Finally a direction: Legal & Ethical issues in Midwifery

This is my newest grandchild due 12 July 2008 - 20 week scan.

I have been bloging for about 10 weeks now. During this time I have experimented with different topics and I have not had any clear direction, except that I wanted to share knowledge with women and midwives regarding pregnancy and childbirth. I have read many other blogs from both midwives and women, some of them have a theme and others do not. I also enjoy having a commentary regarding the subject material. At this point I would like to acknowledge the support of fellow blogers Carolyn McIntosh and Sarah Stewart who have been good mentors. I do find it frustrating sometimes when I do not have the technical / computer skills required to do the things I want to do with my blog. This then entails reading pages of material trying to put a link on the blog. Despite these challenges I do enjoy bloging and find that it is quite contagious even though it can be time consuming. However, I have decided that as an educator it is important to focus on a particular area within my scope of practice. My passion is “law” and “ethics”, to get the message across to midwives the importance of professional practice issues; these being; Legislation that governs our practice, ANMC Competency Standards, ANMC Code of Ethics, Code of Conduct and Nurses & Midwives Board requirements, negligence, confidentiality, consent, documentation, Scope of Practice and any other topic that may come under this heading. This means that this blog will now specifically look at legal and ethical issues (women's rights vs fetal rights) relating to pregnancy and childbirth, of which there are many. If you as a reader of this blog have any questions or issues that you would like to discuss and or cover please just leave me a comment and I will follow it up. Each month I will cover a legal or ethical topic relating the subject to legislation and midwifery practice. If you have any burning issues please ask the question or share the experience so that we may all learn from it.

Caesarean section rate on the rise!

We all know that the caesarean section (C/S) rate is on the rise, currently in Australia it is at 29%, it is interesting to note that in 1993 it was only 20%. Some statistics show a dramatic rise among low-risk women within the private health care sector, an increase from 10% to 19%. The public health care sector was less, from 6% - 8%. So why is there such a disparity between the private and public health care sectors? And what can Midwives do to help stem the rising rate of C/S?
Are women aware of the implications of such a rise in the caesarean section rate and the possible complications for further pregnancies?
One of the complications are placenta accreta which has gone from being a rare occurrence to frequent one. The Sydney Morning Herald viewed this interview: see link below: http://www.smh.com.au/multimedia/2008/national/caesareans/main.html

Its time we worked collaboratively to reduce the caesarean section rate and informed women of all the complications of a C/S, it is not just a simple operation, it is major surgery which will affect them for the rest of there lives, and yes there is a place for a C/S when it is an emergency. Please make a comment, what do you think?

Remembering your midwife

The semester has began again for 2008, new faces, new units, some repeating units, the corridors are buzzing with excitement, university staff are ensuring all is going well. But alas you know the old saying "the best laid plans of mice and men" yes something always goes astray. My week has gone smoothly and I am excited about the new semester. My energy levels are high and I am revving to go. I was given a boost the other day, that I thought I would like to share, because it is good to share the feel good stories, it makes the world go round more smoothly.
I had come out of facilitating my tutorial, happy that the session went well, when someone stopped me and asked if I was "Pauline" and did I work at a particular hospital, do you remember me?' I don't know about you, but this makes my heart stop, you rack your brain for some sort of recognition, a bell to ring, something, but all you do is draw a blank! you finally respond, smiling, and saying 'can you give me some more clues' then she said, 'yes you were the one who helped me birth my twins',your heart sinks, you still draw a blank and apologise, smiling and hoping that your memory will trigger this wonderful event. then when all else fails, you bite the bullet and say, 'I'm sorry, it is a vague memory'.
In this instance the woman relayed the story of how I assisted her not only with the birth of her twins, but in our time together I was able to empower her to believe that she could reach for the sky and attain her goal. Her goal was to do her nursing and midwifery even though she had given birth to her beautiful twins. She said "thanks to you, I am now half way through my nursing course, you inspired me, I am on track. My twins are 4 1/2, I am happy and I am glad I have had the chance to meet with you again and say thank you for encouraging me to go for what I want". I responded by saying "congratulations, she had done all the work and that she must be very proud"
I was floored, and I did remember her and our conversation, she was upset that by having twins it would put her dream on hold for many years, even though she was happy about the twins.
I guess the moral of this story is, that women remember their midwives, both positive and negative experiences. The midwife - woman relationship is the basis of a good shared decision-making process. It is always very important to find out what is significant to the woman and her family, by talking things through. The focus being on 'woman centered' care, being in a partnership with the woman. Our role as a midwife is to respect, promote and facilitate the woman's choice, the choice of individualised, personalised care. We have such an important role, we must never lose sight of that, we can and do influence outcomes for women. I feel that I am privileged to be able to work with women and their families, to attain the best outcomes. Our relationships are based on trust,respect, and commitment, that facilitates communication and enhances care. It is all about listening to women, valuing their opinions and supporting their choices in a safe environment.
"caring is a fundamental necessity rather than being a soft option and is as important as technical knowledge or science" Ann Oakley

The Pinard - The midwives companion

Are we seeing the end of an era? - the death of the Pinard. Why do I say this? in the latest clinical guidelines for Intrapartum Fetal surveillance (2006) The Royal Australian and New Zealand College of Obstetricians an Gynaecologists (RANZCOG)have sounded the death knock for the pinard. Guideline 7 "intermittent auscultation should be performed using Doppler ultrasound rather than a Pinard stethocope" Guideline 8 "auscultation should occur with Doppler signal on speaker mode". Since the publication of these guidelines, I have seen the disapearance of all the pinard on our labour and birth suite, which has promted me to ask the question? are we loosing the art and skill of using the pinard?
It is interesting to note that in the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)2005, this report recommended training for midwives and junior doctors in CTG interpretation, because errors were being made which had a detrimental effects for both woman and baby. The question is asked what about senior doctors? who monitors them? CTG monitoring is technology spreading without justifed research.
It is a well know fact that CTG monitoring is not an exact science, however in the current litigatous climate it is the best we have and clinicans are inclined to feel protected by using this technology, even though you can have several clinicans disagreeing on the interpretation of the CTG.
Mahomed et al. (1994, pp 497-500) conducted a randomised controlled trial on the effectiveness of differnet methods of intrapartum monitoring. They found that the doppler sonicad compared with the pinard stethoscope was better at detecting abnormalities in the fetal heart rate. They also found that the pinard was more uncomfortable for the woman.
The doppler sonicad is the electronic equivalent of the pinard and has the advantage of the woman being able to hear the babys heart rate, and further protecting the midwife against litgation (Seymoour, 1995, p 47).

So is there still a place for the pinard stethoscope?
I would like to see midwives teaching students how to use the pinard again in conjuction with the doppler, so that we maintain the midwifery skill, you never know if technology fails we are still able to monitor the fetal heart.

References:
Ayres-de-Campos D, et al. Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision, Br J Obs Gyn, 1999: 106; 1307-1310.
RANZCOG Intrapartum Fetal Survellance Clincial Guidelins. 2nd edition. 2006
Seymour, J. (1995). Fetal monitoring.

"Midwifery" standing independently in WA

The profile of Midwifery has been given a great boost, in Western Australia (WA). This has been a long time coming and a dream come true for many midwives. As you will be aware in 2006 WA introduced the new Nurses and Midwives Act & the Regulations. Also the Nurses Board has changed its name to the Nurses and Midwives Board of WA (NMBWA). You might say so what? but this had made an enormous difference to the Midwifery Profession in Australia particularly in WA and world wide. This is because now you can be a midwife in WA without having to be a nurse first. You might of heard the terms Direct Entry Midwifery? what is this? this is the term predominately used in the UK, NZ or Eastern States. This is a midwife who is not a nurse first, a midwife who has completed 3 or 4 years education / preparation in the art of midwifery. The education for this midwife is as comprehensive as that of nursing but specialising in women, midwifery. We must remember that women who are pregnant are predominately healthy and pregnancy is not an illness. Now Direct Entry Midwives from the UK, NZ, and Canada can register directly in WA and work as a midwife, whereas before they had to register through the Mutual Recognition Act.
In WA we are fortunate to be conducting one of the first Bachelor of Science Midwifery courses at Curtin University starting in February 2008. This course is for people who want to be midwives not nurses. All student midwives will receive a wide range of clinical experience in both the hospital and community setting, together with and intergration of evidence based theory units. The course will be 3 years full time comprising of 50% theory and 50% clinical. The course has been designed to meet the NMBWA & the Australian College of Midwives regulations and standards. At the completion of the Bachelor of Science Midwifery, the student will demonstrate competency at a begininning level in accordance with the ANMC national competency Standard for the Midwife (2006).
I am very excited about this program commencing and being a great success. This is the way forward for midwifery, to be "with woman" and empower women about their "birth choices".

My Experience of Direct Entry Midwifery:

I am a nurse and a midwife, however when I completed my midwifery in the UK and I soon learned what the difference was between the to professions. Midwifery is a force to be reckoned with in the UK, it is emensely powerful. I guess here in WA I never really understood that there was a difference, because the culture here was / is? that you did your nursing first and then you added midwifery, for some, if you wanted to climb up the corporate ladder it was an essential. There really was never a real distinction between the two professions. I must admit when I was a student midwife (postgraduate degree Midwifery) in the UK, I was very negative about Direct Entry Midwives for the first 6 months because of my ideals or perceptions. I was ingnorant about what their course entailed, when I took the time to find out I found that it was more than adequate. It was only when I stopped being so high and mighty about being a A&E nurse, I really began to see the benifits of the Direct Entry Midwives and learn from them. I began to see that their out look on their women was from a normal healthy perspective as opposed to mine that was 'sick' 'high risk intervention', always looking for the abnormal rather than starting from the normal then progressing to the abnormal. I had to learn to be 'with woman' to ask before 'I did' to be still and 'listen to what the woman wanted' as opposed to jumping in and taking over, being paternalist, doing what we think is right, disempowering women. Once I learned this I knew, what it is to be a midwife providing a safe environement for women to be!
I respect and value both professions of nursing and midwifery, I am proud to be both, there is more than enough room for mutual collaboation, respect and embrace the change.
We need to embrace change, because change is good - ïf you always do what you've always done how can things be different"

Be daring embrace life! do something different!

Definition of Midwife

I thought it would be good to post a definition of what a midwife is on this blog, as I am called infomidwife. There are many definitions of a midwife, if you look in the dictionary you will find some variations. The Collins dictionary; midwife "a woman trained to help women in childbirth", this seems rather limiting and does not really define what a midwife is. Interestingly when parliament is formulating or deciding on legislation and they cannot determine what a word means or should mean one of the ways they determine this is to look the word up in the dictionary - this explains the limited meaning of the word midwife in our legislation in Australia. The WA Nurses and Midwives Act 2006 defines a midwife as " a person registered as a midwife" & midwifery as "means the practice of assisting a woman in childbirth".

The definition that I feel really incorporates all we do as midwives and should be adopted by parliament in our legislation, is that determined by the Internationl Condfederation of Midwives (ICM) & World Health Organisation (WHO).

"A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She has an important task in health counselling and education, not only for the women, but also within the family and the community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child care. She may practise in hospitals, clinics, health units, domiciliary conditions or in any other service"

Jointly developed by the International Confederation of Midwives
and the International Federation of Gynaecology and Obstetrics.
Adopted by the International Confederation of Midwives Council 1972.
Adopted by the International Federation of Gynaecology and Obstetrics 1973.
Later adopted by the World Health Organization.
Amended by the International Confederation of Midwives Council, Kobe October 1990.
Amendment ratified by the International Federation of Gynaecology and Obstetrics 1991
and the World Health Organization 1992.

I welcome your thoughts on this subject, what do you think?

Katie 29/40

Katie was born in NSW at 29 weeks. Mum (Nat) developed high blood pressure (pre-eclampsia), she just did not feel well, a bit dizzy, headaches, bloated, generalised swelling and very tired. On arrvial at the hospital Nat's blood pressure was very high and her blood tests were all abnormal. It was very clear that Nat's baby needed to be delivered sooner than later.

Fact: Most clinicans agree that a blood pressure of 140/90mmHg or more or an increase in diastolic pressure (the bottom number) of 20mmHg from the booking blood pressure needs further investigations.

Little Katie was born by caesarean section weighing 750gms - Katie is doing very well and is now 18mths old, with no current health issues.

Katie can be seen in the bath with her cousins Bradley & Monique, all these babies were premature and their mothers are all sisters.

Monique weighted 1750gms, I am holding her in the formal picture, as she was being discharged from hospital.

Aren't they doing so well now

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