Saturday, January 22, 2011

Reflecting on midwifery practice

Matilda is on the ball!  (it's never too early to prepare for good birthing)
In preparing for my recent professional practice review, I was able to identify several incidents in which I believed it was important for me as the midwife to act within my professional skill to ensure the safety and wellbeing of the mother and/or baby. In other incidents I engaged collaboratively with specialist maternity care providers, also with the goal of ensuring safety and wellbeing.

It's not enough to merely recount the tale. I need to ask fairly obvious questions:
  • What happened?
  • Why did it happen?
  • Would I act in that way again, or not?
  • Why?

This sort of critical reflection demands that I am honest, firstly with myself, and possibly with a trusted reviewer about my own role; that I have a clear understanding of what is outside my sphere of influence; and that I can ask difficult questions knowing that this process is constructive rather than destructive.

A process of critical reflection that is used in midwifery education is Gibbs Reflective Cycle. [more information on Gibbs (1988) is available via a search browser]. In summary, Gibbs Reflective Cycle requires:
  1. Describe factually what happened (objective)
  2. Describe my feelings and thoughts (subjective)
  3. Evaluate the incident: the good and the bad
  4. Analyse the incident: what sense can be made as I apply contemporary midwifery knowledge and research?
  5. Conclusion: was there something else that could have been done?  Do I need to further investigate or study any aspect of professional knowledge or skill?
  6. Action plan: If this were to occur again, how will I act?

An 'incident' that I experience from time to time is the diagnosis prior to onset of labour of a baby presenting breech at Term.  Each case is slightly different.  I cannot assume that any two women in this situation will respond the same.  The conversation between midwife and woman is uncharted - we must discover the unique pathway for that woman and her baby.

I have recently referred to breech presentation in my villagemidwife blog.  I wrote:

In the world of private midwifery in Melbourne today, I sometimes 'discover' a baby who is presenting breech at 35 or more weeks' gestation. The discussion that follows includes:

* understanding breech presentation
* confirming the baby's position and presentation
* options for turning the baby, including referral for external cephalic version
* discussion of breech vaginal birth

Mothers with breech babies have huge decisions to make. A midwife who encourages informed decision making is leaving open the possibility that the woman may choose to proceed, against medical advice, with vaginal birth. The very act of the midwife in encouraging the woman to make her own decision, rather than accepting what is presented as the "standard of care, and there is no really clinically reasonable other way out" (the risk-averse position) can be seen as risk affinity.

Whether a midwife takes a woman-centred and apparently risk-phile position, or a defensive, risk-averse position in guiding a woman's decision making, there are no guarantees. Every decision is like a fork in the road, and it's a one-way road.

A midwife colleague of mine has experienced suspension of her registration, and a long period of investigation, after the intrapartum death of a breech baby in her care. Obviously I am not able to discuss someone else's case, for which I do not have all the information. This midwife has told me her story, and I consider that many of the circumstances that contributed to that tragic outcome were outside her control.

If I were in that midwife's shoes, and asked Gibbs' questions such as
  • Do I need to further investigate or study any aspect of professional knowledge or skill?, and
  • If this were to occur again, how will I act?
... I would probably end up with more questions than answers. The professional knowledge and evidence around the Term Breech Trial, and its recommendations that all babies presenting breech should be delivered surgically, has huge implications for that woman and her family in the future. Midwives who have attempted to go against the mainstream, and retain competence in vaginal breech births do so at huge personal risk from a regulatory point of view.  

A few obstetricians will accept referrals for planned vaginal breech birth in hospital.   There are a few places where obstetricians are willing to attempt external cephalic version.

One Melbourne hospital has a policy that 'sweetens' the woman's choice in favour of an elective caesarean.  It goes like this:
"If you agree to an elective caesarean, we (the hospital) will provide a midwife who will stay with you and your baby in Recovery after the operation, so that your baby can breastfeed, and not be separated from you.  If you don't agree to an elective caesarean, and have a caesarean after labour starts spontaneously, your baby will be taken to the nursery while you are in Recovery."

That precious time in the baby's first hour is now a bargaining chip, which will in some cases be the tipping point for a mother's decision.

No comments:

Post a Comment

Thankyou for your comment, which will be emailed to me for moderation.