... continuing the Journal of a student: investigations and diagnostics

I have returned to the (virtual) classroom, and this year the topic is Investigations and Diagnostics for Midwives, MIDW9010 the second (and final) part of the Graduate Diploma in Midwifery at Flinders University.  My journal of this program begins in July 2012.  I found the study/learning commitment very satisfying, and recorded an overall HD (high distinction) grade for that topic.  Some students completed the two topics in one semester, and are preparing for graduation, and submitting their applications for the 'prize' which is a PBS prescription pad with their name and 'Prescriber Number' on it.  [For Medicare and PBS information, click here.]

There are 78 midwives enrolled for MIDW9010 in this first semester 2013.  Assessment is on a series of weekly quizzes, case studies, and preparation of a portfolio that covers the topic.

In this journal I hope to record parts of the course that I find significant. 

I have begun reading the study guide, and some of the published literature.   Today I would like to record my current practice with regard to the standard or routine screening that women experience in maternity care.  The Shared Maternity Care at the Women's prompt-sheet pictured below, with a pregnancy wheel, is a good summary of contemporary expectations in testing and consultations for women in Melbourne today.

The Women's Hospital guide to tests and investigations - click to enlarge

My usual practice at present is to ask women who are considering engaging me as their midwife to go to their local GP for the initial investigations.  This places the information on the woman's personal health history, and I ask for a copy of results for my notes. At this time they can take a draft letter from me, asking the doctor if she/he is willing to enter a collaborative arrangement with me.  With this arrangement the woman is able to claim Medicare rebate for antenatal and postnatal 'items'.   The amount of rebate is estimated at $700-$1000 for an episode of care.

When I request tests, such as antibody checks for Rhesus negative women, I ask that a courtesy copy (cc) go to the woman's GP.

One frustration that I face each time I request blood tests or other investigations is that I have no practice software that coordinates the writing of the request slip, and the receiving of the results.  I must do this by hand.  This is something that may change with the passing of time, as more and more midwives participate in Medicare.

As with many of the more medical aspects of maternity care, I often have a skeptical attitude about the value of the tests.  There seems to be an expectation that all women will have several ultrasounds to check the dates (early), for Down Syndrome screening (11+3 to 13+6 weeks), and morphology (18-20 weeks).  Other women are advised to have serial fetal growth scans.  I have little confidence in the liberal use of ultrasound, that this practice follows the first law of medical ethics, to do no harm.  I wonder if my attitude will change, as I read and explore this and other tests in greater depth in the coming months?


Thankyou for your comments

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

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