From MIDWIFERY MATTERS, Issue No.108, Spring 2006
Supervisor of Midwives
CNST is a mutual pooling, pay-as-you-go scheme for NHS Trusts in England designed
to enable Trusts to meet the costs of clinical negligence and negligence claims.
The emphasis is on prudent risk management, ensuring that quality healthcare
is maintained and improved and it is hoped that there will be fewer critical
incidents and negligence claims. CNST is about protecting the public - the consumers
of the NHS - you and me. The NMC and before that the UKCC have always done this.
For midwives the statutory requirements of supervision have been protecting
the public since 1902, long before CNST was born. All health care professionals
support systems that improve practice and enhance the quality of care and especially
the introduction of CNST. However, another acronym - to my mind more appropriate
due to the focus on abnormality and pathology - could well be Controlling Normality
and Supporting Technology. The RCOG was a leading light in the formation of
maternity standards and thus the obstetric viewpoint has been dominant in the
risk management of pregnant and labouring women. Criterion 8.22 (p120) states:
"continuous 1-2-1 care of a labouring woman with an epidural in situ is
imperative". Should this not also have read: "Continuous 1-2-1 care
of a women in induced or spontaneous labour is imperative"?
Risk Management - Enabling or Disabling?
CNST can be read as controlling normality and supporting technology due to
its emphasis on the pathology and abnormality; the emphasis being on obstetric
care and not midwifery care. Focusing on the abnormal can be disabling, we would
prefer risk management that enables midwives to do a better job - skill drills
to promote normal birth, enhanced record keeping and, moreover, risk management
that involves the consumer - and there is no shortage of research telling us
what women want. Skill drills are vital in saving lives and the Midwives Code
of Conduct and Rules highlight the need for competence, however, although we
seem to have drills for high risk such as massive PPH, where are the drills
for physiological third stage with its ensuing benefits for mother and baby?
CTG management is vital in detecting and acting on deviations from the normal,
but how expert are we at using our Pinard's to detect variability, accelerations
and decelerations?
We seem to be entering an age where we have certificates for high risk scenarios
and mandatory attendance at study sessions to reduce risk and error but where
is the corresponding ongoing education in continuity of care, or building relationships
with women so that they see a familiar face when birthing their baby? What better
risk management could there be but these?
As well as certificates, should we not also be giving all women 1-2-1 care -
then they themselves will be able to comment on our practice and vouch for our
standards and the support we give. It would certainly be more representative
than a set of case notes.
Midwives have always been risk managers. Our Code of Practice compels us to
respond to deviations from the normal. As a Supervisor of Midwives I know of
no midwife who has gone on duty wanting to jeopardise her practice or wanting
to give suboptimal care. Perhaps it is the system that we work in that needs
rather more inspection and scrutiny instead of the midwife and her mandatory
training needs. Whilst applauding CNST for supporting good practice and identifying
substandard care we should remember that supervison has always done that. Risk
management is enabling the midwife in skill drills and record keeping but can
be disabling by its focus on the abnormal.
Guidelines - Positive or Negative?
Guidelines are there to guide practice - they do not tell you what to do but
they act as a basis from which you can give individulised care. The negative
side of guidelines are time restraints in labour and the difference in some
units of vaginal examination some three hourly, some four hourly - it's almost
a postcode lottery. Should we expect any cervix to dilate within the constraints
of a guideline? This is when the midwife uses the guideline to support her practice
and woman's choices; she uses the guideline as a lever to good practice and
not as a prescription for care. For high risk women guidelines are vital. Why
Mothers Die and CEMACH and CESDI have previously highlighted suboptimal care
and multidisplinary working is vital to support good practice. Every midwife
should be devising her own individual guideline for each unique and individual
woman based on best practice and midwifery research. Intrapartum care can be
seen either as risk surveillance or as supporting a physiological process. As
midwives and as supervisors, are we controlling or are we supporting the labouring
women? Are we watching, waiting and listening while we sit and knit in the room
with her, or are we controlled by the clock, managing and intervening? We can't
make the abnormal, normal, but are we becoming too expert at making the normal,
abnormal? How can we expect women to support midwives in promoting normal birth
when women are not experiencing normal birth?
Tina Lavendar states that a healthy mother and baby is the minimum standard
of care we should be aiming to achieve. By giving fragmented care we are missing
the chance to go on the journey with the woman and not only is the woman the
loser but so are we, individual midwives and the profession of midwifery as
a whole. You cannot miss what you have never had; most women never experience
continuity of care and it is sad that continuity of care is not a mandatory
component of training for most student midwives. Some students do experience
giving continuity of care during their training; should we be finding out whether
it makes a difference to their practice once they have qualified? As midwives
we are missing out on the job satisfaction that comes from forming relationships
with women and, as research continually reminds us, women and midwives both
want the same thing: continuity of care - to know each other - one-to-one care
in labour. Do we want midwifery care to become just risk survellience: measuring
the BP - testing the urine - palpating the baby? Do we want one midwife to 'service'
clinics of 12-14 women? Or do we want sessions of forming relationships? Discussing
family births, grandmothers' births and birth plans are not optional extras
but are as vital as BP and palpation. If we haven't time to sit and talk, or
laugh and cry with our women, then we haven't time to be midwives.
As midwives do we support or control women in labour and are we controlled or
supported in our practice as midwives? Could we start to see risk management
as an opportunity to repossess midwifery? Could we learn the value of placing
as much emphasis on our Pinnard as we do on a CTG moniter?
Should we not be taking our women with us to our yearly annual one-to-one interviews
with our supervisors? We currently take casenotes and discuss our practice.
How much better would it be if we took some women we had cared for to speak
about our practice!
Soo Downe (2004) wants us to focus on positive outcomes, she thinks positive,
not negative, outcomes should drive audit - normal birth rates rather than caesarean
rates; the number of intact perinea rather than episiotomies done; a measure
of well babies instead of neonatal admissions; best practice reviews instead
of just looking at near misses - and a review of compliments given instead of
the 'management' of complaints. We should shift the prevalent focus and ethos
from risk avoidance to the expectation of benefit.
Supervisors could do such things alongside critical incident meetings. They
could promote courses on skills to enhance normal labour as well as courses
to refresh emergency management drills. This would certainly help put the normal
and natural back into birth, celebrating midwifery skills and autonomy.
I really must finish by saying that I do work with some brilliant midwives in
busy obstetric units that can create a positive birth experience amidst monitors
and IVACs and clocks!
REFERENCE
Downe S (2004). Normal Childbirth: The Evidence and the Debate. Elsevier.
Updated LW October 3, 2006