The following fictional scenario illustrates the proposition that the midwifery profession will be shaped by women demanding evidence-based care from midwives who ‘allegedly’ cherish their role as experts in normal childbirth. The views expressed are based on interviews conducted in 2004 with practising UK midwives. This scenario was presented at an RCM midwifery conference in 2006 and at study days for Supervisor of Midwives in England. Since the gathering of this data the author has devised a 10 point action plan for implementation in the clinical areas that were visited in the initial study.
Normal birth is the safest and most rewarding type of birth that most women could and should have. It is the author’s conviction that to ignore ‘normal birth’ will incur the wrath of the law. For low risk pregnancies normal birth is arguably the safest, most rewarding type of birth. It is also the safest for both mother and baby.
The claimant’s lawyer [CL]
CL Ladies and gentlemen of the jury, midwife Sandy Evans [SE] is accused of not facilitating a normal birth for my client Zoe Davies. My client had previously been awarded a risk assessment score of zero during the antenatal period and on admission to the labour unit. This midwife knowingly encouraged my client toward a medicalised labour that resulted in an epidural anaesthetic, forceps delivery and a very large episiotomy. I would like to call the defendant to answer some questions.
[The defendant is sworn in]
CL Is your name Ms Sandy Evans?
CL How old are you Ms Evans?
SE I am 38.
CL I see. How long have you practised midwifery Ms Evans?
SE 14 years.
CL So you are what could be described as an experienced midwife?
SE Yes, I suppose I am.
CL Are you able to fulfil the WHO definition as to the role of the midwife?
SE Well, I suppose I can.
CL Suppose? What do you mean? You either do or you don’t.
SE Well, I do then.
CL Where do you practise as a midwife, Ms Evans?
SE Mostly labour ward by night.
CL I see. Do you deliver many babies?
SE Oh yes.
CL What aspects of your work do you enjoy?
SE Oh, I love theatre, suturing and get quite a buzz when there is an obstetric emergency.
CL Really? What about normal childbirth?
SE Oh, there are enough lefties working here to satisfy that.
CL What do you mean by ‘lefties’ Ms Evans?
SE Oh, those midwives who spend half the time rubbing women’s backs and crawling after them on bean bags.
CL Don’t you do that Ms Evans?
SE No way, I have a bad back! And anyway, what’s the point? The women I care for almost always beg for an epidural.
CL Is that so? Is that the general trend with other midwives?
SE I don’t know, it depends who’s on duty. Some midwives bust a gut to support these high-maintenance women – I don’t know why they bother.
CL What do you mean Ms Evans?
SE Well, its simple, the trick is to get the woman off that ‘normal labour pathway’ crap.
CL Oh yes? And how do you do that?
SE Ha, well when you listen in you just make sure that you hear a ‘tachy’.
CL Could you explain to the jury what you mean by ‘make sure that you hear a tachy’?
SE You listen to the fetal heart with a Pinard stethoscope so that only the midwife can hear and diagnose a fast heart rate, which means that you have to monitor the baby and therefore not have to use the normal labour pathway.
CL Are you telling me that you falsify information Ms Evans?
SE Well, not really. It’s for the benefit of the woman. You see, I don’t like taking any risks with my babies. If her baby is monitored it’s easier to look after her because she has to lie on the bed.
CL Interesting. Yet on consulting documentation of evidence-based practice I note that electronic fetal monitoring has no place in a healthy, low-risk labouring woman. Is that not so Ms Evans?
SE I’m not so sure about that.
CL Well then, Ms Evans, does your governing body the NMC not take a dim view of falsifying information and records?
CL Ms Evans, what do you mean by you ‘don’t like taking any risks with your babies’?
SE Well, I like to see the fetal heart rate. I find it comforting.
CL I see. So the monitoring is really more for your benefit then?
SE No, well… a bit, I suppose.
CL Did you consult with Ms Davies prior to attaching her to the monitor?
SE Look, you don’t understand what it’s like to work on a busy labour ward. You can tell a woman that it’s best for her and her baby and if you say it with conviction, they believe you. Most of the women we care for are pretty thick, so it’s not worth wasting your breath with detail.
CL So you don’t obtain informed consent from the women you care for?
SE They don’t need to consent. I’m the one conducting the delivery. You don’t ask a dentist details of a tooth extraction, or permission from an engineer to build a bridge. That’s the problem these days – there is too much political correctness.
CL Do you not have midwifery rules that you should abide by Ms Evans?
SE Yes of course, but no midwife ever reads them – well I don’t. When you are as experienced as me you don’t need to.
CL Yet you agree that you falsify information and records, and did not inform my client as to the issues regarding electronic fetal monitoring.
SE I object! You are putting words into my mouth. I told you I did it for the benefit of the woman. At the end of the day, all a woman wants is a healthy baby. Frills are not necessary.
CL Do you regard following the midwifery rules as defined by the NMC a ‘frill’ Ms Evans?
SE Look, I told you – you don’t understand.
CL Do you always monitor the women you care for Ms Evans?
SE Yes, unless they come in fully dilated.
CL Do you always deliver the women you care for on a bed Ms Evans?
SE Yes, it’s easier, cleaner, you can observe the perineum and you can crank up the bed to suit you, and so not strain your back.
CL What are the benefits to the woman and unborn baby Ms Evans?
SE Well, the woman can rest nicely in the bed and conserve her energy. The baby is more oxygenated because of this.
CL Does not the body of knowledge regarding caring for women in labour in a bed suggest that a woman generally experience longer and more painful labours, Ms Evans?
SE Not a problem – they can have an epidural.
CL I see. Does this not increase the need for an instrumental delivery?
SE Well, I think so.
CL Then why do you encourage women to lie on a bed during their labour?
SE Look, you don’t understand. It’s difficult to care for more than one woman at a time, so it’s easier to ‘wire her up’ on a fetal monitor. You can then pop in and out between rooms.
CL Ms Evans, does an instrumental delivery increase the rate of trauma to a mother?
SE Well yes, but it’s not a problem because I suture really well.
CL Do you follow the women up to ascertain if the suturing that you stated you do so well is effective?
SE No, when they leave the hospital I never see them again.
CL So you have no way of knowing if your suturing has offered the woman the comfort that you assume?
CL Ms Evans, what about the women who may not be medically suited to an epidural? Do you still care for them on a bed throughout their labour?
SE Yes, I do for the same reasons I have just given you.
CL I see. Does your body of midwifery evidence for low-risk women advise that women should be facilitated to follow their instincts, which may be…
SE Oh, I know what you’re going to say!
CL Do you really Ms Evans?
SE Yes, you’re going to quote the lefties in encouraging women to be mobile and support them during labour.
CL Don’t you ever do this Ms Evans?
SE No. As I told you. there’s no need.
CL What about women who want to eat and drink during labour?
SE No chance. None of my mothers are going to end up with Mendelson’s syndrome, so I ensure that they only have water to drink in labour.
CL I put it to you, Ms Evans that by not ‘allowing’ women to eat and drink in labour, you are denying women their human rights.
CL Do you inform the women of the risks associated with the withdrawal of food and drink in labour?
SE Yes, I tell them they could inhale it and it would be sucked into their lungs.
CL You tell all women this?
CL Even the women perceived as low risk?
CL Ms Evans, do you encourage women to ‘push’ during the second stage of labour?
SE Yes I do, and once they are fully dilated I get them going.
CL What do you mean ‘get them going’?
SE Well, most women don’t have a clue how to push so I train them. Once their hour is up, I call for medical aid – I look after my patients well.
CL How do you encourage this pushing Ms Evans?
SE Well, I tell them to put one foot on my hip and the other foot on my colleague’s. Something for them to push on, you see. Plus, I can see the perineum clearly. I then tell them to put their chin on their chest, take a deep breath and push into their bottoms as if they haven’t been to the toilet for a month. I then tell them to take a quick breath and repeat the process.
CL I see. Does the midwifery evidence support this practice?
CL Have you heard of Caldeyro Barcia, Ms Evans?
CL Then you may not know that as far back as 1957 he stated that the Valsalva manoeuvre was not necessary, as breath holding could have serious physiological implications for the mother and her unborn child.
SE Caldeyro who?
CL Ms Evans, do you maintain a personal portfolio showing evidence of your post-registration education and practice requirements?
SE It’s on my to-do list.
CL Have you attended any courses recently?
SE No. The problem is I work a lot by night so it’s difficult for me to attend. Anyway, what on earth do I need courses for with all my experience? The lefties take all the study leave anyway.
CL Do you have a supervisor of midwives?
SE Yes, she’s my mate on nights and she’s marvellous. Never bothers me.
CL I see. Thank you, Ms Evans. You may now step down.
The expert witness
CL Ladies and gentlemen of the jury, I would like to call upon an expert witness – Ms Lindi Jones [LJ]. I will submit her curriculum vitae for my Lord’s approval. Ms Jones has been a practising midwife for 15 years, during which time she has maintained her professional development with a first degree in midwifery followed by a master’s degree in reproductive health. She has published widely and is perceived as a specialist in normal childbirth. [The expert witness is sworn in]
CL Is your name Ms Lindi Jones?
CL Can you please confirm your date of birth and your current employment?
LJ I work for Cwmavon NHS Trust as a senior midwife my CV clarifies the rest of my accomplishments in midwifery.
CL Ms Jones, would you please describe how you would expect a low-risk woman to be cared for during labour and birth.
LJ That is difficult, as each woman is different.
CL I see. In that case, would you please offer an overview of a desirable scenario that would facilitate a normal birth in a low-risk woman?
LJ Certainly. If the woman is perceived as low risk, I would initially discuss with her where she would like to give birth to her baby. Women must be given the correct information so that they can make an informed choice. She should be well informed and prepared both physically and mentally for birth, well supported during the latent phase of labour and offered nourishment and fluids in whatever setting she chooses to labour. Family and birth partners should also be supported. The woman should be encouraged to ‘listen’ to the rhythm of her body as to the necessity of mobilisation and position during labour, with both pharmacological and non-pharmacological pain relief available. She should be monitored appropriately as per the normal labour pathway.There is no need to instruct the woman to use the Valsalva manoeuvre – once Ferguson’s reflex is stimulated the woman would spontaneously want to bear down. The midwife should work with the woman so that the most comfortable position for birth can be encouraged, be it on her knees, over or on a beanbag or on all fours to name but a few positions. Once the baby is born, the mother should be encouraged to have skin-to-skin contact with her baby. Is this the type of normal birth you wanted me to comment on?
CL It is Ms Jones. Do you believe that most of your midwifery colleagues would support your comments – that normal birth can be facilitated with support and an appropriate knowledge base by a midwife?
LJ Absolutely. Each midwife is responsible for her own practice and has to maintain a professional portfolio to show evidence of updating. Midwives are experts in normal childbirth and why any midwife would want to support medicalised childbirth exasperates me. Both mother and baby are at increased risk as a consequence.
CL Thank you for your evidence, Ms Jones. You may now step down.
The Judge – Ladies and gentlemen of the jury, may I ask you to retire to consider your verdict. Please consider that from the evidence presented here today and having consulted the midwifery literature, Ms Evans in the first instance failed to offer the claimant, Ms Zoe Davies the correct information for an informed choice to be made of the midwifery care that would have facilitated a normal birth. She admits to falsifying information and records, did not apply evidence-based midwifery care to a low-risk woman, has not maintained a professional portfolio and has neglected her educational needs. Would the jury please raise their hands if they think that Ms Sandy Evans is guilty of not facilitating a normal birth for the claimant Ms Zoe Davies?
[Members of the jury raise their hands]
By facilitating an inappropriate medicalised birth to a healthy low-risk woman, Ms Evans’s practice contributed to the need for an epidural anaesthetic, forceps delivery and an episiotomy that has been painful to this day. I find Ms Evans guilty as charged and award Ms Zoe Davies the sum of £3.5million.
10 Point Action Plan
This 10 point action plan has been devised and midwifery supervision has been used as a vehicle to implement the changes.
1. Study days on the facilitation of normal birth
2. Individual sessions on ‘normality’ with midwives involved in the interviews
3. Shadowing experience with ‘women centred’ practising midwives
4. The development of ‘normality competencies’ that have to be achieved within a defined time frame.
5. Weekly reviews with supervisor of midwives.
6. Audit of midwives’ notes
7. Rotation of midwives day and night
8. Rotation of midwives in clinical placements
9. Mandatory development of professional a portfolio for clinical practice and midwifery supervision
10. Referral to the Local Supervisory Authority if satisfactory outcome is not achieved.
Author’s note: Any similarity to persons or events in this scenario is purely circumstantial
Janine Wyn Davies is Senior Lecturer at the University of Glamorgan, Clinician and Supervisor of Midwives at Abertawe Bro Morgannwg University NHS Trust