Saturday, August 21, 2010

more on risk management

In a previous post I explored the presentation of 'risk' by a doctor to a woman who was planning for vaginal birth of her second child after a caesarean birth of her first.

We live in an information era. Our challenge, as midwives, is to understand reliable information and to present it in a way that enables our clients to make good decisions. A good decision is, literally, a decision that leads to good outcomes for that mother and her baby.

Managing risk is a difficult topic to write about, and can be even more difficult if you are confronted with decisions needing to be made. The pendulum of risk-managed maternity care has swung a long way from the centre, to the point where any identified increase in risk is immediately considered a valid reason to interfere with the natural process.

When research has been carried out on a group of 'patients' in a way that quantifies a particular risk, the practitioner has a duty to inform the client about the research. This is obvious. Yet, in my mind, the prevailing risk-averse culture in maternity care today robs women of any semblance of informed decision making. Instead, by even mentioning risk of death (known as 'shroud waving'), maternity services ensure a high level of compliance with the prevailing culture of intervention, and devaluing the spontaneous physiological birth process.

Recently I was with a woman who was advised to have an induction of labour a couple of days after 41 weeks' gestation. The reason given was that the volume of amniotic fluid (AFI) around her baby was less than the normal range (AFI 5-25) - a feature that was identified coincidentally when untrasound examination was carried out for another reason. The fetus was active, and there were no other unreassuring features identified.

The doctor who presented induction of labour as the planned course of action explained that there was an increased and unacceptable risk of death of the baby. In quantifying 'risk' he stated that at 41 weeks there was a risk of 1 in 1000; while if the AFI was reduced the risk was 3 in 1000, or 1 in 333. Furthermore, the doctor stated, induction of labour at 41 weeks does not increase the 'risk' or likelihood that a baby will need to be born by caesarean.

The numerator in the equation is death of a baby at or around the time of birth. The denominator is all births with that particular set of features.

Most women who hear words such as "we need to induce labour because there is an unacceptable risk to the baby if we don't induce labour" will be frightened, and immediately agree to whatever plan is presented to them. They cannot contemplate the thought of losing this precious baby. They cannot ask questions that enable careful consideration, because that makes them feel as though they are willing to place their baby's life at risk.

Words such as 'unacceptable risk' are used deliberately. The argument by the doctor is that he or she would be taking an 'unacceptable risk', from an indemnity point of view, if he or she did not recommend action to get the baby born without unreasonable delay.

The pathway to healthy, normal, physiological birth begins long before labour, including:
* a healthy mother, who cares for her body and the child she carries
* a fetus who has grown normally
* a fetal head whose position inside the maternal pelvis, in relation to the internal os of the cervix is able to bring about normal onset of labour

We don't know what gets human labour started in nature. Not 'knowing' makes waiting for spontaneous onset of labour an 'unacceptable' delay in many situations where an increased risk has been identified.

Logically an increase of 2 in 1000 births is not a big risk. As I have discussed previously, there is a background risk for death of a baby of about 1 in 100 for all births. Many of the babies who die have increased risk because of abnormality, prematurity, or illness of the mother. That means that the real risk to a healthy woman with a healthy baby is greatly reduced.

The question I am placing to myself, and to other midwives who may face this dilemma, is:
at what point does it become unreasonable to wait for spontaneous onset of labour,
at what point does it become important to move out of Plan A?

A midwife's decision-making is a constant process, and it continues throughout the episode of care. The woman whose baby has not been born by 41 weeks, and who has been told by a doctor that she needs induction of labour, may look to her midwife to help her unpack the issues so that she can understand the situation well enough to make a wise decision. The informed woman who accepts induction of labour, or any other departure from 'Plan A', does so because she believes it is the best course of action for her and her baby at that time.

A midwife in the situation described here would be unwise to insist in a blinkered way that 'natural is best' - yet she could also be challenged if she supported the plan for immediate induction of labour.

The midwife has to see beyond the risk of a perinatal death, and evaluate all the other reasons for promoting, protecting and supporting physiological processes in the childbearing continuum. The birth of a baby, although hugely significant, is not the 'end point'. It's only a beginning. The ability of a mother to accept her baby, to form lifelong bonds, to nurture the child, to feel well physically and emotionally in herself: to get along in life, cannot be trivialised. Similarly, the ability of the baby to make those huge natural transitions from the womb to the outside world, to search for and take life-giving milk from the mother's breast, and to become resillient and grow strong: these are all matters of immense value to the mother and her child, and the midwife.

I have written enough for today. I have a big pot of soup on the stove, and am looking forward to enjoying a bowl with my family. I hope that today's discussion supports other midwives and women who have to confront risk management in their daily lives.

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