raising awareness of childbed fever or puerperal sepsis, but more about that in a minute.

First, I'd like to introduce you to my family and give you a small and brief glimpse into our lives.

This is my wife, Jessica, and I just after we were married.

This is Jessica and our daughter Emily, just after she was born ... we didn't know she was a girl, so she's in her brothers hand me downs already.

It is one of only two photographs of the two of them together. Emily keeps it beside her bed wherever she stays.

Jessica died in June 2004 when Emily was just 6 days old, and three weeks after Harry's third birthday. She was 34.

This photograph is hanging in poster size on their bedroom wall, so that they will never forget her.

This is my family today.

Emily is a relatively carefree 4 year old still learning about who and what it is she has lost. Harry is a seven year old, unfairly burdened with the reality of maternal death. I'm less troubled than I have been, but a little greyer than I used to be.

This is a story that fills numerous files, but I'm going to condense it right down, hopefully retaining the salient information. Please remember that the small amount of medical knowledge I have now is 98% more than I had at the time.

I'm also going to illustrate the story with an early warning chart that I have filled in retrospectively from Jessica's notes. Unfortunately they were not being used at the time.

Emily was born at 6.26 on a Thursday evening after a complication free vaginal delivery. She was 9lb 13ozs. Jessica and I were ecstatic after the birth of our daughter - a sister for three year old Harry.

Jessica's temperature at delivery was normal, heartrate 78, BP 120/56.

After a sleepless night because of Emily's constant crying for milk, Jessica was shattered and wanted to go home, but her midwife was worried – Jessica was tachycardic.

At 9.40am Her BP had dropped to 80/40 and she was hot (although her temperature wasn't recorded anywhere that I can find it.) and her heart rate had increased to 90.

The SHO was bleeped just before 10am. Had the hospital been using this chart, these obs would have registered as a red score and should have made her a priority.

Through the day Jessica's heartrate rose to 100 - which would have registered as a yellow score - and with no sign of her, the SHO was bleeped again.

And again.

At 8pm the doctor at last visited Jessica without (Jessica told me) taking any fresh observations. Looking at the notes, it might appear that she re recorded the previous ones and then discharged her.

After supper that night, an hour or so later, Jessica was shivery and had blue lips.

I got her into bed and then took her temperature as she now looked flushed. It was 38.9C.

I could have called the hospital or, indeed, an ambulance, but two things occurred to us.

1. that her previous symptoms - not that we fully understood them - had not been cause for concern, and
2. that both of us had had high temperatures in the past with no ill effect.

I had no reason to think that Jessica was in any danger after a normal delivery. And anyway, as second time parents, we knew that the community midwife would be visiting the following day.

Jessica was tired and made it quite clear that she wanted to be left to sleep until the next feed.

Yes, the benefit of hindsight makes me uncomfortable about this. It was my missed opportunity.

Unfortunately, the midwife was too busy, with too many mothers, to visit the next day, but I told her on the telephone about Jessica's temperature and so she recommended paracetemol for the fever, should it return, and promised to visit the next day, Sunday.

Had the discharge form mentioned the problem or concerns in hospital, again with hindsight, I might have thought to mention it, but the 'Other problems' box was empty.

We were reassured and so got on with the business of looking after our young family.

Jessica came downstairs once over the weekend - in fact it was the only time she did in the three and a half days she was at home with us - and it wasn't for very long.

So, when the midwife visited on the Sunday, Jessica was in bed with Emily beside her.

She didn't have her thermometer with her, so just recorded that Jessica was feeling feverish.

She didn't know what Jessica's hot and red looking abdomen meant, so it was forgotten about. The midwife left Jessica after about 40 minutes and she carried on resting.

On Monday morning, Jessica was in a lot of pain in her lower back and so rang the GP's surgery. She was diagnosed as having sciatica and given Diclofenac. The medicine was great and made Jessica much more comfortable for the rest of the day, but the pills were obviously masking a worsening crisis.

By breakfast on Tuesday, Jessica was beside herself with pain and barely able to walk, and so I drove her around the corner to our GP. Jessica was seen immediately and referred back to the maternity ward by blue light ambulance.

On the way, her BP crashed and she was redirected to A&E. She was diagnosed with septicaemia and soon moved to Intensive care.

During the next twenty hours or so, I slept little, and shuttled between my home where my mother was looking after Harry and Emily, and Jessica's bedside.

She was given drugs for the infection and failing blood pressure in ever increasing strengths and dosages.

During the night she was put onto dialysis and a ventilator. I left her bedside at 6 in the morning to be at home when Harry woke up, but by eight in the morning, when I was called back to hospital after 40 minutes sleep, it was apparent that she was in very grave danger and deteriorating.

As a last ditch attempt to save her, Jessica was taken into theatre for a possible hysterectomy in the late morning. Almost immediately after the first incision, she went into cardiac arrest, and death was recorded just before midday.

Jessica died of multi organ failure caused by group A streptococcus.

I don't mean to judge or criticise - I just want to tell you what happened and why I'm here. Legally, the matter is closed after admissions of liability, but I hope there is something that everyone can learn from Jessica's case; parent, midwife and doctor.

I'd hate her death and our loss to be a wasted opportunity.

You don't need me to tell you:

• that puerperal sepsis is no longer a disease of dirty practitioners like in Semmelweiss' day when it was being spread from mother to mother in the wards;
• or to tell you that it is a community bacterium that many of us live with harmlessly - until it is given the opportunity to invade a body as in the case of a postpartum woman,
• or that it is still the cause of 14% of maternal deaths in this country.

In the grand scheme of things, 18 deaths between 2003 & 2005 may be a small statistic, but the human impact is not.

What I do want to tell you is what happens when you wake up as a single parent and a widower, with small and confused children.

When I got home, broken hearted and in shock, I had to go on and on breaking others' hearts. Jessica's parents, my parents, our friends and family and my son Harry's.

When I told him that the doctor's had tried really hard to mend mummy's sore tummy, but that she was too sick and now she was in heaven with God and the angels where her tummy couldn't hurt any more, he just looked at me.

He didn't say a word. He was three - how could he understand what I was also struggling with?

Thanks to my mother and sister, and subsequently a nanny, our day to day life carried on during the first few weeks: meals were cooked and our routine was followed, but we were crumbling inside.

Harry's fear and confusion usually manifested itself at bedtime. He wouldn't settle, would often wet the bed, and frequently woke me in the night to climb in to bed beside me, but it was the shouting, the screaming, that was most upsetting,

"I DON'T LIKE MUMMY ANYMORE" he yelled at me once after an extended tantrum. He was angry with her for deserting us. Another time, he thought that maybe she and I had had a fight and was now living somewhere else.

How could she not want to see him or live with him anymore?

I lost count of the number of times we'd go through this sequence, and I quickly ran out of answers. In the end he - and sometimes I - would fall asleep on his bed, him in my arms.

Every time I took him to a party or to a friends house there would be trouble at night. He couldn't express it to start with, but he was angry that other children had a mum; what had he done wrong that meant he couldn't.

My own reaction over time was not much better. Consumed by anger, isolation and despair, I sunk into depression. I was eventually diagnosed in 2006 as having agoraphobia, anhedonia, dysthymia, depression and an alcohol dependence. I was drinking, on average, two bottles of wine a night - over 120 units of alcohol a week.

My work - I was self employed - was too much for me, and my clients politely drifted away one by one. I just couldn't stay focused. I got to the point where I didn't care about anything, myself included, other than Harry and Emily.

After being diagnosed, I was lucky enough to have counselling and a long course of cognitive behaviour therapy, and I have now stopped awfulising.

Eventually, life does start to get easier every day, but we'll never be 'better' - bereavement isn't an illness and it never goes away, you just have to learn to live with it.

Emily has never kissed her Mum, she and Harry will never have their mother there on red letter days. On Emily's first day at school last month, in her new dress, she looked at me with a sadness and simply said, "I wish my mummy could see me today."

What will she say if she graduates, or gets married?

My point is that death never goes away once it has struck, but what I want to underline, through Jessica's Trust, is the vital importance of regular and continued observations, fast recognition of symptoms and of action. By the time sepsis is clinically obvious, it may already be too late.

That was where the mistake was made in Jessica's case – too many people passed off the increasing symptoms as anything but dangerous, and Jessica and I were reassured into accepting symptoms that now make me shudder when I think of them.

My focus is to raise awareness of childbed fever - I want all of us, midwife and parent together, to understand it and to talk about it. The last thing I want to do is to invoke terror, but childbed fever should still be feared as it once was. That way another mother's life may well be saved, or she may just be saved from a long recovery from organ damage or a hysterectomy.

I want to see early warning charts being used routinely, and they should go home as well, for the community midwife.

I'd like to see more midwives, so that no one is too busy again, and I'd like to see a maternity service that is as valued with funding as it is needed by us as parents.

I hope that you will remember my wife, our motherless children and all the others like them.

I deserted the children last night, leaving them in the capable hands of a family friend, and drove to Birmingham. It was a wrench: I'm not used to being away from Harry and Emily, and I didn't want to go. They didn't hugely want me to either. But go I did.

The Sixth National Conference on Current Issues in Midwifery organised by the British Journal of Midwifery asked me ages ago to talk about 'The reality of maternal mortality: a father's perspective'.

I'd been dreading delivering the short speech - how would they react? Would I falter, would my mouth dry up?

When I started I was nervous, and midway through I started to think I was losing them - there was rustling and shifting in seats. That made me really nervous.

Then I realised - it was tears and tissues. Jessica was touching them, Jessica was making a difference.

Afterwards, there were thanks, invitations to do it again elsewhere, write for the Journal, and so many hugs. What had I been worried about?

I've come away feeling like I've made a roomful of friends. Would I do it again? Yes, most certainly. For as long as I can reach someone who hasn't heard Jessica's story. For as long as Jessica can make a difference.

For all the women like her.

Update
Following a few requests and my off-blog correspondence with dovegreyreader, the text of the speech is reproduced here:
The reality of maternal mortality: a father’s perspective

When I picked Emily up from school this afternoon (and I can hear what she'd say to me here, "It's not school, Daddy, it's NURSERY school") I said hello to the head teacher as Emily came rushing out.

"I saved this for you," she said, "It's missing a bit but I thought you'd be interested." She handed me a pulled out spread from a newspaper.

When I got home I started reading it. It was an article from Times2 last week, Save the independent midwife, along with a personal tale, right at the end in the on-line version, written by a mother, Alex O'Connell, who had had a horrific first delivery, and had opted for a home birth the next time, assisted by an independent midwife.

I finished reading it on-line and something jumped out at me. It was the reference to Alex's post-puerperal fever after discharge from hospital first time. How lucky she was that it only took two doses of antibiotics to shift it, and how wrong she was to assume that the lack of infection second time around was because she was far from a maternity ward.

Yes you can acquire an infection in hospital - MRSA, C diff etc - but puerperal/childbed fever is not a hospital acquired infection - it is caused by community bacteria, and nobody is safe. I'm going to go on and on saying it. I'm even going to shout it. NOBODY IS SAFE FROM THIS HORRIFIC DISEASE, whether they deliver in hospital, a birthing centre, their own bedroom or the back of a taxi.

It doesn't matter whether they are young, old, fat or thin. It  doesn't matter if the midwife is independent or NHS employed, it just matters that the symptoms are spotted in time to give you your antibiotics.

I've just read a good post on Mother at Large's blog about childbirth, pain and expectations about delivery.

It does sometimes seem as though birth has become a bit too competitive, and often I also hear talk of how quickly a mother was discharged, as though speed of discharge is a measure of success. What we shouldn't forget is that, while now comparitively safe, childbirth is a trauma and the historical and natural risks are still as present as ever they were.

While an extended hospital stay is not on anybody's wish list or birth plan, there is merit of staying in for days, rather than hours - as used to be the case. How better to pick up on the warning signs of a complication such as infection than by regular observations by a midwife?

But on that subject, all too often I hear that regular postpartum observations are no longer routine, unless infection is suspected - indeed the NICE guideline on Routine postnatal care of women and their babies [PDF] even says as much for some reason.

This is madness: how on earth is an infection going to be suspected early enough unless it's being checked for?

Another postnatal phrase I hear a lot of is: 'Mother and babe both doing well'. It's what everyone wants to hear and illustrates the feeling of joy and euphoria of a new and safe delivery, but a caveat: Childbed Fever can hit anybody at anytime - even weeks after a trouble free delivery.

I wouldn't want to cast a cloud over anybody's happiness, but never be complacent - please keep an eye on the symptoms, even if your midwife isn't.

Jessica Tate has been pregnant since 2004 and has been examined by countless student midwives.

She is a computer based training package, created by two midwifery lecturers from Swansea University, Susanne Darra and Marian Mclvor.

The project has just won an award at the Royal College of Midwives (RCM) sixth Annual Awards Ceremony, and there is a plan to roll Jessica out to other universities.

It is a genius project, and although Jessica Tate's pregnancy is 'normal' there are just a few minor warning signs thrown in. Susanne Darra, one of the program’s authors, says, “There is a big issue in the western world with ‘problem’ births and it doesn’t have to be like this. We have a strong trend to alert people to problems, but most of the time things turn out fine.”

If only Jessica could develop a fever and a rash, a few days after being discharged from a normal delivery, then she could be a really powerful teaching aid.

External Link: Royal College of Midwives (RCM) Sixth Annual Awards

BBC NEWS | Health | 'No plans' for migrant birth rate

The government should have done more to help the NHS cope with the increase in foreign-born mothers using maternity services, the Conservatives say.

How can the government keep saying that they are working towards having a named midwife for every mother, when the number of midwives is so low? 36 midwives per 1,000 births are required, yet the average is only 31 and it is as low as 26 per 1,000 in some NHS Trusts.

If the birthrate continues to rise (whether caused by immigration or not) then maternity services are going to be even more stretched unless this vital area of care is properly resourced. There is no way that any midwife can provide the recommended level of care if she is spread amongst too many mothers. That is the case in hospital and within the community.

CEMACH recommends* that 'routine observations of pulse, BP, temperature, respiratory rate, and lochia should be made in all recently delivered women for several days postpartum' and yet most women are turfed out of hospital within a few hours, and often receive only one or two visits from a midwife in the community. How is anyone going to spot the signs of serious illness?

* Saving Mothers' Lives 2003-2005, p102