Journal: Prescribing portfolio ready for submission

Today I am finalising the prescribing portfolio, which is worth 10% of the marks for the topic.  
The finished document contains dated responses to questions posed by the writer of the course, and summaries of my learning and reflections through the course.

September and October were very busy months for me, with a full caseload.  I have not been able to devote all the time I would have liked to, to the course.  Babies have been born, and I have been privileged to accompany a small number of women in their birthing journeys.  In this brief time I have shared great joy, and great sorrow.

I started this course without much idea of how to navigate an online learning situation.  As I now prepare for the exam in a month's time, worth 50% of the mark, I am seeking to consolidate the new knowledge that I have accessed in the past few months.  I expect to do well in the exam, and I am satisfied that I will have met my personal learning objectives at the conclusion of the course.

Personal Learning objectives:

30 July 2012

• To critically review my knowledge of the medicines which I currently use as a midwife
• To develop a useful body of knowledge about the prescription of medicines which will become part of a midwife’s formulary
• To explore and reflect on published scientific work that is relevant to pregnancy, birth, and breastfeeding.
• To undertake the course of study that will meet my undertaking to the NMBA, to successfully complete "an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

These objectives are within the topic’s stated learning objectives

Some of the issues I have reflected upon and explored have already been mentioned in this blog.  In summary, here are a few highlights: 

Journal of a new student: I have learned a lot about working within an online learning site, and I can now work my way through MIMS online.  This is a big achievement.  I do not yet feel 'fluent' in a virtual library - I just get lost!

Writing prescriptions: I will need to continue to work on the knowledge and skill of prescribing.  The small number of medicines is OK.  I think there are many aspects of the various formularies that still need to be ironed out.  The Victorian law is in the process of being amended to allow midwives to prescribe.

The two Case Studies in which we explored the prescribing of Metoclopramide for nausea in pregnancy, and Benzylpenicillin for Group B Streptococcus (GBS) colonisation of the genital tract, provided good opportunities for learning and critical thinking.  Where I exceeded the word limit, and needed to remove some of what I wrote, I brought it across to this blog, such as in Case Study 2.  Blogs have no word limit!  

A significant piece of work that this study brought me to is the pharmacology of uterotonics.  I am not surprised that the study of pharmacology has confirmed my desire to work in harmony with wonderful natural processes in pregnancy, birth, and nurture of the infant. 

This study has given me information which confirms my commitment to protecting, promoting and supporting unmedicated, physiological birth, except in clinical situations where there is a valid reason to intervene.  The benefit of synthetic oxytocic treatment in preventing excessive blood loss after birth is undeniable.  My reluctance to use these drugs routinely rather than as indicated is related to the majority of women for whom the treatment is not required, and who are thereby exposed to unnecessary medication with attendant risks.

I am also concerned about the extent of possible adverse effects in newborn babies, particularly any sick babies who may need to receive drug treatments, and who may experience adverse drug reactions to syntometrine in mother's milk.  

A question on collaboration has given students the opportunity to engage in the maternity reform process that requires a collaborative arrangement as the starting point for women to receive Medicare rebate for a midwife's services.  It looks like this:
$$=carrot; collaboration=stick 

Collaboration is actually not onerous; it's basic to midwifery practice.  The problem with collaboration as the Australian government requires is that it's one-way collaboration, which is an oxymoron.  'co' + 'labor' requires at least 2 parties to participate.


As I look back on (most of) the pharmacology course, it's worth stepping into the assessor role, asking questions about how the course met my learning needs, and how it could be improved.

I am conscious of a great deal of new knowledge that is foundational to an understanding of pharmacology.  The course lacked systematic teaching of that basic body of knowledge.  I believe this could be corrected by offering weekly lectures for the first month or so, using the webinar function of the interactive online learning site.  Although the course is post graduate, most students have not studied undergraduate contemporary pharmacology courses, and even those who have would do well to refresh their minds. 

A further step is the application of that knowledge to effective midwifery practice.  This is a challenging topic, and could be used for debate between midwives working in various settings.  

Are midwives who have achieved the endorsement as 'prescribers' likely to take a liberal attitude towards medicines, and prescribe excessively, like a kid with a new toy? 



Thankyou for your comments

Journal: collaboration

Activity: Establish a working relationship with a doctor 
There is currently much grief and anger surrounding the term “collaboration” when used in the maternity care setting in Australia at present. ... discuss the following issues –
• What actually is collaboration?
• What would the best model of how women and their babies can have their needs met in pregnancy, birth and the postnatal period, including midwives AND doctors, look like?
• Discuss your own individual situations where you presently work, or intend to work.
• What ways are you currently able to work with local doctors?
• What works well?
• What doesn’t work well? Why? Is there scope to change this? ...

I have reflected a great deal on collaboration, especially in the past few years, with the rules demanding a formal and pedantic process that is called a collaborative arrangement, for each woman in my care, in order for that woman to access Medicare rebate.

Collaboration is, in my mind, simply working together 'co'+'labor'.  One person can't collaborate.  It takes two.  In maternity care, the woman+baby unit is at the centre of the care, and a midwife+/- others work together to provide the maternity care. 

+/-?

This is the point at which disagreement arises.

For maternity care at its most basic level, the midwife is able to provide the entire episode of care, on her/his own responsibility, provided the woman and her baby are well and progress through pregnancy, labour, birth and the puerperium without complication.

Collaboration is added to the care mix if the woman or her baby need care that is outside the scope of the midwife's practice: whether it's collaboration with a dentist, obstetrician, physiotherapist, or paediatrician.


When I read the heading for this activity, "Establish a working relationship with a doctor", I asked myself, "which doctor?"

I have initiated collaborative arrangements with about 30 doctors in the past 18 months.  Most are GPs; a couple are obstetricians.  On a couple of occasions the same doctor has provided collaboration for more than one woman.  Most of these doctors I have never met or spoken to.  One of these doctors has given birth at home in my care.  Another doctor knows a woman for whom I have been midwife.

My understanding of good collaboration in maternity care is summarised in the letter that I send to a doctor when a woman asks me to be her midwife. (If the doctor is an obstetrician, and the woman is planning birth in a private hospital, the wording is slightly different.  Most of my work is with women planning birth at home, or in a public hospital)

"The plan is basically to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications arise. We plan to go to the [X] hospital without delay for urgent obstetric concerns, or [the woman] would be referred to you for non-urgent medical indications."

Collaboration for midwives who are participating in Medicare has been set out in the National heath (collaborative arrangements for midwives) determination 2010
In the real world these rules present midwives with a difficult, though not impossible, situation.  I don't have energy to waste on resisting.  I hope that when my turn comes to be audited, my processes and records will be acceptable.
Thankyou for your comments

The hospital problem

It's two years since our federal government's maternity reforms have provided significant new support for private midwifery practice.

Since November 2010, midwives have been able to provide taxpayer subsidised services to patients outside of the public system.  A search of Medicare statistics for the financial year July 2011 to June 2012 reveals that there were 16,474 'Midwife services' rebated, accounting for more that one million dollars of taxpayer's funds. 

A key component of the reform agenda was hospital access for births: that midwives would be able to deliver maternity care, including antenatal and postnatal care in the community, and, as the then Health Minister Nicola Roxon announced, "undertake deliveries in a hospital."  

Access for midwives to maternity hospitals has turned out to be problematic.  Except for Queensland Health, which has established processes for midwives to have access to public hospitals in Toowoomba, Ipswich, and Gold Coast, midwife-attended births in hospitals have not become a reality.

In fact, I have observed a gradual increase in resistance to midwives attending our clients privately in hospitals in Melbourne over the past two years.  I am trying to understand why this is happening.  Here are a few pieces of the puzzle:

• Private in public:  Melbourne's large tertiary maternity hospitals (Women's, Monash, and Mercy) employ specialist obstetricians rather than the visiting consultant who, in return, is able to use the service for his or her private patients.  The director of obstetrics at one of these hospitals has told me that 'private in public' is the major obstacle to midwives being granted clinical privileges.  
• Credentialling for clinical privileges: Smaller metropolitan and regional hospitals rely on doctors to provide consultancy services for obstetrics, anaesthetics, paediatrics, and other specialties, as well as GPs who provide primary care that includes basic maternity services.  The processes for credentialling of these doctors for clinical privileges in public hospitals are managed by each hospital, guided by the Health Department and the VMIA (public hospital insurer).  This process was expected to be extended to provide for credentialling of midwives, and meetings of key stakeholders were convened in 2011.  I attended these meetings, as representative of Midwives in Private Practice (MiPP)   A report was given at a conference in May, but since then there appears to have been no progress and the report has not yet been made public.
• 'Support person':  At present when a midwife in private practice attends a private client in a hospital (private or public), either with a woman who intended to give birth at the hospital, or when transferring from planned homebirth, we may be called a 'support person'.  This is a head in the sand mentality on the part of hospital employees: we are midwives, are accountable for all our actions, and have a real duty of care to those who employ us as midwives.  

Here are a couple of examples of the increasing resistance to midwives by Melbourne's public hospitals:

Recently I visited a mother and baby the day after the birth: the mother had experienced a complex and life threatening labour, and had been delivered by caesarean.  I introduced myself at the desk and asked if I could visit my client.  The nurse in charge told me somewhat grudgingly that she would let me in, but that I was not to discuss clinical matters with the patient.  I must have looked shocked (which I was).  "Why?  Is something wrong?" I asked.  "No, but you must not interfere with the hospital's care of patients", was the reply.  I informed the nurse that I had no intention to interfere; that I was there for the woman and I would discuss anything the woman wanted to discuss!  I reminded the nurse that 'patients' are not prisoners: that they are free to discuss anything with anyone. [see comment after this post]

Another private midwife was invited to meet with a senior member of the midwifery staff to discuss complaints about her behaviour in the hospital. A midwife in the birth suite had complained that she could not work with women who had this private midwife with them, because the women looked to their midwife for guidance and support!  (And this is a hospital where research has demonstrated a range of improved outcomes for mothers and babies when the woman is attended by a known midwife who has a personal caseload!  It's no secret that women value a trusting relationship with their own midwife.)


What should we be doing about hospitals?

Some Medicare-participating midwives have negotiated casual employment arrangements with a hospital, so that when their clients are admitted in labour, the private midwife becomes an employee of the hospital, and provides midwifery care for that woman.  The midwife is paid by the hospital for the hours of employment.   I do not see this as a solution - it's a temporary filler at best.  The Medicare provisions for midwife attendance in labour and birth cannot be applied: Item #82120, Scheduled Fee $739.25

Management of confinement for up to 12 hours, including delivery (if undertaken), if:

(a) the patient is an admitted patient of a hospital; and

(b) the attendance is by a participating midwife who: (i) provided the patient’s antenatal care; or (ii) is a member of a practice that provided the patient’s antenatal care

(Includes all attendances related to the confinement by the participating midwife)

[Health Insurance (Midwife and Nurse Practitioner) Determination 2010 Health Insurance Act 1973 Part 1 Midwifery services and fees – revised 1 November 2011]



Earlier this week I wrote about women's rights in childbearing, and quoted from the recently updated Cochrane review of planned hospital birth compared with planned home birth for low-risk pregnant women, in which the authors commented:

"It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications."

If maternity services are serious about basing practice on evidence; if the government is serious about providing maternity services that are appropriate and in the interests of safety and wellbeing of mother and baby, then the option of homebirth MUST be seriously addressed across the board.  As long as there are disincentives and professional biases that prevent the majority of women from accessing homebirth, and that prevent midwives from offering affordable private midwifery services in all communities, we will continue to see the cascade of interventions fast-tracking women and babies into medical emergencies.


Thankyou for your comments

journal of a new student

The text book: Pharmacology for Health Professionals 2011

This month I am beginning university studies at Flinders (SA), in order to undertake

"an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing"

This is a requirement for midwives who have notation on the Register as eligible for Medicare.  It is a new extension of practice for Australian midwives, as I noted in a previous post.

The topic is within a Graduate Certificate of Midwifery; will be by distance education, and is to be completed part time in one semester.  The text book, Pharmacology for Health Professionals, Bryant and Knights, 3rd edition 2011 (pictured) is a weighty tome that appears, on first glance, to be well presented and comprehensive.

I plan to make entries to this journal each week, for my own record as well as for readers who are interested. I would like to record an overview of this journey - not a step by step process. I hope to be honest and objective, not sugar-coating, and not bad-mouthing any aspect of the experience.  There will be times when I expect I will find it difficult to set aside time for focused study.  I won't be the only one experiencing this.  Any midwife who has a caseload has a high degree of unpredictability in life, when we must put the women and babies in our care first. 

I have not been enrolled in a university course since the late 1960s, and I have pretty well forgotten the details of that year! I completed hospital-based nursing studies (Royal Brisbane) in 1972, and hospital-based midwifery (Women's, Melbourne) in 1973.  I studied for, and passed exams for the International Board Certified Lactation Consultant certification on several occasions in more recent decades.  (Oh, I also studied Chinese painting, but that doesn't give me any prior learning credit!)  My other university experience is that I am a casual lecturer, tutor and marker in midwifery at Deakin University.

As I embark on this journey I wonder if my ageing mind will be a problem.  It's not that the knowledge is new learning - it will be good to review current evidence, and to check my 'knowledge' against what the course topic expects.

My style of learning is to take note of anything that varies from my current body of knowledge.  I think of it as a flashing red light, and I use this system in all areas of life.  When I listen to a lecture, or a sermon in Church, or a documentary, or read something, most is unremarkable, because it's what I expect.  But if something different comes up, I take note.  In a sense it's an editorial skill, but in stead of looking at the spelling and sentence construction, you look at the thought content and the conclusions.

When I go into my Flinders Learning Online site, and type in my password, I find topic information, and a forum to which all students of that topic are automatically connected (oh, the wonderful web and electronic databases!). There are 90 students enrolled at present.  Some have written introducing themselves; some have added a picture of themselves ...

There is an email site to which the course posts direct communication, and through which students can contact the faculty.  There are probably other aspects that I haven't found yet - you don't know what you don't know!

Enough for now.  As someone said, "Watch this space".




Thankyou for your comments

Prescribing

It was reported last week in the Australian that

Midwives still await PBS script training

by: Adam Cresswell, Health editor

From: The Australian April 20, 2012

MIDWIVES have not written a single prescription under the Pharmaceutical Benefits Scheme, nearly 18 months after they were supposed to begin, because no training courses exist to teach them safe prescribing.

Link


There are approximately 200 midwives nationally who have achieved eligibility for Medicare (MBS) and pharmaceutical benefits (PBS) - 'prescribing'.  Each of these midwives were required to sign an undertaking to the Nursing and Midwifery Board that we would
"undertake, and successfully complete, within 18 months of recognition as an eligible midwife:-

1. an accredited and approved program of study determined by the Board to develop midwives' skills and knowledge in prescribing; or
2. a program that is substantially equivalent ...  

A few midwives have completed university courses that have been accepted as 'substantially equivalent' to such an approved program of study as determined by the Board.  They have completed courses that have been accredited and approved for Nurse Practitioners, and submitted a comprehensive 'mapping' of the course against the standard set by the Board.

Many midwives, including yours truly, are waiting for (1) an 'accredited and approved program of study' before launching into this endeavour.  It is unlikely that midwives who have not commenced their course of study within 6 months of receiving notation as eligible for Medicare will be able to complete their courses within the required 18 months of recognition. 

Looking forward

From time to time I have taken the opportunity on this blog to write about the complex and often challenging position I and other midwives have found ourselves in as we work through and apply government 'reforms' and changes to our practices.

Now, at the end of the first week of January 2012, I want to summarise my position as a midwife, attending individual women for birth and associated prenatal and postnatal care, and what developments I expect and hope for in the coming year.

Firstly, on the positive side of the ledger:

• Babies are being born, and thriving - beautifully.
• Women are being transformed in the process of giving birth.  That's a wonderful thing to witness.
• Collaborative arrangements are being set up with a couple of supportive GP-obstetricians, who are happy to give women referrals for the midwifery services they choose.
• Collaborative arrangements are being set up occasionally with obstetricians, after the woman and baby have been discharged from hospital, enabling one-to-one postnatal care for the woman.
• Medicare rebates are being paid to women who use the services of participating midwives.
• I am happy to bulk bill additional antenatal and postnatal visits, which continue until the baby is 6-7 weeks old.

On the negative side of the ledger:

• Some public hospitals at which women make homebirth back-up bookings are refusing to acknowledge the collaboration in the way that has been spelt out in the legislative determination, in that there is, for example, no provision for a 'specified medical practitioner', who is "a medical practitioner employed or engaged by a hospital authority and authorised by the hospital authority to participate in a collaborative arrangement.", or any acknowledgment "when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner — acknowledgement that the named medical practitioner has received the copy" ...   
• Midwives eligible for Medicare are required to sign an undertaking to complete a course in pharmacology within 18 months, yet there is no such course accredited.  
• No midwives have access arrangements to privately attend women admitted in hospitals.  This means that women who choose to give birth in hospital, with their private midwife in attendance, must accept the hospital's employed midwife as the leading midwife at the time of the birth.  This situation can lead to unnecessary conflict.
• There is no insurance product to indemnify midwives attending women privately for home birth.  The government has exempted midwives from the requirement until 2013, and we don't know what (if?) plans are afoot to rectify the situation.

Logically, indemnity insurance does not change outcomes - it simply provides a pot of money that can be fought over in the law courts, should there be an adverse outcome.   I consider the only solution to the insurance problem is to set up a no-fault compensation scheme, to which all health professionals contribute, which provides a suitable level of financial support to those who suffer disability or loss, separate completely from the apportioning of blame.

Midwives who face regulatory or coroner's inquiries into incidents in which they were involved are being advised to obtain legal representation.  While ideally a professional should be investigated by peers, it seems that the process of investigation into conduct is becoming increasingly formalised, with inherent costs and isolation of the practitioners.

I have recently accepted a role as Vice President in Australian Private Midwives Association (APMA), which represents private midwives nationally.  I have been a member of this organisation, and have written and edited the APMA blog for the past couple of years.  It is a privilege for me to work alongside the President Marie Heath and the other committee members.  Keep an eye on that blog if you are interested in the national private midwifery scene.

I continue my involvement in Midwives in Private Practice (MIPP), which represents midwives practising privately mainly in Victoria.  See the MIPP blog.  MIPP is a participating organisation in Maternity Coalition (MC).  The concept of partnership between the woman and the midwife is carried through into the relationship between MC and MIPP. 

There are plenty of challenges to keep me busy in the midwifery profession broadly, as long as I have the (physical, mental, spiritual) strength to continue my practice.  I enjoy consulting with women and attending them professionally in their homes, mentoring  other midwives, giving lectures to midwifery students at Deakin University School of Nursing and Midwifery, and my involvement in the Professional Development Unit at Deakin.

Family and home responsibilities keep me busy, and my beautiful grand-children remind me of the every-changing needs of our most precious resource.

Thankyou for your comments