As a midwife the art of listening is imperative, not only listening but hearing what the woman is saying and wanting. This in its self comes with its own inherent problems because as a midwife you know what a woman wants, however this can be like walking a tightrope as a midwife is bound by rules and regulations, therefore it is about the language you use and the compromising you can implement to satisfy both the woman and the institution.
Language is commanding, it is all in the way it is presented; an example would be; you are having trouble monitoring(cardiotocograph (CTG) a woman and she is having a syntocinon (a synthetic form of a hormone oxytocin) infusion for an induction of labour (IOL). It is important to monitor the baby’s heart rate through this procedure as sometimes babies have a negative reaction to the drug and it needs to be stopped. The policy states that a woman having a syntocinon infusion needs to be on a CTG –however in this instance you cannot effectively monitor the woman. What is the midwife to do? The midwife reports to the doctor, the instructions are “the woman must be monitored, put a fetal scalp electrode on”. The procedure is explained to the woman, a small, tiny hook is put on the scalp of the baby, so we can monitor the baby – the woman flatly refuses this option, a definite “NO”. Next: the woman is told, “If you don’t have the scalp electrode and we cannot monitor you, our policy states we must do this. Therefore we will stop the drug and you can walk around for an hour, and if you don’t have contractions, we will start the drug again and you HAVE to have the scalp electrode attached”.
There is something profoundly wrong with this statement: the language is authoritarian, demanding, controlling, there is no compromising, no listening, no discussion, and it creates fear and rebellion and backs the woman into a corner. There has to be a better way of walking the tight rope without losing our balance and falling off. It may be sometimes possible to hold the monitor in place enabling a good CTG reading, thereby giving a good outcome, however I acknowledge that this can be difficult.
What do you do if a woman is refusing best practice, policy, or guidelines?
The answer, discuss the issues in a non-threatening way; give the reasons / evidence why it is important to do whatever it is you want; get the doctor to discuss the issues with the woman; clearly document all discussions and the reasons why the woman is refusing the treatment, however ensure that the woman understands the implications for her decision. It is also a good idea to read back your notes to the woman so that she clearly understands the implications of the discussions and it is how she sees the situation.
At the end of the day the decision will lie with the woman, if she is of sound mind, she is able to consent to treatment or equally refuse treatment. Part of our job is to give her balanced information to enable women to make an informed choice.
A policy is usually best practice and is to be followed. A guideline is as it suggests a guideline that usually outlines how the policy works; both are usually well referenced and evidenced based. In a legal proceeding the policy and guidelines of the time are called to guide the current practice at the time and the expected care to be provided.
Midwives are not and should not be expected to be doctor’s messengers; if doctors have these sorts of explicit instructions, they should be discussing this directly with the client/woman and not expecting midwives to pass on these instructions. The ANMC Competency standards, code of ethics and code of conduct all state that collaboration is essential with health professionals, this means discussing and sharing finding the middle ground, not just regurgitate doctors sentiments, doctors need to be building this relationship with the woman to also find a way to compromise. Midwives need to be mindful of the issue of “failing to obey a doctor’s order” this is a whole separate blog which I will be doing very soon. Working within a system you could face disciplinary action or be sacked for “Gross misconduct”…. Watch this space.
It must be remembered that the woman is the consumer, with her own freely chosen subjective preferences and desires. Doctors tend to practice paternalism – thinking that they know best. Paternalism in medicine is defined as acting for the welfare of the woman, often interfering with or disregarding the woman’s autonomy. Doctors need to find the middle ground.
Autonomy means ‘self-rule’, to act autonomously a woman needs liberty and independence from controlling influences, it is the right to hold your own views. As a midwife we walk a tightrope, balancing the woman’s needs, the requirements of the regulatory bodies and doctors recommendations…….the bottom line remains if a woman is of sound mind, well informed of her choices, she can refuse any treatment, however she needs to clearly articulate these choices together with the possible implications of her choice.
ref pic: http://lukespad.wordpress.com/
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