Patch of sperm plasma membrane
Plasma membrane of egg Perivitelline space Zona pellucida Inner acrosomal membrane
Corona radiata
CONTENTS: Page 1.....Reflection on reader 4. Pages 2-3.....Drawings for the second stage of animation process of a pregnancy. Page 4-5.....Animation frames development days 19- 28. Page 6.....Digital processing of drawn imagery for animation. Pages 7-11.....Listening with Justine Howlett 39 weeks plus 3 days. Pages 12-13.....Text ‘reports’ of birth experiences Justine, Phoebe and Angie. Pages 14-15.....Location drawing at the Hungarian Museum, R. C. of Surgeons Page 16-19.....Location drawing of birth related objects at The British Museum. Page 20-22.....The Times Newspaper articles covering poor birth experiences. Pages 23-24.....Donna Ockenden on cover ups in maternity services. Page 25.....Drawing development of ovary and ripening egg in an ovum. Page 26.....Day 0-9 of the fertilisation and implantation of the ovum. Page 27.....Meeting with Dr Kate Scott, discussing ethics clearance. Page 28.....Drawing of the sagittal section of the female pelvis. Pages 29- 30.....July - October Reading List. Page 31..... Drawing of sagittal sections through human embryos from 16-30 days. Page 32.....Acronyms of birth terminology.
Reflections- October 2023 This reader is still broad in the range of content. I am assuming that as this is still an early stage of the PhD narrative, the breadth of looking at a subject through the title question comes before the depth of what these findings are and how they can be developed into a design process that will be useful to my intended audiences. Three new babies have been safely delivered in this reader. I have stepped back from interviewing them since their babies were born in July- I have meetings set up in the following weeks as they have settled into such a life-changing event of having a first child. On pages 12 and 13, I have included the ‘text’ reports postpartum from my participants. After being privileged to be shared the imagery of an assisted IVF embryo in the first stages of development, Justine had an induced labour with an eleven-pound giant baby delivered thankfully by C-Section. Phoebe experienced six days in early labour, which ended in an emergency C-section when the baby became distressed. Angie’s birth went ‘pretty much the natural birth that I wanted.’ What I have found so eye-opening about this joyful casual sharing of a massive event through text or WhatsApp messaging through a picture and maybe 20 - 50 words is extraordinary. Angie’s natural birth was followed by a haemorrhage, blood transfusions and issues with breastfeeding due to a tongue tie. Justine’s baby also has a tongue tie; she begins her journey with extreme difficulties feeding a baby herself and from another call with her, which I felt was insensitive to ask to be recorded. She felt immense pressure to bottle feed her baby as he was a larger baby and needed to be fed enough. I recall my friend when we had our boys in 2006- he also had a tongue tie, he was labelled as a baby ‘failing to thrive.’ This label is still triggering to her - 17 years later. Should a person in any other situation have a haemorrhage and require several blood transfusions - this would be an enormous event- a trauma! Something that would be recognised as needing time off to recover and nourish yourself to build up your haemoglobin levels and rest. Instead, Angie makes this experience feel quite casual- part of the ride. Phoebe’s birth occurred in the hottest week of the year when temperatures broke records. Had I not been partial to the ‘Big room’ at Kingston Hospital- where a similar case was presented- I would not have believed that spending six days in early labour was possible. The lack of sleep and discomfort must have been literally exhausting.
Having a C-section is a major operation. You can’t pick up a kettle, drive a car, lift a car seat with a baby in it, have sex or do heavy housework. The last two, I am sure after having a baby in any way, you may be forgiven these things for at least six weeks. I have been reassured by these very quick communications how we underplay the gravity and the trauma of the process of the physicality of birthing a baby and having to ‘run’ with the care of this new life with such little consideration for our physical health as birth givers. What potentially would be a significant trauma in any other health setting appears to be ‘normalised’ as a path and par for the course. I recently attended a lecture given for our Level 6 six students by Rachel Gannon co-author of Illustration Research Methods, Bloomsbury 2020, ISBN 978-35005143-0. The talk was a whistle-stop tour of the book. As a Senior Lecturer and year leader, I find that sometimes it can feel that you are continuing to ‘empty’ yourself of advice and information to students. It was a joy to listen to someone giving a lecture that reiterated my methodology for this project. Within the book and talk, she talked about the importance of not perhaps ‘interviewing’, but as practitioners, we should actively ‘listen’ to the participants and stakeholders of a project. Rigour in illustration practice is essential in having a responsibility as a public-facing communicative art form. In that sense, these are things you need to consider. What methods can you use to acquire the information, experience or knowledge you need to progress? What research methods are best suited to the project’s needs and why? What research methods do you prefer and why? What factors might inform or influence your results? Do these influence factors then compromise your project in any way? If so, how? How do you determine the success and failure of methods relevant to your aims and intentions? How much time do you invest in pursuing a line of inquiry before moving on or adapting your methods? What governs this decision-making?
The Birth Rites Collection Summer school wasn’t held this Summer, which was disappointing. They will potentially hold a version in January, which I hope they do. It would be an ideal place to meet other artists and practitioners focused on communicating about birth. The collection is based at the University of Kent. “The Birth Rites Collection facilitates the exploration of many facets within the historical, current and future maternity narrative while cementing the belief that art can be used as a legitimate form of public health education.” This quote is taken from their website from a former school attendee. The collection is the only collection of contemporary artwork dedicated to childbirth, and the course is designed to be relevant for midwives, academics, curators, artists, medics, health professionals, art historians, policy advisors and makers. I have been looking for conferences to present my project as a paper this academic year. There is an upcoming conference at the University of Shannon, Athlone, Ireland, called ‘Graphic Medicine.’ 16th - 18th July 2024. The call for papers has yet to be out. Previous locations have been Toronto, Chicago, Brighton, Vermont and Seattle.
Day 31 Drawings for the second stage of animation process of how an egg forms into an embryo and foetus.
Day 56
Day 34 Day 38
Day 19
Day 20
Day 21
Day 22
Day 23
Day 24
Day 28
Listening to Justine Howlett 39 weeks plus Hello, it is Wednesday, the 12th of July, 2023, and I’m here with Justine. Justine is quite pregnant. Yes, 39 plus three days. I know you’re under Kingston Maternity Unit, and I would like to ask what that experience has been like from talking to you just now. You said that you had a different experience in the run-up to your pregnancy. Yes, I had IVF and ICSI for male-factor infertility. It was a perfect cycle; like I was saying, it was really successful. Hence me looking like this! Once sperm and egg met, it was all good. We had that private, though Kingston does offer it; it was the NHS wait- it was huge because fertility is not a huge priority. It’s not life and death. So we went private. We walked out of fertility, and then as soon as you’re pregnant, they release you at six weeks, five days ish, and you’re just a ‘normal’ pregnant person- which is nice. Kingston differs from many trusts because many hospitals will induce you at 39 weeks or 40 weeks if you’re IVF because they think the placenta has more chance of failing because of its lifespan, ay KMU they’ve never mentioned that to me. I’ve just been a normal person. That’s been from all my own research that I’ve found out, and I’ve never been worried about it. You say you’ve gone into your pregnancy being well-informed. You are a graduate of the illustration animation course, so I assume you like to know how stuff works. Yes, I have been looking at different diagrams and processes; there’s quite a lot of variation online. It’s been primarily things like implantation every little step of the way, like just trying to find out almost obsessively what was happening in my body at that point, so I’ve seen a lot of illustrations or infographics of what happens with when they because of ICSI. The process is when the sperm is injected into the egg. There’s been a lot of visual aids all the way through. How do you spell that? It’s an acronym, it’s ICSI, I forget what it stands for now, it’s been so long I’ve been saying it, ICSI, but it’s something like intra-something, something seminal, I don’t know, injection, but it’s very common now because a lot of men have that. It’s like an undercurrent of infertility that isn’t reported hugely- as it’s in men. People often think it’s the woman who’s infertile, but it’s 50% the men and more now.
He made many lifestyle changes leading up to IVF to try kind of and literally like hone what’s sperm there was there. So you know you have to ejaculate every few days to keep it fresh so it doesn’t get oxidised, and you have to be careful about coffee, alcohol, hot baths, where looser boxers, all sorts of things, proxies, fertility vitamins and things. We don’t know if it helped, but it went well, so we think it probably did. We were lucky that Jake had plenty.
track they are used to. Otherwise, even though our treatment was private, and we were paying, I had to really push for that lubeon injection. Even though we were paying them, I had to talk to a consultant and fight my case.
We had seven eggs, so you only need seven sperm.
So, in your experience of having, as you just said- that critical word to ‘advocate,’ which very much is what this project’s about. Focussing on having to research heavily and being so aware of your body, do you think that’s been the way you’ve probably approached your pregnancy in the same way?
True
Yes, I have.
And they all fertilised.
My midwife, I’ve got a really lovely community midwife; she’s very old school. I think she’s probably past retirement age. And it’s very reassuring. But because sometimes I’ve been very informed before I go in, she doesn’t really, and I’ll leave and think, oh shit, I should have asked that. And then I look back, and she might have, she should have said possibly, because she’s always like, I love our little appointments. They’re always very quick and things like that. And last time she had a student, she felt for the engagement, and the student couldn’t feel it, but she went, “Oh, it’ll be three-fifths.” So she just thought that. And then when I was worried about his size because he’s all the way through, he’s measuring at the high percentile and sometimes off the scale, and I haven’t got gestational diabetes. They tested for it. At 37 weeks, I had a scan that week, and they said he was about 7 pounds 13 then. So he’s going up and up. She said, “Oh, don’t worry, you can go either way, 10-15% either.” I said, “But what if it’s the other way? Then what if he’s more than that?” And she was like, “hmm.” And she eyeballed my bump and said, I think he’s about eight and a half. Can you guess like that? So all I can do is find out on the day as well. So yes, I might be saying, “Christina, you know, he was ten pounds?” Because Jacob was nine and his dad was eleven!
That’s fantastic. Because there’s a considerable drop off in IVF as well, another graphic that came up a lot where it shows you like a little timeline, and you get ten eggs and then by. Eight were fertilised, and then by day three, six will still be alive and then by day five, which is the day that they transplant one fresh and freeze the rest, you might be lucky to have two. But for us, it was the entire number all the way through. Amazing. One slowed down on the last day and didn’t get frozen, so we had six eggs out, six embryos out of seven eggs, which was good. We didn’t have a huge rate of contrition. And are they frozen now? Yes, I’ve got four frozen. So this one is a frozen transfer. The fresh one didn’t work, but usually, it’s because of the hormones you’ve been pumped with. Your body’s not quite ready; it’s only been five days since you’ve had egg collection, which is quite invasive. They put you to sleep, puncture your vaginal wall and then aspirate every follicle in your ovaries to get the eggs out. So it’s quite invasive. You feel very bloated, very uncomfortable for a long time. And your ovaries have grown from like two centimetres to 10. Wow.
I have read that things like heat from laptops can affect male fertility.
So you feel very heavy in your pelvis and things. So the frozen cycle two months later was great because it’s just estrogen pills and progesterone pessaries. I had injections as well because I was convinced that that’s why the first one didn’t work because I didn’t have enough progesterone. And because I get a bit of spotting in between. And then, I took an injection every day. It was like 100 pounds a week for 12 weeks, and that one stuck, So I think that also helped.
My husband was terrible for that, and this wasn’t what caused it, but you have to change your habits.
Everything’s been very researched. Oh, Yes, and you have to advocate for yourself as well because they’ll just put you on a
Eeeek! And I’m 5 foot 4 So it’s quite a big difference in both your heights- It’s like giving birth to another species! Yeah, exactly. So, yeah. Many women I speak to on Mumsnet when I use the internet and in the forums with the same ladies who are pushing on pregnant now, they all have to kind of, you have to push a little bit with things because they see so many people coming through.. You’re unique, and your story’s individual. So it’s important you have to get that across. Yes, and also, you’re dealing with a timeline, aren’t you? Your timeline is the timeline of your pregnancy in that it’s You know, they have a duty of care and obliga-
tion that once you’re in their care, that baby has to come out within a certain amount of time. So, everyone’s body’s different, aren’t they? Yeah, but they haven’t talked about that yet, so I will talk to her tomorrow at my appointment and ask her, like, what’s the plan? Are you going to let me go over my dates? Are you going to do a sweep? Like, because that’s not being talked about yet, which feels quite late. Yes, I think that does feel quite late. Yeah, I think to make sure you ask that and also ask what an induction entails, I know from my own experience I went 18 days over; I didn’t want to be that much over, I was absolutely beside myself, but they kept pushing it back, pushing it back, I mean this was 17 and a half years ago. But then I just thought, oh, they’ll put me on a drip, do this and that for you, and three hours later... Oh no, it’s days. Well, it’s brilliant that you know that. Yeah, I’d like to avoid induction. Again, it’s from reading and watching the antenatal stuff and talking to friends. My friend had one but didn’t want one, and it took ages. So again, it’s my own research. You have to research yourself sometimes because you’ve got so many people to look after, and they can’t possibly... And sometimes they don’t want to scare you. Exactly. Some women want to know lots of information, and other people will be like, ‘la la la la la,’ -fingers in ears. I don’t need to know that. And, like I said, talking to the head of ethics at Kingston Hospital, who said she didn’t get the project proposal and asked, ‘Why do you want to scare people?’ Yeah, you can’t please everyone, can you? No, no, exactly. I mean, for yourself, from, in illustration, it’s subjective. In subjective things: Does this work for you? Or does it not? Do they still use paper-based communication and recording with the pregnancy information - notes? Yeah, I’ve got a big folder. A BIG folder, and you bring it home; my mum said it was kept somewhere in the hospital in her day, and you didn’t have access to it. (I show Justine an example of maternity notes pack from KMU - from 2020)
So that’s interesting that they’re still paper-based. And do you, so looking at it like this, have you had instances where you’ve been given information like that where things have been copied and copied with
legibility issues? Maybe just the gestational diabetes thing; they’re just about instructions about what to do. That information is quite complex and time-based- do this/ do that/ do this, then that. I was talking to a friend who works at the unit, who said, you know, women will come, and they would chew chewing gum, which then makes the whole thing obsolete. Yeah. No, I was really strict on it because I’ve had some like sedation stuff before, and I know it’s different, but I know how strict it is. I overheard a lady come in, and they said what time did you have your last food it was it wasn’t 12 hours. It was something like 10. They said we’d wait two hours, then do it. Which she was really annoyed about. Yeah. But that’s the way it is, yeah. So that’s interesting. Isn’t it about patients being compliant or thinking those rules don’t apply to me? Yeah, but then they can’t do it, and they’re pretty good; they’re quite strict because what’s the point? Yes. So, it must be interesting if English isn’t your first language, or if you aren’t literate, or you’ve got a neurodiverse way of reading, where you sort of scan information without necessarily taking it all in and processing the instructions. Yeah. So, how much information do you feel the hospital is giving that? is it overwhelming or too little? The weird thing about the hospital is they say, “OK, so why are you here today? So they don’t have your background often, so when I go in for a scan, they’ll ask, “Why are you having a scan?” And I’ll say, “Oh because he’s measuring large.” Oh, fine. And then they’ll look at that because I could say anything. I’m curious if I could say, “Oh, his heart’s weird, and they’ll look at that. Because they ask me, they almost, they lead for, maybe because it’s sonography? Whenever I’ve been for a scan, not the 12-week or the 20-week one, I’ve had a few cross scans, so they always ask me, why, so why are you here today? And then I’ll say, and then they’ll get on and do that, and the consultant always says, so why are you here? Because I’ve got a subclinical hyperthyroid, I think I’m off that now because they realise I was 34 when I got pregnant, which dropped me down to low risk. But again, they haven’t done a consult on it. They have 6,000 births a year, though-
it’s a lot. It’s a really desirable place to have your baby. Oh yeah, I’ve read a lot about how good Kingston is. Still, there are so many people who assume that you know your story. You’re managing your own admin in a way which, if you can’t - that must be difficult. I can because obviously I’ve done IVF, and that’s my personality, but if you’re not like that, it could be really hard if you come in. They say, why are you here? You feel a bit worried or a bit anxious, or being at all with doctors, because they are very focused and there’s not a softness in the sonography and consultation department, it’s not like the community midwife where they’re like, oh, come in dear, how are you? They’re very clinical, which you have to just accept. But it’s not like a clinical thing, is it? Pregnancy sometimes to the person, it’s very emotional. Completely, you know, it’s one medical process where you’ve got more than one person involved. Yeah, exactly. I know you said you don’t have a particular birth plan in the fact that what will happen will happen. But anything that you think, oh my God, I really don’t want that? Yeah, it’s like the usual - an episiotomy and forceps sounds hideous. Yeah. And that’s why I’ve been a bit worried about size because it’s almost over-informed. Jacob keeps saying, just don’t worry about it. And I say, I’m not worried, but I want to know because he might be nine pounds or more. You’ve got more chance of shoulder dystocia and him being distressed in the birth canal, so then going in for an emergency C-section. He feels back to back at the minute, which I believe is even harder to get out. If my back hurts out now- what will it be like when I’m actually in pain? Because I was very much else you’ve got tri gassing there maybe sitting in the water for like the labour but because I want to know what the paths could be if that happens what’s the path if it happens what’s the path. So I’m going to be prepared and make the right decision, so I haven’t got a birth plan as such; because I know when you go in, you get triaged anyway, so I can’t see the point of having a vast birth plan. And I go in, and they’re like, ooh, he’s back to back, oh gosh, goodness, we can’t do this, we’re going to have to go to labour ward, not the birth centre. So I haven’t got my heart set on anything because I don’t want to have the addition of being disappointed and having to go through labour. The fact that you even know the word episiotomy is pretty impressive. People don’t do - people really do not know what it is. No, I didn’t know what it was until someone said, we’re going to give an you
epidural. So I couldn’t really see. And she was telling me off for wriggling. And basically, your husband will appreciate that you need to be still. And I’ve heard from this research that in America, they do what’s called the ‘Daddy stitch?’ Daddy stitch, yeah. It’s gross. Make it a bit tighter it’s so disgusting. It’s vile. It’s one for your husband. Yes, that’s horrible. The fact that you know that is great. I want to avoid instrumental if possible, just because it looks so brutal. And I know there’s risk; this was in everything. If I could avoid an epidural - that would be great because I’ve got a funny back from gardening. If not, I’ll take it again, and I don’t want to be in agonising pain that distracts me. I think I can focus enough to push when the midwife tells me I’d rather just feel everything and let my body do what it needs to do, but there are no prizes, no medals for it, going through it for nothing. The prize is your lovely baby, and you’re both safe. Yeah, without a dislocated shoulder and without it looking like it’s black and blue or pulled out of the... because emergency C-sections, like elective, is so much better because they’re not in the birth canal. The injuries a bit more often with emergency C-sections and because my friends have had everything. So you’ve had many friends now who’ve all got different stories? Yeah. And have you, have they talked about their stories quite openly? Oh yeah, yeah, very open. Oh, that’s really positive. And I’ve been very open about IVF and using IVF and stuff because it’s so much easier than having secrets and carrying stuff around. Yeah. So we all talk about it. That’s interesting because I’ve found that only as our children are, have all hit 15 that people have actually talked about the narratives they had given birth to. My mum used to tell us, but it was like that sanitised version, where it’s just the story of it, but it wasn’t anything in major detail. And then she’ll drop in some more graphic facts. Jake’s Grandma was the same. She dropped bombs recently, like, oh, I had three 11-pounders. And I always went, oh, Jesus, it’s not talked about. So it’d be interesting if it’s OK with you if we chat after your postpartum experience. Is it a case of you thinking, oh my God, why didn’t anyone mention that? But you can only know once you do it, can you?
Exactly, I’ve never jumped off a cliff. If I did, I’d hope there was a parachute or something to catch me. Yeah, or a trampoline or something.
It is. Incredible- absolutely incredible.
Yeah, that’s why I’m not worried about it as well. It’s not my nature anyway; I don’t get it, my husband gets anxious or thinks about stuff before it happens, and I’m just more like I worry about it five minutes before, and then it happens, it’s fine.
Yeah. I’ll have to send you the sequence and download them off Instagram, but I can show you if you are interested. I’ve got, so it’s the most photographed child. I’ve got a picture of him when he was that big.
You sound like a perfect blend of people. We balance each other out, yeah. He’s lovely, and he’s a proper soul mate. The best mix Yeah, he is. Between you, you’re making a brand new person. I’m also so relieved because he can be a daddy and feels like it was his fault, and it’s not. But yeah, it’s such a relief because he will be a great dad. He’s really going to be a great dad. We got married to Hampton Court just before the lockdown. It was really lovely three weeks before, so no one thought it was happening! We were like the last wedding for, like, the whole of the pandemic. And how lovely to be newly-wed in the lockdown! He lost his job because it was at the palace, and he hadn’t started yet, but I was on furlough. Still, it was really fun till it was like it was a challenge, you know, we realised we could live on one salary, yeah or an 80 salary and then because of that, when he got a job quickly, we saved loads of money. Then we spent it on IVF, so in hindsight, we needed that money. Yeah, it worked out well. Isn’t it amazing how things turn out and come around? We were lucky to have it because we probably had to spend 15 grand in the end. You know, with everything. It’s a lot of money. It’s a lot. It is a lot of money. But we just said, we were saying for a deposit, but we said we wanted a house to have a kid in, you know, you can’t get a house any time. Exactly- and there’s no right time to have a baby anyway. No, we always planned to be 33 because my mum had me at 33, and we loved our 20s. We were travelling a lot, just very free. So it was a decision to have a kid at 33. It didn’t work out. He’s two years latebut on the way. Now we will only have one instead of two, but again we only just wanted one. It feels incredible to have one. Yeah. After thinking we wouldn’t have one at all. So it’s fantastic that IVF exists.
So you said you’ve got pictures of your embryo forming.
That’s amazing - the size of a pencil lead tip! The ovum is the only human cell that you can see with the naked eye. Every stage because it was so worrying, the initial pregnancy because I couldn’t, I didn’t think, we’d been knocked so much I didn’t think it would happen. That’s in there. It goes bloop, bloop to songs. I’ve got pictures of the first one that didn’t work, but that’s a bit more of a bet it’s a better video because it’s a more classic expansion. Yeah, yeah, that was the one. Can I show you what I’ve been doing animation-wise on my PhD? As you can see, these are 220 frames not on a timeline yet. So what I’ve been doing is that’s the start, and then that’s the implantation into the uterus lining. I’m working in the way I would naturally draw and illustrate. Where’s that layer? There it is. So, the whole intention is that it’s medically accurate with a softness to it, instead of the hard language of infographics or the plastic language that CGI can have. I am trying to work out the formation of the umbilical cord as the cells form into the fetus; there are many clips or sections of embryonic formation -but everything I am finding is jumping to another section and needs a smoother transition of information. I was hyper-aware of implantation. His fertilised egg got transplanted from the lab- he got transferred on a Thursday; I was really grumpy on Sunday and had a bit of pink spotting, and then on Monday, I had a faint positive. Amazing So that’s why I’ve been anxious. See, I’ve never seen one like that image before. Oh, yeah, that’s how much, only the wrong one. This embryo is a bigger one. I’ve got the images from him being so small. That was in the IVF clinic. And there as well, a little heartbeat. Literally, like every step of the way, when he started, he was a gummy bear And then became a baby shape, And as he went along, I thought I was so fat once upon a time, my god I look back now and think, oh what a waste Yeah, and he’s got a little face and things and yeah.
So how do you feel? Oh yeah, the 4D scan, He’s got quite a big nose like Jacob. How do you, do you feel having scans? How does that make you feel in terms of your pregnancy journey? Oh, it’s reassuring! It’s reassuring for a little while, and it goes away. So the first trimester was reassuring for a few days, and then I’d have a heavy day at work, worry about lifting up a plant pot, and then go back in for another one. So I must have seriously spent about £1000 on private scoundrel beds because they’re expensive; they’re like £70 when they’re that small. But that was in the first 12 weeks, I’d say, because it was so much riding on it. I’m looking back now and wouldn’t do that again. But because it was the only way I could check-in. It’s so interesting isn’t it, that being able to see what’s not tangible to see, but actually see it. I’ve been reading a lot about how in Western culture, we have that facility, that ability to do that, which is amazing. And then you get the movements, the quickening movements. I’ve had no scans since then, so I was in there. I’ve had scans at the hospital for growth, but as soon as I could feel he was in there, it’s that weird phase where you’ve got a hormonal sickness, and you’ve got that kind of thing, a sign, but you don’t know what’s happening to that little being in there. I just needed to make sure he was all right. And I think for men, that realisation of that is in there, you know because it’s your body. And have you felt that with your body? As in some women, like our friend was, horrified by the idea of that, about body horror and stuff. But because before, I was doing IVF anyway, and that messes you up a bit. I was really fit before, gardening, I was doing weightlifting; I used to run a lot, and I knew that I wouldn’t do that, so on my private Instagram, I’ve got like a day when I went for my last 10K, and I made it like a last thing. It was lovely to think it was my last 10k before. Hopefully, I’m pregnant, and then when I got pregnant, it’s for a reason you’re not doing it. People can still exercise. Still, because it was such high stakes, I’m just trying again if, naturally, if it had gone wrong, I just embraced that. As a pregnant woman- do you feel like a kind of Venus, like a goddess? No, definitely not. My friend was like this; she said I used to feel so special. I felt like I just felt unique. Even though she was like, I knew I wasn’t. And I’ve got an enormous bump; it’s nice. It’s not, and I look down, thinking, oh yeah, I’m pregnant. But no, I don’t particularly feel like Mother Earth or anything like that. I feel like Rueben’s mother, and I am looking forward to
having him. But yeah, and it’s just, again, because it was such a practical way of having him. And because I’ve got such a practical job and I was on my feet a lot. So I’ve been quite smug about, like, I haven’t had pelvic pain. I managed to work quite late. Yeah, so having that kind of fitness and having that core strength if you’re a gardener, if you’re a runner, if you’re all those things, it’s going to be helpful Yeah, and I know I can put like pull that back as well But again, I’m not I wasn’t like Svelte and I wasn’t like a goddess before so I’m not like lamenting As I’ve always wore huge underpants underwear, so it’s not like I’m going, I can’t make it, my legs are white again, you know. I’m not trying to get back to anything. It doesn’t worry me. I’m not that worried about my body image anyway. I could always look better, but I could look way worse.
I’ll send them. See you soon, Justine and trust your body, ask questions. Good luck with Ruebens birth and let people help you after wards. Thanks Jane - that sounds like good advice. See you on the ‘other side.’
Stop it; Oh, that’s just, what an exciting, exciting thing to happen. I can’t wait. I’ll be excited when I’m there in the hospital. Yeah, because then you feel like they won’t let you out. They’re going to take excellent care of you. Yeah. It’s exciting. It’s almost like going to the airport for holidays, which sounds weird, but when you want to have a baby, when I’ve imagined having a baby throughout my life, it’s that excitement of when you go into labour, and you think, Jesus, you know, I’m going to have a little one. So when it happens, I’ll be more excited. But for now, I’m just going with the flow and trying to get everything ready for him. Watch a lot of shit telly. Yes, I do that anyway. My sister keeps asking- are you going out today? Aren’t you just going to relax? I’m like, no, because I’m not used to it. And I go, it was tough to leave work because it’s so lovely, and they’ve given me a great send-off. And they know it’s a 99% chance it’s a longer bye. Even though I’m still employed for a year, It’s unlikely I’ll be back. So that was hard for a few days. But yeah, now that I’m out of that, I can look forward to having a few years of doodling on the side, but with Ruben, it’ll be nice. . Aw, thank you, Justine. It’s alright. Obviously, on your terms, but talking to you afterwards would be lovely. and those images are just incredible.
On the right are the images of Justine’s baby’s embryo development in the clinic before her implantation. She explains the process.
Eggs are collected- on the day of the egg collection, you visit the clinic for the procedure, which takes around half an hour. The doctor passes a fine needle through the vaginal wall and into the ovary to collect the eggs. You are mildly sedated—the same day as the eggs. IVF involves sperm being added to the eggs in a culture dish. Intra-Cytoplasmic Sperm Injection (ICSI) is where the embryologist selects a single sperm, injects it into an egg, and then puts the egg into a culture dish. Within 24 hours, they tell you
how many eggs have been fertilised and let you know their progress. They have a grading of the embryos on day three that will tell you their potential for development. Some of those embryos will hopefully develop into blastocysts between days three and five. Then, the clinic will give a blastocyst grading. This complex assessment helps the clinic decide which embryos are best to transfer. Shortly after egg collection, you start taking drugs that help your body prepare to receive an embryo.
Your scheduled embryo transfer is around five days after egg collection, though this can depend on the number and quality of your embryos. This takes place at the clinic. The embryo transfer procedure feels like a cervical smear but lasts longer – around 20 minutes. A catheter deposits a tiny drop containing an embryo into the uterus. Other fertilised eggs can be frozen at this stage for future use, and we have four frozen.
Location Drawing The Hunterian Museum, The Royal College of Surgeons Lincoln’s in Field, London
Thirty-one years ago, in the first weeks of my degree experience, we were introduced to drawing on location. One was the Hunterian Museum, named after the 18th-century surgeon and anatomist John Hunter (1728-1793), of the Royal College of Surgeons of England’s headquarters at Lincoln’s Inn Fields. Hunter’s work was one of the collections we were encouraged to explore within the unique collection. Since that initial experience, my interest in communication about the body in both healthy and diseased states. I have visited and redrawn parts of the Museum’s collection many times. The Museum has been closed for the last five years during an
extensive redevelopment, and it reopened on 16 May 2023. It now has two thousand anatomical preparations from Hunter’s original collection, alongside instruments, equipment, models, paintings and archive material, which trace the history of surgery from ancient times to the latest robotassisted operations. The Museum includes England’s most extensive public display of human anatomy. The Museum contains thousands of specimens of human remains gathered before modern standards of consent were established. The museum quotes, “We recognise the debt owed to those people – named and unnamed – who in life and death have
have helped to advance medical knowledge.” Many mounted wet tissue collections have been cleaned, and new specimens are displayed from their archive. On previous visits, there were no black or brown anatomical exhibits. Below is a series I have drawn of their foetal collection depicting the development of the foetus from nine to thirty-two weeks. They are displayed similarly, demonstrating the size and growth development. Drawing them meant I was partial to the visiting public’s observations and thoughts. Most questioned, ‘Are they real?’ ‘How did they die?
Some women talked of their experience of abortion or pregnancies that ended in miscarriage and the relating size of the particular foetus. These specimens are all dated as being produced between 1760 and 1793 by John Hunter and with collaboration with his brother William who was the author of the The Anatomy of the Human Gravid Uterus.
Object: RCSHC/3635 Scientific Name: Homosapiens Category: Wet Preparation Production Date: 1760 - 1793 Twin embryos estimated to be of eight weeks development. Each embryo is within its own amniotic sac, although they share a chorion, indicating that these are monozygotic twins.
Object: RCSHC/3645 Scientific Name: Homosapiens Category: Wet Preparation Production Date: 1760 - 1793 The ovaries, fallopian tubes and uterus of a woman in the seventh month of pregnancy. The uterus has been dissected to show the placenta and the foetal membranes. The right ovary has been bisected to show the corpus luteum. The blood vessels have been injected with a dyed resin to make them show up clearly. John Hunter’s interest in the anatomy of the human uterus stemmed from his early work with his brother William Hunter. William practised as a man-midwife and published a lavishly-illustrated atlas of the gravid uterus.
Object: RCSHC/3644 Scientific Name: Homosapiens Category: Wet Preparation Production Date: 1760 - 1793 The uterus of a woman eight months pregnant, with the ovaries and fallopian tubes. The posterior wall of the uterus and the corresponding foetal membranes have been removed to expose the foetus and placenta. Both ovaries have been dissected, with the right one showing the corpus luteum. The uterine arteries have been injected.
Location drawing at the British Museum, looking at representations of pregnancy, motherhood and birthing through the extensive range of collections housed there. Obviously there were many, many others. These were selected through the range of materials and time frame that they were created.
Object Type Baby-rattle
Museum number: Production ethnic group Made by: Hadza Africa: sub-Saharan Africa: Tanzania Materials baobab fruit
Object Type Baby-feeder Museum number:
Western Greek Production date: 320BC-300BC (circa) Made in: Europe: Italy: Sicily
Object Type Figure
Museum number: Excavated: Carchemish Asia: Turkey: Southeastern Anatolia Region: Gaziantep Materials: fired clay Technique: slipped
Object Type Amulet: Pouch
Museum number: Production ethnic group Made by: Plains Peoples Production date: 1936 (before) Region: North Americas
Object Type Figure
Museum number: Found/Acquired: Khotan (town) Asia: China: Xinjiang Khotan Materials: fired clay Technique: moulded
Museum number: Production ethnic group Found/Aquired: Baname (?) Africa: sub-Saharan Africa: Republic of Benin: Baname
Object Type: Figure
Object Type: Figure Museum number: She wears a jacket with wide sleeves and a pleated skirt. Part of her hair is in a topknot held by a bead circlet, the other part is in a ponytail which is looped up to the top of the head and held by two bows. Production date: 2ndC-3rdC Excavated/Findspot: Yotkan Asia: China: Xinjiang Khotan (district): Borazan: Yotkan Materials: fired clay Technique: mould-made
Museum number: Production date 7thC BC-6thC BC Found/Acquired: Phoenicia Asia: Middle East: Levant: Lebanon: Phoenicia
Object Type/ Figure Museum Number As1904,0416.62
Production/ Ethnic group Made by: Kalamantan Production date: 19thC Found: Baram River Asia: Southeast Asia: Borneo Materials: wood
Object Type/ Figure votive plaque
Museum Number Some features were carefully carved out of a rectangular limestone block to produce this relief votive plaque. Cultures: Late Period Date 630BC - 400BC Made in: Lower Egypt
Object Type/ Figure
Museum Number Cultures/periods: Hellenistic Date: 300BC-200BC Production place: Cyprus
Museum number Cultures/periods Hellenistic Date 300BC-200BC Production place Made in: Cyprus
Object Type/ Dolls Museum Number
Cultures/periods: Falasha Production date: 1959 Production place: Ethiopia Findspot: Gondar Materials: pottery cotton Technique: woven
Object Type/ Figure
Museum Number Cultures: Ptolemaic Roman Period Production date: 3rdC BC-2ndC BC Made in: Nile Delta Africa: Egypt: Lower Egypt: Nile Delta Findspot: Naukratis Materials: terracotta Technique: mould-made
Amy Worrall-Thompson and Sarah Doherty shared their traumatic birth experiences. Rachel Adams AND Nicholas Strugnell for THE TIMES: Sunday May 28 2023, Amy Worrall-Thompson, from Byfleet in Surrey, conceived in October 2019 and had a straightforward pregnancy until Covid hit. Unsure of her birthing options, she paid for an online course from the Positive Birth Company to design a plan that included a water birth and avoided an epidural and an induction. “I looked at it like it was a sort of menu — like a pick and mix of options when it’s absolutely not the case.” In July 2020 Worrall-Thompson, 35, who was overdue at over 41 weeks and five days, had four sweeps and was admitted to the Royal Surrey County Hospital accompanied by her husband, Paul, also 35. The couple wanted her to give birth in the midwife-led unit rather than the medical ward, and were told that this would only be possible if Worrall-Thompson were induced so she wouldn’t go over 42 weeks. However, the couple felt they were not fully informed about the potential consequences of being induced. Worrall-Thompson, who wanted a natural birth, said: “What I didn’t know is when you agree to be induced, it makes the likelihood of medical interventions much higher.” Two pessaries were given to kick-start the contractions, and she was told that she could give birth in the midwife-led unit. She made little progress, so she was put on a permanent monitor that eliminated the midwife unit and birthing pool. Doctors broke her waters, and to avoid infection, Worrall-Thompson was put on an IV oxytocin drip. “The doctors and midwives were giving me and my husband conflicting information. They said I couldn’t have an epidural but the midwife was telling us that it was still an option, and about when to break my waters. We were getting mixed messages. “Time passed and a clip was put on my baby’s head and I became fully dilated. I was immobilised, given gas and air and tried to deliver naturally but I felt like I was dying.” Amy was taken to theatre after about 48 hours of labour, where she was given the epidural and a ventouse vacuum delivery was attempted. It failed and doctors had to perform an emergency C-section. Their daughter, Penny was born fit and healthy shortly afterwards. Worrall-Thompson received follow-up care at Ashford and St Peter’s Hospital, where she was told by a midwife that she could take care of her C-section wound herself. “She was concerned with the baby — making sure she was healthy but when it came to me . . . I said ‘Can you check the wound?’, because I hadn’t taken the dressing off and she said, ‘No, no, you can do that’.”
“Not one person checked it at any point. I had to remove the dressing on my own and hope that I wasn’t going to crack open,” she said. Six weeks later, Worrall-Thompson organised a birth reflection appointment at the hospital to understand what had happened during the birth. The session was held in the same delivery room where she was treated and the midwife was shocked at what had taken place. Worrall-Thompson found out that the C-section was classified at the top end of the most high-risk of cases, and it had severed ligaments in her pelvis. This had been recorded in her notes, but no one had told her. Worrall-Thompson recovered physically but she suffered from severe post-natal depression. She said that she would have had a better experience if there was better collaboration between the mother and the community midwife about birthing plans in the first instance, and if the doctors and midwives were clear in their communication throughout the birth. “If I have another child I will do multiple birth plans for multiple eventualities not just the one, that is my ‘do or die’ kind of scenario because it left me feeling like I had no power whatsoever. The Positive Birth Company emphasise this idea of being in control — it’s your birth, and you’re empowered . . . Whereas I didn’t know in the first place that a lot of the things I had wanted were only possible under certain circumstances.” Worrall-Thompson self-referred to mental health services and feels every woman should get support after giving birth. Amy Stubbs, the professional director of midwifery and paediatric nursing at Royal Surrey NHS Foundation Trust, said: “We know that effective communication is the cornerstone of patient care and we have made significant improvements over the last three years in how we provide information to women. Resources have been designed in collaboration with Maternity Voices Partnership (MVP), an independent group representing our service users to make sure information meets the needs of women and their families.” Andrea Lewis, Ashford and St Peter’s Hospitals NHS Foundation Trust’s chief nurse, said: “We are sorry that Ms Worrall-Thompson feels like she hasn’t received the level of care she expected. We take all feedback seriously and we would welcome the opportunity to discuss this with her if she would be willing so that we can investigate and make any improvements that may be required.” Siobhan Miller, chief executive of the Positive Birth Company, said: “At the Positive Birth Company we do everything we can to ensure people have the best chance of a positive birth experience. “We have resident midwives available for one-to-one calls with our customers, and none of our teaching materials advocates for one type of birth alone. We encourage people to create a birth preferences plan
that includes their wishes for birth in all types of birth scenarios.” I was told I was just tired — two days later I had emergency surgery Sarah Doherty, 36, was classified as a “high-risk” mother and suffered multiple haemorrhages after doctors failed to remove her placenta during the births of her two children. Doherty, the lead training co-ordinator at an engineering company, lives with multiple sclerosis (MS), a lifelong condition that affects the central nervous system, and is seen regularly by a team at Addenbrookes Hospital in Cambridge. Doherty’s pregnancy was consultant-led at Ipswich Hospital and after the birth of her son her full placenta did not deliver, so doctors had to retrieve it in parts and as a result she lost a lot of blood. “What came to light afterwards was that, on the birth record, none of this was put on it. They said that the placenta had come out whole and healthy, with no issues — and I didn’t find this out until I got pregnant with my daughter Elsie.” About three weeks after giving birth, Doherty visited her GP with a high temperature and flu symptoms. “She fobbed me off and said, ‘This is what it’s like to be a new mum. It’s just exhaustion.’ She didn’t even do a swab or anything. I went home and two days later, I bled really badly.” Doherty suffered a severe haemorrhage and was rushed to the early pregnancy unit in the Ipswich A&E department, where she was asked to sit on a chair for 45 minutes while waiting for a scan, despite bleeding heavily. A large chunk of the placenta was still present in her body and the following morning, she underwent emergency removal surgery but was not given a follow-up appointment. After the birth of her son, Doherty suffered two miscarriages. “It does seem to be a pattern, that my body seems to hold on to placentas, because my first miscarriage in-between Alfie and Elsie, I also had retained placenta.” One of Doherty’s miscarriages happened just shy of 12 weeks and she was treated in the early pregnancy unit at Ipswich Hospital. Doherty was given two tablets to take on the morning of the surgery to open her cervix. “I feel like the main nurse that always seems to be there — and I’ve been quite a lot of times — she’s quite rude and dismissive. This was during Covid, so you weren’t allowed anyone with you, so I had to go in by myself without my husband, Darren. I sat there all day, and I was bleeding really heavily. I ended up blocking the toilet, and it flooded. It was so embarrassing. Then the woman said that the doctor didn’t have time to do the evacuation, so I said that I was going to wait here until I had it because I wasn’t prepared to go home.” She held her own and waited between a toilet and a chair in a waiting room for a further hour before the doctor called her in for the procedure to remove her miscarriage. She waited approximately six hours for treatment.
When she became pregnant with their daughter Elsie, Doherty made her consultant aware of her history who agreed to “one hundred per cent make sure” that the placenta was removed, and if there were any doubts, surgical action would be taken. This was written in her notes. Last year Doherty’s daughter Elsie was born prematurely at 33 weeks under an emergency C-section. She asked the doctor to double-check that the placenta was removed and they confirmed it was. However, after being discharged, she was rushed to hospital with heavy bleeding and a scan showed that a part of her placenta was embedded in a hard-to-reach area of her uterus. An emergency MRI scan was booked, but slots were limited. Elsie, who was born with clubfoot, was in the intensive care baby unit, so she was able to stay in the hospital and a midwife was able to assist her in getting scanned. “They said the results would be in later that day because it was an emergency,” she said. “Then we didn’t hear anything, so my husband phoned — and I reckon we phoned every day for the next two weeks. We got through to someone and they said, ‘We’ve lost your notes. Who are you again? What scan?’ I was so worried I was going to get an infection.” “The year before, a friend of a friend who gave birth had exactly the same thing and she passed away at that hospital, so that’s why I was extra worried . . . then they lost my notes, they didn’t have any record that I’d gone for an MRI. It was just a bit of a nightmare.” She avoided a hysterectomy when a consultant stepped in to co-ordinate her care, and her body was able to absorb the remaining placenta. Dr Angela Tillett, chief medical officer at East Suffolk and North Essex NHS Foundation Trust, said: “We’re very sorry to hear that the patient is unhappy with her treatment. We would urge her to contact us through our Patient Advice and Liaison Service to discuss her concerns.”
Poor maternity care left us in danger, say one in four mothers Rachel Sylvester THE TIMES: Sunday May 28 2023 Nearly a quarter of mothers say that the maternity care they received left them or their baby in danger. Almost a third were not given all of the medical care they needed at the birth and 9 per cent said their baby did not get all the necessary care. A quarter of mothers rated the maternity care they had received during the past five years as “poor” and 23 per cent believed they or their baby had been put at risk. The Mumsnet survey for The Times Health Commission raises fresh questions about NHS maternity services in England after scandals that have highlighted serious safety concerns and cover-ups and bullying in some units. Last month the Times commission found that the NHS was spending more than twice as much on the cost of harm caused by maternity services as on maternity care itself. In the Mumsnet survey, 19 per cent of mothers said they received a standard of care that resulted in them being put at risk and 17 per cent said their baby had been in danger. Almost half of respondents said they had not been given enough information to make decisions about planning for the birth of their child and a third did not feel sufficiently informed about pain relief during labour. More than a fifth said the care they received was “not kind and caring”. Several respondents in the survey of 1,018 users said that they had been given a diagnosis of post-traumatic stress disorder and some reported terrifying flashbacks. One mother said she had suffered “longterm trauma” since the birth of her baby. Having been refused an epidural, despite
requesting one, she said that the hospital “used me as a guinea pig for students to do my stitches, without anaesthetic and without my consent. It was barbaric and has put me off having another child.” Another described being “left alone and for too long waiting for C-section. My previous scar ruptured and my son suffered a stroke on delivery. He now suffers from cerebral palsy.” One mother said she “felt very scared and alone [and] had to have counselling sessions after traumatic sudden premature birth”. Almost 60 per cent of respondents said they did not feel listened to by healthcare professionals. One mother said: “I wasn’t allowed pain relief as a consultant mistakenly mixed my notes up with another patient. This patient had a history of substance abuse and this somehow ended up on my records.” Mothers also felt unsupported after the birth. One said: “I was left feeling like a bad mother right from the beginning of our journey together, which has left me with lasting regret and fears for having any more children.” Asked what would have made the most difference, one mother said: “Midwives with empathy. They hated their jobs and made that very clear by bullying vulnerable women who had just given birth.” Justine Roberts, the Mumsnet founder and chief executive, said: “There’s no doubt that maternity staff are stretched to their limit, but this is . . . a cultural problem which sees women ignored and their concerns trivialised.” Last year the Care Quality Commission rated 39 per cent of maternity units inspected in England as requiring improvement or inadequate.
Cover-ups and lies in maternity care keep happening, says Donna Ockenden The senior midwife whose review produced a scathing indictment of maternity services in England fears lessons have not been learnt after new scandals 
Rachel Sylvester THE TIMES: Friday 21 April 2023 Donna Ockenden found that disastrous failings at the Shrewsbury and Telford hospital trust had contributed to the deaths of more than 200 babies. A week after Donna Ockenden published her damning report on the catastrophic failures in maternity services at Shrewsbury and Telford Hospital NHS Trust in March last year, she was contacted by families in Nottingham asking her to investigate how dozens of babies had died or been injured in their city hospitals. Six months later, Ockenden — herself a senior midwife — was put in charge of another inquiry by the government and yet again she is finding a culture of cover-ups and lies in maternity care. “Of the families that I have met in Nottingham to date, some of them have expressed concerns to me that the trust were not truthful in discussions around their cases,” she tells the Times Health Commission. “We have all the systems and structures in place that should be able to spot maternity services in difficulty and here we are again. Families are having to fight to get answers.” The independent Ockenden Review was the largest of its kind in the history of the NHS and produced a scathing indictment of maternity services in England. It found that disastrous failings at the Shrewsbury and Telford hospital trust had contributed to the deaths of more than 200 babies and laid bare a culture of bullying, anxiety and fear of speaking out. In her final report, Ockenden set out a series of “immediate essential actions” that were required both locally and nationally, refusing to use the word recommendations because as she puts it “we’ve seen so many reports where recommendations come and go”. Now she worries that the lessons have not been learnt after a series of scandals in maternity services in Morecambe Bay and East Kent as well as Shrewsbury.
Hundreds of parents and staff members have raised concerns about the Nottingham University Hospitals NHS Trust which in January was fined a record £800,000 for failing to care for Sarah Andrews and her baby Wynter, who died 23 minutes after being born at the Queen’s Medical Centre in 2019. Maternity care has too often been treated as the “Cinderella service” in the NHS, Ockenden says. “We weren’t listened to. The workforce in maternity has not been right, the funding has not been right for a very long time. There was a failure to learn. Maternity services have to do more to genuinely and meaningfully put family voices at the heart of everything that is done.” The woman who has done more than anyone to highlight the problems with maternity care is reluctant to use the word “crisis” but she warns: “I think that without urgent and rapid action, from central government downwards — on funding and workforce and training — mothers and their babies are not going to be able to receive the safe, personalised maternity care that they deserve and should expect. “That should be happening for all mothers across the country on a consistent basis and from what I hear I cannot be confident that that is happening every day in this country.” Although Ockenden insists that many maternity units are doing an excellent job, she says a concerning number are failing to deliver a good level of care. Last year the Care Quality Commission, the NHS watchdog, warned that two out of five maternity units in England were providing substandard care to mothers and babies. It rated 39 per cent of maternity units inspected as “require improvement” or “inadequate”, the highest proportion on record. This chimes with Ockenden’s findings. “In terms of the experiences that women are having, I do hear a lot of worrying accounts,” she says. “I also hear worrying accounts from midwives and doctors on the front line who are struggling with what is asked of them on a daily basis. There are a number of maternity services under very great pressure, very great strain and despite the best efforts of so many staff on the ground, they are struggling to provide consistently good care. “There is a consequence. If, on a daily basis, the conversations between the lead consultant and the lead midwife on the labour ward is all about managing . . . the risk of not having enough workforce to support all the women who have presented that day, then, of course, that will put women at risk and their babies.” The workforce is “demoralised and exhausted” which is making it harder for staff to deliver kind and compassionate care. “We’re talking about midwives working 12-hour shifts where they can’t even take a loo break, let alone a lunch break, it’s not sustainable,” Ockenden
“There is a consequence. If, on a daily basis, the conversations between the lead consultant and the lead midwife on the labour ward is all about managing . . . the risk of not having enough workforce to support all the women who have presented that day, then, of course, that will put women at risk and their babies.” The workforce is “demoralised and exhausted” which is making it harder for staff to deliver kind and compassionate care. “We’re talking about midwives working 12-hour shifts where they can’t even take a loo break, let alone a lunch break, it’s not sustainable,” Ockenden says. “I’m not ever going to say being rude and short and not 100% compassionate is acceptable but when you are in a situation where you are running between two labour rooms trying to give your best to two women in labour or short staffed yet again on your postnatal ward . . . I can appreciate why it happens.” This week the House of Commons women and equalities committee said racism in the NHS had been underestimated by health chiefs, with black women four times more likely to die in childbirth. “We can’t say these things are shocking when we’ve known about them for twenty years,” Ockenden says. “Maternity is not an island, we don’t exist in our own little world. Everything that’s going on in society, we are very much a part of. And, of course, the increasing deprivation that there is within our society in the UK, the increasing inequalities, all that affects maternity services as well.” Ockenden says it is “absolutely wrong” that the NHS should be spending more than twice as much on the cost of harm caused by maternity services as on maternity care itself, as revealed by The Times last week. “It’s a false economy not spending the money that we need,” she argues. “When harm happens in maternity services it goes on to affect a family’s life forever. First of all, there’s the human cost, in terms of relationships in caring for a brain-damaged child, and then there is the enormous financial costs.” Grieving families can be left penniless while they fight court cases that can last more than a decade. “I’ve listened to so many families who have been through that lengthy and combative and exhausting process. It cannot be right that until such time as the payments are made that families struggle,” Ockenden says. “I’ve seen parents come in to talk to me, and they are grey with exhaustion.” Sometimes, during the Shrewsbury inquiry, she would find herself at the end of the day sitting on the bed in her hotel room in tears about the conversations she had had. “When a young mother dies, and you then meet with a family to record their account, you are left very clearly with an image of the huge hole that has been torn in this family life. Mothers are central to our upbringing and if that mother is taken away unexpectedly, abruptly and as some
families will say, to me, avoidably, it’s horrible. I don’t think it’s an exaggeration to say that a family is left almost beyond repair.” Most do not want revenge or retribution. “Families say to me that they want the legacy of what’s happened to their babies and themselves to be positive change — real meaningful lessons to be learned, not just the glib phrase lessons will be learned,” Ockenden says. “For a lot of families, there were themes, and there were trends, and they were repeated. So we’ve had Morecambe Bay, we’ve had Shrewsbury, whilst Shrewsbury was ongoing we had East Kent, and by the time East Kent published we were under way with Nottingham. “We’re not going in the right direction, we’re not getting the number of outstanding maternity services increasing in the way that we should and in fact my sense is that the numbers requiring improvement are the ones that are increasing.” Does she worry that there will be another scandal? “I hope not,” she replies. In response, Michelle Rhodes, chief nurse at Nottingham University Hospitals NHS Trust, said: “The trust are 100% committed to making the necessary and sustainable improvements that are required to provide the best possible care for the women, babies and families who use our maternity services. “Six hundred and sixty families have, thus far been accepted into the review by the IMR [Independent Maternity Review] team. We are also encouraging current and former staff who work directly in or closely with our maternity services, to come forward and engage with the review.” Parents’ five-year fight for justice Sarah Hawkins spent six days in labour but was repeatedly turned away by midwives and doctors after going back and forth to hospital in pain (Eleanor Hayward writes). By the time she was admitted at Nottingham City Hospital to give birth, her baby, Harriet, was already dead. Hawkins, a physiotherapist and her husband Jack, a doctor, faced a five-year battle to get justice and answers over why their daughter died in April 2016. Nottingham University Hospital Trust initially falsely blamed Harriet’s death on an infection, meaning her body had to be kept in a mortuary as “evidence” for two years. The trust finally admitted gross negligence after an independent review concluded Harriet’s death was “almost certainly preventable”, identifying 13 serious failures in care during labour. The Hawkins were awarded a record £2.8 million in compensation from the NHS in December 2021, the largest payout for a stillbirth clinical negligence case. It soon became clear the horrific case was not a one-off; hundreds of other families alleging failings in maternity care in Nottingham have come forward in recent months.
Within these drawings, I have been exploring ways to show cells developing in the ovary before becoming an ovum. These are still feeling rather like GCSE science books, and will work at loosening these up - remaining anatomically correct but feeling fresh but having a sense of design. At birth, a girl’s ovaries contain up to one million follicles, hollow balls of cells, each with an immature egg (or ovum) in the centre. A girl is born with all the eggs she will ever have. You can have as many as seven million eggs in your ovaries when you are born, and these will be released every menstrual cycle throughout your fertile lifetime. Because you’re born with all your eggs, a seemingly bonkers thought is that - if you are female, all of your eggs were once inside your mother when you were a fetus in utero.
The number of eggs a girl has depletes as they grow into puberty. When a girl reaches puberty, she has an average of between three and four hundred thousand eggs, yet the monthly loss of oocytes (oocytes are immature eggs) decreases to one thousand. As a woman ages, fertility can drop due to the decreasing number and quality of the remaining eggs. An oocyte cannot support normal embryo development as it is not mature. An oocyte will go through two separate meiotic cell divisions before becoming a mature egg or ‘ovum.’ Meiotic cell division leads to the oocyte’s growth and maturity, not additional oocytes. Towards the end of prenatal development, the oocytes stop multiplying in number and begin to mature individually. I was ignorant or had forgotten that fertilisation of the matured egg or ovum happens in the fallopian
tube. Once the ovum is fertilised, it is then termed as a zygote before implanting into the uterus lining. The timing for the implantation from fertilisation is days 8-9, when the egg is now called a blastocyte. The stages are: Day 0- fertilisation, Day 1- the first cleavage, Day 2- a two-stage cell, Day 3/4- a four-stage cell and an eightstage uncompacted morula, then an eight-stage compacted morula. Day 5- an early blastocyte Day 6/7- a late-stage blastocyte.
Meeting with Dr Kate Scott, supporting PhD researchers. 5th September 2023. JW -Blue KS- Red Hello Jane, we have half an hour, what do you want to discuss in that time? I wanted to ask you about ethics clearance, how to go about that, and who is the best person to reach out for support. The best person is Christopher Luerer. He knows the process inside out. There are instructions on how to go about filling in a form. I can send you a link to the ethics web pages. You have to go and do some training, first of all, which is online. It takes about an hour and a half, two hours. So you have to do this. It’s one of those modules, you know, where you have to go through. It’s not too bad. You have to set aside a couple of hours and do it. And then you get a little certificate. You have to do that before you can apply for ethical review. Then it does; I would leave aside a decent amount of time to do the ethical form. It does ask for quite a lot of detail. I always tell my students that it’s not wasted time because the methodology you lay out in the ethics form can be recycled and used and will become part of your thesis. But you do have to have an obvious idea of who you’re going to be, who will be your participant, what you will be asking to do, why, and how it fits into your project. You have to justify all of that. You must also provide all the materials as part of the ethical review. So, any participant information sheets, consent forms, any questionnaires, if you’re giving them anything like that, or descriptions of the sessions if you’re running workshops, that kind of thing. So you do have to have it all thought out before you go and say it’s for approval. It can then take a couple of months to get the approval. It’s meant to be something like 20 to 30 days. It’s a very small pool of reviewers, so sometimes it can take a bit longer, depending on the complexity of it as well. Your supervisor has to approve it as well. And then they’ll come; if they’re not if the reviewers aren’t satisfied, it usually comes back with some comments, and you have to make some amendments, and then you get the approval. You know, and that’s the most common pattern. So, it is quite a procedure to go through. Great, that’s helpful. I did it recently last year for a project I was doing that I never did. And it was stressful. I’ve been reviewing them, but it does force you to think about your project. Yes, that’s an excellent way to help focus: What do I not want to be involved with, and what do I not? The other thing is you don’t have to do everything you get ethical approval for.
But you can only do it if you have it in your ethics form. So, if you’re going to ask an extra question, put it in and get the approval. You don’t have to ask that question. It depends. You may have to if it’s part of the process. But you know, it’s better to have the approval and then say, actually, I’m not going to do that extra work, so I’m not going to send out the questionnaire as well. I think a good place to start would be an NCT group, which wouldn’t necessarily be an NHS group. What’s the NCT? The National Childbirth Trust. Yeah, if you’re doing it in conjunction with a charity. Within the NCT, the idea is that you get an understanding of what that process is: in becoming a new parent in finding a support network of people who will be giving birth at the same time, so that you don’t feel isolated and alone in the new stage of your life. So, one thing to consider for the ethics is how to recruit your participants. So, if you’re going through a network like that, do they have a research ethics policy that they may have, but it’s unlikely to be as daunting and impossible to navigate as the NHS one? Brilliant. So what I’ve been doing is I’ve been following three people who have been ex-students who I now know who’ve all had babies recently. They’ve been good enough to share the journey of their pregnancies to their births. The results included, “Oh my God, it took six days, and ended in an emergency C-Section.” I’ll ask them what relevant questions would be about being inciteful for other new mothers. What questions might they have been helpful to have addressed or thought about while it’s still relatively fresh in their minds? To say that the questions you ask are informed by previous research, previous discussions, or by participants and stakeholders themselves. Yeah. Because, yeah, that’s probably more around the methodology. Mm-hmm. Um, rather than the expectations. That is helpful. Thank you, Kate. That was my main reason for booking a chat with you and what I was thinking about, and needing to consider..
Other than that, I’m really enjoying the process of studying and beginning to make links between my illustration practice, and how it can be formed into a ‘helpful’ form of visual communication.. I’ll send you the links to the training and the procedures. There’s a portal that you do it on, and you have to log in and get an account and stuff. But yeah, they should be familiar. John must have done some of his dimensions in his PhD. So I’d have a conversation with them about it as well. Great, so that’s really helpful. Thank you. Brilliant. Have a lovely day in the blistering heat. Will do; see you later, Jane.
Suspensory ovarian ligament Fundus of uterus
Colon
Body of urinary bladder
Public symphysis
Urethra
Cervix
Labium Minus Anal canal
External anal sphincter
Vestibule of Vagina This drawing is referenced from a book called Atlas- Clinical Anatomy. The Stamford Project published by Mosby ISBN: 08151-402-6. Co-written by Robert Chase, John Gosling, John Dolph, Eric Glasgow and Lawrence Mathers- academics from Stamford University. This is a dissection of the medium -This is a particular view or plane of the pelvis used within medical imaging to show the main organs of the pelvis. These include those
labelled above. The bladder, urethra , uterus and vagina have been sectioned in the median plane. The rectum and anal canal are exposed, but not opened. The peritoneum remains intact in the left half of the pelvic capacity.. In labour rectal examination is often used to evaluate the extent of effacing and dilation of the cervix and the assessment of the progression of the labouring woman. This is rarely discussed as part of a birth plan and it can be a shock to an already vulnerable position of the woman.
Perineum
Rediscovering Birth- To discuss birth only in terms of a Western Culture. Sheila Kitzinger
Birth Crisis Sheila Kitzinger
This book explores how much we can learn from other cultures and histories about how we support birthing women through the journey of pregnancy. Traditionally, in some cultures, women give birth in a woman’s space, rarely in a clinical environment. They are encouraged to move around, not to be strapped down with a CTG reading in a passive position. Sheila Kitzinger is a well-known feminist, childbirth advocate, campaigner and author. An MBE, she was passionate about women being provided a birth that they choose. Her books advocate that mothers not at high risk should be offered a home birth. The chapters of this book cover the feelings that a new pregnancy generates within the family and community. The policing of women’s bodies through behaviour, diet, alcohol consumption and exercise. The origins of women supporting other women through the birthing process. The importance of midwife-led care that is not rushed. The importance of sonography and scanning to build a relationship with a baby in utero and how culturally early scans are not wholly available due to choices of favoured sex and lineage of the baby. This book is eye-opening and has led me to read another six of her texts. My previous understanding of Kitzinger’s work was misplaced in thinking she was a hardcore natural drug-free birth warrior. The next book ‘Birth Crisis’ is the next eye-opening read.
This book was published in the same year as my first experience of giving birth; this book examines thousands of hours of women’s experiences and testaments. This book focuses on the range of their experiences and choices and her depth of understanding of the maternity system. It is a distressing read, with accounts of women expecting to ‘pull themselves together’ after a traumatic experience. Her research at the time of publication, ‘One in Twenty new mothers is diagnosed with traumatic stress after childbirth.’* The chapters of the book extensively cover how hospitals are time-based machines, where if your body hasn’t complied with the norm - interventions to speed things up are often presented to the mother at a time of fear, discomfort and pain. Kitzinger explores how birth is turned into an ordeal through women being treated like products moving through a factory production line. She uses many harrowing quotes from women’s lived experiences of trauma and feeling ignored and labelled neurotic women, feeling that they were not informed of questions and decisions being made for them. Episiotomy’s healing is slower and more damaging to a woman than managed perineum tearing. Many references and quotes within this book are and will be essential to my developing research and thesis.
Pinter & Martin Republished 2012 ISBN 978-1-905177-38-7
Routledge 2006 ISBN 0-415-37266-6
*j.Czarnocka and P. Slade, ‘Prevalence and predictors of post-traumatic stress symptoms following childbirth.’
The Story of Pain From Prayer to Painkillers Joanna Bourke 2014 Oxford University Press ISBN 978-0-19-968942-2
This book has taken me most of the summer to get through. Academic Joanna Bourke writes the book. It’s rich in historical context and content, focussing a lot on the role of religion and the experience of the Western perspective of pain. It explores how pain has been politicised in the chapter titled ‘Sentience,’ Exploring how the perceived perception of the pain threshold of the unborn embryos and fetus’ was brought into play in the late twentieth-century debates about abortion. This chapter also explores women’s perceived relationship with pain from the Eighteenth century to the present, how women were used to pain -from the blows of the ruder sex. Childbirth is alluded to being the reason women handle pain differently in the day-to-day in comparison to men. The Story of Pain is a fascinating read, academic in tone, although witty and wry. The most relevant chapter for my research is the last chapter, which focuses on pain relief. Pain relief, such as the properties of nitrous oxide, was known as early as 1800.- However, the usage of the drug as post-surgery pain relief wasn’t taken up for another half a century. Bourke writes that this had to do with societal attitudes and concerns about ‘the democratic distribution of happiness.’ The chapter explores physicians’ reluctance to use pain relief, fretting over the negative side effects of rendering a patient lifeless during an operation. Is pain required, and is it necessary for the healing and recovery process?
Human Embryology and Developmental Biology.
Bruce M. Carlson ISBN 0-8016-6415-2 1994 Mosby
I have had this book since 1995, from my M.A. When I was researching ‘how medical conditions can be communicated through wearable and soft materials.’ This time was pre/ early internet and googling information. The publication is written for medical student’s use and reference. It covers exactly what it says on the tin and provides in-depth clinical guidance and 456 illustrations, many of them in the photographic form of some rather harrowing images of when things don’t go to plan in fetal development. It has proved a valuable guide to the details of understanding how a pregnancy forms— starting with Early Development and the Fetal-Maternal Relationship; it takes the reader through the forming of sperm and the maturing egg or ovum—the formation of the range of body systems with comparisons to other species, newts and rates. The language is medical and not for the general public. This textbook has proved invaluable in providing the science lens of embryonic and fetal development from the beginning.
Dr Spock’s Baby & Childcare
The One Essential Parenting Book 9th Edition 2011 Dr Benjamin Spock revised by Dr Robert Needlman Simon & Schuster
Patient Pictures Gynaecology Michael Stafford 1996 Health Press Oxford
ISBN 978-0-85720-526-1 1946
ISBN 1-899541-60-8
Extraordinarily, this book has sold over five hundred thousand copies, only outsold in America by The Bible! It was written by a left-wing paediatrician, a political activist concerned about the U.S.’s family dynamics and the welfare of children being brought up at that time. He focussed on the need for children to feel special, loved and physically supported with hugs and affection. Children should be brought up with a less controlled strict schedule and fed when hungry. With 1118 pages, it could make a good doorstop. It starts with a chapter encouraging new parents to ‘trust yourself,’ ask about your aims in raising a child, nature and nurture and the challenges of raising different children in different families. The writing is clear and practical. It has a tone of authority but with a friendly and reassuring manner. It is extensive in practical advice for pre-birth, newborns, and the first three months. ‘Enjoying your baby,’ ‘Touch and Bonding,’ ‘Early Feelings,’ ‘Feeding and Sleeping.’ The book follows up on your baby becoming ready for university (hence the weight of it. There is extensive support for the healthy psychology of you as a parent, that of the child, and any subsequent children you may have. If I were pregnant and given this book, I don’t know if it would have put me into a blind panic about all of the scenarios, expense and considerations that parenthood bring. In its tenth Edition, with a new happy-looking baby smiling out from the cover.
Katherine Gail - who I interviewed in reader number three is an expert in Women’s reproductive health, recommended this book to me. The book is published in its second edition and is designed to help women understand their anatomy and what each procedure or treatment involves. Most women will attend a gynaecology clinic and want to know how and why a particular disease affects them and what treatments are available. The illustrations by Dee McLean are clinical line drawings with a hue of green to represent the depth of an anatomical cavity. The images are set in a bold frame, which gives them a textbook aesthetic- classic 1990’s medical illustration. They aren’t warm but an unambiguous indication of scaling, placement, instruments, and implements. It covers an array of female reproductive treatments. It introduces the female genital tract, the position of the uterus, laparoscopy and hysteroscopy (D & C or uterine evacuation), cystoscopy, hysterectomy. Also, I have yet to hear of many, including bilingual, salpingo-oophorectomy, mymomectomy, endometrial ablation, salpingectomy, salpingostomy, and laparoscopic adhesiolysis. colposuspension. Kate reports this book has been essential to her communication with patients for the last 25 years in explaining the treatment they are about to, or have undertaken.
Hensen’s node
Notochord Neural plate
Cardiac primordia
Chorionic villi
Amniotic cavity
Primitive Gut
Allantoic diverticulum in body stalk Yolk Sac Neural folds beginning to fuse
Foregut
Amnion (cut)
Heart
Hindgut Midgut
Pericardinal coelom
Anterior intestinal portal
Posterior intestinal portal Body Stalk
Thyroid
Cloacal plate
Pharynx
Lung
Stomodeum
............Posterior neuropore Tail bud
Liver
Anterior neuropore
Yolk sac
Heart
Body stalk
Pancreas
Stomach
Dorsal Aorta
Lung bud Notochord Thyroid
Rathke’s pocket
Allantois Brain
Proctodeum Yolk sac Heart
This diagram depicts sagittal sections through human embryos from 16 days to 30 days. Sagittal means a cross section of a structure, a vertical plane passing through the body from front to back. The four images show the developing structures of the organs, heart, lungs, thyroid, pancreas, lung, liver and the formation of the gut.
Amnion (cut)
Birth terminology of acronyms AIMS- Association for Improvements in the Maternity Services. ARM- artificial rupture of membranes CTG- Cardiotocograph EDD- Expected delivery date EFM- Electronic fetal monitoring HBAC- Home birth after Caesarean IMA- Independent Midwives Association LMP- Last menstrual period MIDIRS- Midwives Information and Resource Centre NCT- National Childbirth Trust PTSD- Post-traumatic stress disorder PUPPS- Putrific urticarial papules and plaques of pregnancy RCOG- Royal College of Obstetricians and Gynaecologists TENS- Transcutaneous Electronic Nerve Stimulation VBAC- Vaginal Birth after Caesarean