Empowering women - not as easy as you think

Thoughts to ponder on!

There are times it is difficult empowering women.... there is a fine line that you walk and the only way I find to walk it is to be true to yourself, let go of your ego and just state the facts and what you see.

As any midwife knows there are always two sides to a treatment and this is where the fundamental problem arises, because you can have several responses from the woman, and you as the midwife have to know which way the woman wants to go.....and often you will sense that...

Often women only get one side of the treatment, often a paternalistic point of view. Not that a doctor consciously chooses that, it is what the doctor feels is in the best interest of the woman... now how he puts across that treatment option is often to sway or dis empower the woman to his way of thinking rather than giving the woman the complete facts and allowing her to make that decision. Now why is that?

The second option of course is that the woman does get the compete treatment option from the doctor and then says "I don't know what to do, you make the decision"? now I understand this option and I can live with this option.... it is the first option I have problems with...here is an example....

A woman comes in with a query rupture of membranes...40/40 (she is due) not a convincing history of her waters breaking...she was lying in bed, knowing she wants to go to the loo.... gets up and feels a gush of fluid but she is unsure her waters have broken.... she waits several hours.. and then calls the hospital.... she is asked to put on a sanitary pad to see if any water leaks and come in to be assessed. She arrives several hours later, her pad is slightly wet so she is asked to lay down for 20 mins to see if any water is leaking (amniotic fluid)... the woman has an assessment...the fetal position is LOA, presentation-longitudinal, position-cephalic (head down) head ?3-4/5 palpable..(a high head) and a speculum examination is performed to see if there is any water pooling.... there is none...she then has a real time scan (ultrasound) which shows reduced amniotic fluid.... and on reviewing her notes it is noted that she is GBS positive... which means she needs IV antibiotics in labour... the woman is contracting irregularly 1:10..it is now 9 hours since query rupture of membranes....and early evening... the doctor recommends induction of labour (IOL)due to GBS positive, high head, and irregular contractions..... the woman is unconvinced... but her questions are dismissed by the doctor.....when the midwife attends the woman and asks what are we doing for you this evening... the woman is hesitate about the upcoming procedure... when she is asked to explain what is going to occur...she states "the doctor wants me to have the drip"...language is very important... if you are listening to women you hear the unspoken question or the resentment....the next question needs to be... "is that what you want?" she replies " what are my options, I would prefer to wait until the morning to see if I can go into normal labour", she was asked, did you discuss this with the doctor....she said yes.... but he said this is the best option, "you will not go into labour with the baby's head so high".....I would still like to wait said the woman... the midwife discussed it with the doctor and he repeated, his reasons as already stated..... now here is where the conflict lies..... how far do you push for the woman? yes I hear you say all the way.... but how many times do you do this and then the doctor walks in and speaks to the woman and she says to him ok do it......

In this instance the midwife sat and spoke to the woman asking what did she really want and why? and gave the woman the pros and cons for having the IOL now or waiting until the morning.....presenting all the evidence including information about her GBS status & ruptured membranes including the option not to accept (refuse the treatment option) the doctors treatment option and that all this information will be documented in her progress notes. The midwife left the woman to discuss her options with her family, the woman then made the decision to wait until the morning before having the drip. The doctor was notified and the information was documented in the clients progress notes. The woman had some dinner, was happy with her decision and went walking around the hospital for the next two hours.... when she returned she was contracting every 6 minutes... and they were lasting about 45 seconds... it was great......everyone was happy..... the woman went on to labour all night and birth in the morning... it was a vacuum extraction.... there was no induction....in this instance it all worked out well.... the empowering of the woman was because she was given all the information and the woman made her own choice knowing all the risks... she just wanted to wait until the morning..... it really was not a lot to ask... she was being monitored.... that is, pulse, temperature, IV antibiotics 4/24,she did not want to go home... just wait until the morning... to have her baby the way she had planned....

Sometimes I think as a midwife you need to choose the battle.... read the woman's Birth Plan, and most importantly listen to what the woman wants......

picture ref:http://mdean.tripod.com/justice.html

Midwives opinion disregarded by doctor

Trust to pay millions after brain damaged boy's 'mismanaged birth'
This story was reported in The Independent UK, it is a sad story of a mother’s (Kristi Riches) labour & subsequent birth in 2001 that went wrong and resulted in her child (Oscar) being born with catastrophic cerebral palsy, severe cognitive deficit, impaired vision, epilepsy and painful muscle spasms. The midwives involved in the care of Kristi were very troubled and tried to influence the doctor’s course of action, to no avail.

Oscar Riches would have been unharmed and grown up to live a normal life if he had been born swiftly by emergency Caesarean, Mr Justice Holroyde heard at London's High Court.
But the delay at Eastbourne District General Hospital had left the now seven-year-old with catastrophic cerebral palsy.
Oscar's counsel, James Badenoch QC, said that East Sussex Hospitals NHS Trust had admitted liability because of the behaviour of the locum obstetric registrar - an overseas doctor who has now left the UK - who "grossly mismanaged" his birth. Mr Badenoch said that before Oscar's birth, the heart-rate trace showed that he was in great jeopardy but not yet damaged.
But the locum "inexplicably" insisted that Mrs Riches should continue in labour and then failed in a ventouse delivery. Eventually extracted by forceps, Oscar was severely asphyxiated with the umbilical cord tightly around his neck and did not breathe spontaneously for 20 minutes.

"It was effectively an admission of negligence against the doctor - it was not a system failure... and we are happy to acknowledge that the midwives were very concerned and did seek to influence the doctor to take prompt and effective action."

Mr Badenoch said that the locum refused to speak to the midwives, hummed and whistled while attending to Mrs Riches after the birth and wrongly recorded the amount of blood lost when she suffered a potentially dangerous haemorrhage.

"It was effectively an admission of negligence against the doctor - it was not a system failure... and we are happy to acknowledge that the midwives were very concerned and did seek to influence the doctor to take prompt and effective action."
Mr Badenoch said that the locum refused to speak to the midwives, hummed and whistled while attending to Mrs Riches after the birth and wrongly recorded the amount of blood lost when she suffered a potentially dangerous haemorrhage.
It was also reported that as a result of the trauma of Oscars’ birth in December 2001, Kristi (mother) suffered stress and anxiety that she could not contemplate having any more children.
It was not believed that he had worked again in this country but his present whereabouts were unknown.
Oscar is totally helpless and would require constant care long as he lived, which was likely to be into his 20s, funded by an agreed lump sum payment of £1.118m plus annual payments.

Mrs Riches who, with her husband Clive, cares devotedly for Oscar at their home in Glenleigh Park Road, Bexhill-on-Sea, East Sussex, has reached a further undisclosed settlement with the authority for her psychiatric injury.

It is interesting to see the CTG submitted as evidence relating to the fetus’ well being; however there was no mention of any fetal scalp sampling or cord bloods. Also the midwives documentation and concern were duly noted, it would be good to examine this case further to see what other options the midwives may of had in relation to the doctors who were leading this case.


Reference:Posted by The Independent
Friday, 30 January 2009 at 06:54 pm
Published: 2009-01-30 14:18:38
Author: By Jan Colley, Press Association

Poor Record Keeping has Midwife Cautioned

An experienced midwife was cautioned by the NMC for failing to maintain accurate records and then falsified records once she realised she had made an error. The midwife failed to maintain appropriate records which lead to a patient being given the contraceptive drug Depo-Provera while the woman was pregnant. When the midwife realised her mistake and that the patient was pregnant, she falsified the previous entry by adding the words "last menstrual period - first day 11.5.2005" and two weeks later made a further entry - "remembered conversation with patient".

This raises the question of lying to save yourself, however, the fundamental behavior of our nurses and midwives is that of “trustworthiness” that honesty is the best policy – to be dishonest brings our profession into disrepute. Our Codes of Conduct clearly give us guidelines of how to behave and what the expected standards are, this is clearly a breach of these standards.

The ANC did take into account the midwives good record, and that her actions did not result in direct or indirect harm to the patient and the subsequent outcome for the patient was not as a result of her actions. However the committee did find that the inaccuracy of recording and the incidents of falsifying records were not of the standard required of a registered nurse/midwife and resulted in misconduct.

"Nurses are required to adhere to their Code of conduct which says that they should act in a way to uphold the reputation of the profession. The panel considered her behaviour to be unprofessional and dishonest and outside of the NMC's guidelines on record keeping which say that "records should be written in such a manner that any alterations or submissions are dated, timed and signed in such a way that the original entry can still be read clearly".

The midwife had produced good testimonials and that this behaviour was out of character, also the midwife had been dedicated to the profession of nursing and contributed to academic teaching and nurse training.
The report also stated that “last year nearly 10% of the cases that went to a full hearing were to do with poor record keeping”.

Nurses and Midwives need to remember that accurate record keeping is a fundamental part of their practice. Poor sloppy documentation (record keeping) equals a non professional attitude.

Remember if it is not written it is not done!

ref: http://www.medicalnewstoday.com/articles/116988.php