Tuesday, February 26, 2013

The politics of birth for the private midwife: A minefield from all directions



Being a private midwife can be a minefield, you never know what action will set of an explosion. We all know minefields are designed to destroy or disable.  This means you can have a varying degree of damage from slight, mediocre or catastrophic. Clearing minefields is a long, slow, time-consuming process, and there is no room for error, a bit like the life of a private midwife. There is no clear pathway every woman (case) presents another set of issues often a new battle or the same one revisited but it is the same minefield, you just pray that you don’t step on one and get damaged. You have to select your path carefully.
What is so infuriating; the level of bureaucracy that is required…. let me share a story or two…..you have a so called ‘low risk’ woman who wants a homebirth, she needs to be booked into hospital as a backup – this is required by several governing bodies, however the hospitals play ping pong with you – Hospital ‘A’ says ‘No’ this woman is ‘low risk’ she needs to birth in hospital ‘B’. Hospital ‘B’ tells you No ‘we don’t have the infrastructure’ to support a homebirth go to hospital ‘A’ and whilst this toing and froing is going on….. The woman is progressing through her pregnancy…..God help you if you have a problem…because everyone wants to pass the buck.... And in the meantime the Director General has resigned; there is a State election so the Minister of Health does nothing to assist you and no one in the dept. responds to your urgent requests for help……What is the private midwife to do? However if the private midwife is found to be lacking in some capacity the hammer falls very quickly and very hard…... There is just no equity in this at all…it seems that progress is ever so slow: however I am grateful for the help I do get from some corners  and without that this journey would not be worth it….  I am also thankful for the women for without them we would not be midwives and the breaking of new ground would not be possible.

On the other hand the minefield is the choice some women make: they choose for whatever reason to go outside any boundary the midwife has…outside of the scope of practice the midwife has, and each midwife has their own limits….. now the midwife can choose to accept that woman’s sole choice at her own personal risk… as there is nothing to protect that midwife when she works outside the boundary of the so called ‘low risk’, accept her documentation and sometimes that is not even enough – the woman is only wanting what she considers is in her best interest. However the midwife ends up having to defend themselves and this means $$$$$ in legal fees, even if the midwife did everything within her power. Who looks after the midwives best interest? Not the regulatory body, not the government and certainly not the AMA - The Midwife has too….because no one else will…. This is sad reflection of Midwifery practice in Australia – I for one am not prepared to risk my registration and pay out $$$$ in legal fees…. until the midwife is afforded protection as her counterparts in the UK and NZ the Australian private midwife is becoming are rare commodity and will become extinct.

I will end by saying I have had some wonderful experiences with women along this journey and every single one has taught me something about myself and pushed a boundary – I reflect on every experience and say ‘how can I make the next one better’. The major drawback is the political battle that each case brings in access to hospital, collaboration and the support required…. The burden of collaboration is tremendous….it is a one sided affair….every now and then you step on a landmine and you get damaged….. And you contemplate when will the damage be catastrophic and you pray it won’t be you and it won’t be today.

Monday, February 11, 2013

Where to find some Evidence - pregnancy

This is a great Blog - have a look at the video regarding Evidence Based Birth Tutorial - very informative, shows you how to find the best evidence - you can then discuss this with your health professional - see what they say - to have knowledge is to be forearmed....for all those pregnant mums...check it out: Evidenced Based Birth Tutorial:




Communication, pregnancy & labour - women



The way we communicate with women:

I was saddened today by again listening to a woman retell her traumatic first birth from two years ago: it is really disheartening that our health system is letting these women down by not providing the right care. Something really needs to change about the culture and language used within maternity services and the paternalistic attitudes of our midwives and obstetricians; It really is all in the way that messages are communicated to the women:
I am sure we all have a story to share, I recently experienced this first hand as an observer: the woman attends hospital and is 6cm dilated on arrival, she requests an epidural. 

Doctor “I want to do a vaginal examination first
Woman “I really want the epidural first, then you can do an internal examination”
Doctor “I must do a vaginal examination first, now, you might be fully dilated
Woman “I don’t care I want an epidural now please
Doctor “but don’t you understand it is important for me to do one now
Woman’s husband in a cross tone “did you not hear my wife she wants an epidural first then you can do your examination”
Doctor “alright then I will call the anesthetist but he may not come for an hour or so”

This process had already taken an hour; this woman did not get her epidural for an hour and a half.
After a long labour, now fully dilated and a failed vacuum it was determined by the doctor that a caesarean section was required. There was no fetal distress – he had called another more senior obstetrician for trial forceps in theatre.  When the senior obstetrician arrived the woman was upset, she had worked damn hard, she was tired now crying and when the obstetrician introduced himself to her, she looked at him and pleaded..she said ....

Please try everything before having to do a caesarean section; it really is the last thing I want’. 

The doctors response was “I will do whatever I need to do, that will be best for the baby, and if that means a caesarean section, well, so be it”. He then went on to say “ a friend of mine did a small research study on women who are fully dilated after failed vacuum and the outcome is much better for the baby if you go straight to c/section’. ‘Now let’s get on with this to theatre now’.

The woman and husband were shattered on so many levels; they surrendered to what was to come:

My point is not whether the woman required a caesarean section or not, it was the manner in which the obstetrician had spoken to her.  There was no explanation, no informed choice, there was no empathy, and there was no consideration for what she was feeling, it was pure unadulterated power pure and simple. 
The obstetrician could have said “I am so sorry that this has been such a long hard journey; I will do my best to assist you, however I must let you know that a caesarean section is quite possibly on the cards, but I will assess the situation in theatre and keep you fully informed, explaining the situation to you and we can make the decision when I know the full picture”.

More consideration is needed when communicating with women that enables informed decision making – clear explanations as to the clinical picture therefore empowering women and their partners: More often than not when the clinical picture is spelt out in clear simple language, women will do what is necessary because they understand the situation and they are making the decision.

As health professionals we need to constantly think about the way we communicate with women.... think about the language you use, don’t be paternalistic be empowering – give an accurate explanation of the clinical picture and accept the decision that is given, not the one you want:
Remember the old saying ‘you get more flies with honey than vinegar’ – so true

Sunday, January 6, 2013

An action packed 2012


It always amazes me when I get to the end of a year and look back, so much has been achieved. My intention each year is clear, I make a list and by the middle of the year it has doubled and by then end of the year much more than I planned is achieved… how does that happen? One thing was for certain my work load was vast…. From 300 plus students, my private practice and my study not including family and friends…..
2012 started with various College activities and takes me through the whole year as this is an important part of my professional life as a midwife.  Then comes my usual trip to Singapore and my 140 students, my usual local students another 150 plus, as well as whatever extra your workload includes. Our private practice was steady… and my usual two units of my personal study and whatever extra summer/winter intensive units I could include. Most importantly there was the family, 6 children and 8 grandchildren to fit into my life….. You might well ask how it all happen…. It just does.

Highlights for the year included: Major decision about changing my work place – I was asked to review my study plan and consider switching to a PhD – this was a major turning point in my academic work life and chose not to commence a PhD at this time in my life as I was already committed….half way through my Law degree and did not want to change at this stage. This gave me the opportunity to re-evaluate where I was in terms of my study and my working life and made a decision to reduce my work hours therefore my workload….by far the hardest part of my work was the marking component, it always coincided with my own study and made this time of the year extremely stressful for me…and therefor my husband and made me unbearable to live with. So began the process of changing my job.

Our holiday to Thailand was a brief respite, it gave Ian and I time together just sitting on the beach, reading I read all three 50 shades books and found them brilliant…. Good light-hearted reading. We did some sightseeing; dining, walking and just general fun… the only problem was it was so brief….
The midwifery private practice is steadily growing however the political struggles continue; we still do not have visiting or credentialing rights to government hospitals….each woman brings with her a new challenge…. And we have been rejected from more hospitals than I care to think about…. But we continue to serve the women who employ us and continue to take the issues up with both the Health Minister and the Hospital directors….. Interestingly the Director General Kim Snowball resigned due to pressure of the job…now there was a surprise… NOT.

My study, I usually take two units a semester, and a winter and summer intensive… I really enjoyed Bioethical and Medical law… a brilliant unit as well as Occupational Safety and Health Law… they were my highlights. I also committed to the Flinders Graduate Certificate of Midwifery, two units pharmacology and diagnostics…..the two worst units ever… disorganised, time consuming over assessed and inconsistent with the marking of assessments….. Thank God I passed and will be an endorsed midwife able to prescribe……Worst law unit was evidence…. It just about broke me…. but have a good handle on it.... I must learn not to show what I am thinking on my face....

Change of job midyear as another major step…. Moved to half time (.5) as a senior lecturer… this reduced my work load significantly… and allowed me more time to complete the extra units for my midwifery prescribing …..this job has been challenging in a different way…the private sector is always different..... new courses are always difficult and have teething problems….but most of them have been overcome….watch this space.

With so much study and work, sadly my blogging has taken a back step…. But I hope that I will have more time to do more of this in 2013…. As I do enjoy blogging… I am always thinking of blogs...but finding the time to write and post them is difficult....
My diet has been fantastic....very hard work....I just did not realise I was as fat as I was.... sometimes I think I am mad deciding to diet when my life is so busy...there is never a good time.... you just have to do it..... it has been well worth it.... have lost now 18kgs.... would like to lose another 10kg.... I always think you never see a fat lawyer..... a  shallow reason for losing weight...but it has worked for me....I feel really good for the weight loss.
The family is all good…. I am so blessed.. I had some personal struggles with a decision made… I guess this is normal, the challenge is to give your opinion and then stand back and watch how it all plays out…when it doesn’t go your way….it is about letting go… continuing to love & support and deal with how you feel in your own way… and that is not always easy…. And sometimes you find you don’t even like each other for the decisions made…time does heal…. the trick is to accept and move on…and that was the biggest lesson I learned in 2012.


The grandchildren are the delight of my life… Christmas is always my favourite time of the year…. I love watching them open their presents….. and it is the time of year in which I can spend some quality time with them……watching them all growing … wow… Jasmine is 8 now… Talia 6, Sam 4, Dylan 7, Isabella 4, Jessica 7, Logan 4 and Tayla 18mths…. And a new one due in April……one of the grandchildren has just been diagnosed with Dyslexia…. Which will bring us some new challenges… the highlight for the year was the family portrait with nanna and pops… I didn’t think it was going to be as hard as it was to get all 8 in  a picture, between Sam having a sad, Talia falling of the fence, Tayla teething and off course Isabella deciding not enough attention is being paid to her…. But the photos were a great success… can’t wait to receive them, they were overpriced and the copyright annoys me…but they will be well worth it…
2013 will bring many new changes for me…as I am going to work towards my career change… not that I want to leave midwifery… but I really want to see some changes from a political stance….our practice will be busier…. Three of the grandchildren will be in kindy…and the rest will be in year 1,2,3,4. My study will continue and hopefully my plan is to be finished by the end of this year…..Wow!
Wishing everyone a happy, successful and healthy 2013.....go forth and reap the benefits of life you only live once.... and don't forget to play:

Wednesday, December 12, 2012

Hospitals in WA not accepting Women who are choosing Homebirth with a private midwife:




The 2010 Maternity reforms are still not working.....Access for Private Midwives was to be achieved within the first year….Still not achieved…I wonder why it takes Australia so long to instigate credentialled private midwives. Surely it can't be that hard to set this up...after all Visiting Medical Officers (VMO's) have a system already....why not just emulate that one? It seems that procrastination is rife within the Health Dept.….2 and half years and where are we? absolutely nowhere:

As a private midwife I still cannot get access to hospitals…..here I am playing by the rules and some hospitals refuse point blank to accept a woman who is going to have a homebirth and being cared for by a Private Midwife…The Safety and Quality framework to which I as a private midwife have to abide by as dictated by the regulatory body (NMBA) states that the woman has to have the closest hospital to her (within 30mins) as her back-up hospital…. The Director General of  WA Health  has given a direct instruction to hospitals to allow access for midwives conducting homebirths….are the hospitals abiding by this directive? NO….what happens to these hospitals…..nothing…. What happens to the Midwife when she/he does not follow directives….we get the sack or reported to NMBA… where is the parity…where is the justice? Who is holding these hospitals to be accountable?

So where does this woman and midwife go? Where does the woman give birth? Does the midwife birth her at home with no back up hospital? Because the hospital refuses access the woman is not booked there, if anything was to go wrong we would then have to travel over 45 mins to get to the tertiary hospital. This is a complete farce of a system that is nothing but prejudicial against women’s choice of place of birth and midwives facilitating the woman’s choice. 

Midwives and women need to stand up and be counted…. There is a multitude of evidence to show that low risk homebirth is safe…..  The AMA is propagating fear and control by the constant mantra “We do not believe or support in homebirth”….it is time to fight back……..Midwives are not handmaidens to doctors…..Women have the right to choose and refuse treatment.....and women do have  a right to homebirth with a skilled midwife.


Sunday, December 9, 2012



Goodness me I have been so busy with studies and work that I have not had time for my blog. Sorry to all my readers.... for not keeping up with regular posts. I will try to make up for it in the next few weeks. 

Interestingly I have just finished a summer intensive in the Law of Occupational Health and Safety and thought I would share some of the key points I learned.  I have had my head buried in books, study and work that I did not realize there was a big debate regarding changes to our Occupational Safety and Health (OSH) Laws in Australia..... shame on me. This has made me think if I didn't know how many other midwives did not know....WA's current legislation is Occupational Safety and Health Act 1984 (WA) & OSH Regulations... remember regulations outline how the Act is implemented.

Currently each State and Territory in Australia has their own safety and health laws. They impose broad general duties on key stakeholders such as employers, controllers of workplaces and designers, manufacturers and suppliers of plant to workplaces in relation to ensuring the health, safety and welfare of people.  

As from the 1st January 2012 the Commonwealth, NSW, QLD, ACT and NT have actually passed the new legislation, Victoria, WA, Tasmania and SA will be delayed until sometime in the New Year.

Harmonisation would mean each State and Territory will still have their own safety laws, but they will be based on an agreed model Work Health and Safety Act supported by model Regulations and model Codes of Practice. The new law is called Work Health and Safety (WHS) - WHS laws create obligations on employers to put systems in place to prevent workplace injuries.

Harmonisation also involves a National Compliance and Enforcement Policy, designed to support the consistent application of the laws across Australia by the different state regulators. These laws will only come into play when each state/territory passes them through their own Parliament.

There are several key elements to WHS, they are: duty of care, meaning of worker, cooperate with other business, consult with workers, upstream duties, union right of entry and due diligence.

A key element of the new National Law is the legal term ‘person conducting a business or undertaking (PCBU)’. This term is not intended to mean individual persons unless they are operating the business in their own name, for example as a sole trader or a partner. A person who is a director of, or employed by, a company is not a PCBU, the company is. The responsibilities of individuals who are directors or senior managers of companies are covered under the new element of ‘due diligence’. 

Most of the concepts in WHS are not new, they are just reworded and definitions have been redefined; such as workers means more than employees, this is due to work being completed by people who may not be employees. WHS defines worker very broadly to include; employees; contractors; sub-contractors; outworkers; employees of labour hire companies; and volunteers. 
 
WHS requires persons conducting business or undertaking therefore to as far as is reasonably practicable, ensures the health and safety of workers it engages, or workers whose work activities it influences or directs, while they are at work in that business. Ensuring health and safety is imperative and this is defined as eliminating risks, so far as is reasonably practicable, or if that is not possible, minimising the risks.

“The phrase “reasonably practicable” means something narrower than ‘physically possible’ or ‘feasible’. What is ‘reasonably practicable’ is to be judged on the bases of what was known at the relevant time and to determine what is ‘reasonably practicable it is necessary to balance the likelihood of the risk occurring against the cost, time and trouble necessary to avert that risk (Gaudron J at para 53. Slivak v Lurgi (Australia) Pty Ltd (2001) 205 CLR 304.). 

Alright let me put this in plain language and use water-birth for an example. Under the new laws you are required to exercise due diligence....this means you are required to have updated knowledge of health and safety matters...in this instance we are relating it to water-birth - have you considered how you will inflate and deflate the pool? access to power points? How is the woman going to get into the pool? is there a step or stool, is it safe? can she slip? is there a non-slip surface? get the woman out of the water if there was an emergency? what will you do if your pool has a leak? what will happen if the woman faints, hemorrhages etc
Is there a safety culture present? an informed culture? a reporting culture? a just culture (a no blame)? a flexible culture? and lastly a learning culture?

What safety measures have you in place? do you practice safe evacuation? what measures have you in place to protect your back, the clients partners back? 

What is important to remember is that everyone owes everyone a duty of care, as to what is reasonably practicable.

WA has rejected the model WHS Bill, it has highlighted four areas that it did not agree with and consequently would not be adopting as law in this State. However none of the four issues relates directly to safety outcomes within the workplace.

The four issues are penalty levels, union right of entry, Health and safety representatives’ capacity to direct the cessation of work and Reverse onus of proof in discrimination matters. WA agrees in principle that the penalty fees should be increased; however feels that the proposed increase is too high. In terms of workers’ rights to cease working if it is considered too dangerous WA feels that this should remain with the worker and not be delegated to the Health and Safety Representative. Union right of entry is already provided for in WA legislation and to have it in this model would be a duplication of the rules. Lastly WA considers that harmonisation will allow a company to be prosecuted without the opportunity to prove that the company tried to fix the safety issue and also considers this to be contrary to one of the issues that initiated harmonisation.

WA will probably accept the national Model Act with some minor modifications.  

Remember to work safe and always consider is your work environment safe? what can I do to make it safer? Watch out for when these laws come into place and make sure you are aware of the changes and how it will affect your work practice.





                   WHS At a Glance: New National  WHS Laws
Picture ref: http://www.quality-improvements.co.uk/images/banner-18001.jpg
 


Monday, November 12, 2012

The ACM's draft Water immersion for labour and or birth



Well it has been a while since I have written, and this is due to being very busy with four units of study, work and family life.
I am looking forward to the semester finishing so that I can have some free time to blog, play and have some fun...... However I have taken some time out of my study plan today to write this blog, as I am very frustrated about this issue.

Firstly yes I think water is a fantastic source for women to use for pain relief, and if I had my time over again I would have a water-birth - so I am no opposed to this concept, in fact I am highly supportive of it. But equally so I think it is important to maintain a safe environment for both mother and fetus (baby).

Please have a look at this draft position statement on the ACM Website: Water immersion in labour and / or birth:

Here are some excerpts:

Position Statement on use of water immersion for labour and birth
"The ACM supports the choice of all women at term to have the opportunity to access water immersion for labour and/or birth."........
 This opening creates a problem for me as not 'all' women are suitable for water immersion - and I think that this statement is a potential problem because it could be seen as encouraging 'all' women even those with a know high risk factor to use water immersion (in the bath/pool) - this in fact could work against the college if there was an adverse outcome.
However equally the problem arises when such tight restrictions (the current policy for water immersion states only low risk women) are placed on women who don't necessarily fall into the 'high' or 'low' risk category......

The other major problem I have is in the achieving best practice.......all maternity services to be encouraged to provide telemetry... for water immersion ( that is CTG monitoring in the bath/pool)
To achieve best practice use of water immersion for labour and birth, it is necessary for:
 all maternity services to be encouraged to provide women with access to water immersion in labour and/or birth including telemetry as required;

My concern with this is two fold, one if a woman needs a CTG (fetal monitoring) then it is considered that she has a risk factor that should not necessarily be in the water - and are we putting her more at risk?
Second issue is that but stating this point even the low risk women might end up having monitoring in the water...will we be opening Pandora's box?


What I really like about the position statement is the following excerpt....because this tells women that they can so 'NO' and have the right to say "NO" to any treatment they do not want.
Informed decision-making, informed consent, and right of refusal are accepted legal principles in Australia. Each and every woman has the right to make informed decisions, including consent or refusal of any aspect of her care. Women must be respected in the choices that they make.
I also think that the College is compromising the position of midwives on this issue, because most state-wide hospital policies all state that 'water immersion for labour/and or birth is recommended for low risk women'.
We have only recently taken the step to have water immersion in labour and/or birth accepted as a part of the childbirth care options.....and some hospitals are still not offering this to 'low risk' women let alone 'all' women.....lets take some baby steps first....otherwise we will lose the lot.....all it will take is one bad outcome and it's gone.........

Take some time out and give some feedback

DEADLINE FOR SUBMISSIONS: 5pm (Canberra time) 21th December 2012: Submissions received after this date will not be considered.
Submissions (and any questions about this consultation process) may be sent by email to: sarah.stewart@midwives.org.au



picture ref :http://watersongline.com/wisdomcorner/waterways/







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