Forgot to copy this to the list, sorry. so here it is. Trish
>Dear Kathleen
>I worked in KYM for about three years, then had a small break while I took
up senior midwifery and management positions and academic positions, but
came back to clinical midwifery through my role as a clinician lecturer. I
chose to do caseload for a lot of reasons, but mostly for the satisfaction,
professional identity and the opportunity to be with women in a way I had
only dreamed about. I didn't even know this was what it was called, but I
clearly saw it as a professionalising strategy for midwives that would be
acceptable to women. Since I have no caseload partner, I am on call all
the time that I have women due to birth. I feel, therefore, that I am
uniquely qualified to answer this question.
>
>Being on-call in my KYM days was far preferable to me to being on night
duty (which I hated with a passion) becuase when you were called out, you
were fairly sure it was for genuine work, and not to fill in for others
whose numbers were down, etc. Caseload is even better. When I am called I
know the woman is in labour (or has some ante or postnatal question that
really needs addressign), and I know she wants ME! I know her, and know
what she is capable of and am ready to meet her requirements whilst
enjoying hte experience. There are really few surprises which is less
stressful than working in a normal delivery suite etc.
>It does interfere in some ways with my other work and with my family life
though. I take a mobile phone and beeper with me so that if I am called I
can get back to women. Teh beeper makes a nice buzzy feeling in the
pictures or lectures etc. I can't be over .05 when i have women about to
birth, but that doesnt limit my intake when I know there is no one imminent
for a few weeks. I can't go interstate or more than an hour away, either,
but that's not so bad if I only have about 20 women per year (last years
numbers were 18), I gladly accept these restrictions in order to organsie
the rest of my clinical work around all the other things I like to do, such
as going to events with my children, partner and friends, teaching,
shopping, etc. The women (as my partners in practice) happily negotiate
times for visits etc, and I can offer visits that suit them that are
outside of 'normal' clinic hours, such as evenings and weekends. I use my
own car and claim expenses on tax for visits in homes, etc. I have only
missed ONE birth through being away. She was a multi having her second
baby with me, and who I organised to come to the birth centre (her second
choice of care) jsut in case to meet them and see the place. She delivered
with them and I did her postnatal care when I got back (from the Models of
Care Conference as it turned out!). Everyone else has known my commitments
interstate or at nether conrenrs of the state and has 'crossed their legs'.
One might say this causes unnecessary stress, but the women say they
rather this than other forms of care. And if I had a caseload partner this
would be removed as well.
>
> >Professional relationships with colleagues are very interesting,
though. Doctors deal with it better than some other midwives. They relate
to you more as a fellow professional than as their fixed staff, and if they
see you also coming and going, making decisions, conferring with women,
they tend to follow your lead. Excellent. I have had GP and obstetrician
referrals, and have done some share care with a GP for women who have
needed teh extra input and ongoing followup with the GP later. The GP has
respected me as the primary care giver in that context. They do not tend
to question or second guess me in the way they did even when I was in the
KYM. There is just something about being the ONE responsible that develops
respect in self, others and the women/public. One grows in stature out of
proportion to the mere performing of the role.
>
>Other midwives have found it harder to take (some at least). They
question the wisdom of 'being the one responsible' or being on call, or
working long days, or leaving the family to cope, etc, or not getting
enough high risk (whatever that is) experience, and of not being 'in touch'
with hospital protocols etc. Various discourses of danger for either me or
the woman or my relationships. Others envy me my mobility and ability and
the connections I am able to make with women, between theory and practice,
and between my perosanl and professional identities.
>
>The strain on my partner got greater last year. He felt I did too much,
and he was right, becuase my job also entailed teaching (30-45% of my role)
and research and etc. Teh clinical work did take over, but if all I was
doing was caseload in my job, then it would not have been so much of a
problem, becuase I could have been even more flexible, not having the other
fixed commitments. If I had a caseload partner, I could also have had some
time off call, which would have made HIM feel better.
> >
>The long hours in labour are fairly rare, especially if a visit in early
labour (to the woman's home) or several reassuring phone calls are made.
The woman spends most of her time at home. I can only remember about three
labours of more than 12 hours of my attendance. If I had a partner, I
would have called her in to help, or to take over (but mostly to help). I
have used teh Delivery suite midwives to do this, and more importantly,
when I have had students, I have used them as my resource. The physical
and emotional assistance is great, and you can go safley for longer with a
resource/assistant/partner. If I was there for longer than about 14 hours
(dependign on the time of day, what else I had been doing etc) I would ask
another midwife to take over, but would stay as resource adding continuity,
relfection, intimate knowldge, and the woman still sees me as HER midwife
doing importatn work, but who called for help when it was needed. Again I
can only remember in four years of caseload practice that this has happened
three times. Then I go home and sleep and recover and don't come back till
the next day to do some post-natal work. The women accept this very well.
The real postnatal work for me begins on about day 2 when the woman goes
home, and I do the postnatal care at home. I do visits until about day 7
depending on the women's needs, and may continue for a couple of weeks
keeping contact.
>
>One of the benefits I have found is the personal contacts I have made
with community resources. I can help women make easier transitions to
other forms of care or services becuase of the responsibility I have taken
on, and the intimate knowledge of the family they have shared with me, and
because with so much personal investmetn, I am able to learn more.
> >
>But the transition was not without hiccps. The sense of respnsibility was
very great, and I suffered all sorts of crises of confidence (still do take
my mistakes very personally) and imagined all sorts of 'what ifs'. It took
me about a year to learn to share the responsibility with the women, to
become true partners in the care/experinece, and to be able to say without
fear that 'I don't know...' sometimes. Mind you, I tended to look stuff
up, do courses, read, read, read.... and TALK! I asked questions of
midwives, women and medicos till my ears were ringing with the discussions,
opinions and facts. I would have loved a peer/fellow traveller at the
time, and used the homebirth midwives as sounding boards a lot. You need
to have a formal peer debrief/review/appraisal system as well as an
informal one. Good mentorship/critical friend/clinical partnership between
more experienced and less experienced midwives is essential. You learn
even more by teaching becuase you have to talk and write what you do and
know, which is after all what buildign theory is all about.
>
>In short, I can't imagine another way of working now, and would shrivel
and die in confinement in hospital shift based routines. Tehy don't call
it confinement for nothing, you know!
>
>I wrote a bit about other tensions in my paper (Feminist Praxis, etc) for
the Truth, Virtue and Beauty Conference (ACMI 1997), and my paper for the
September conference will address other aspects of teh conjoint experience,
touching briefly on combining practice and academia in this way (a midwife
academic in caseload practice might not be taken seriously by anyone, i
sometimes feel).
>
>You are free to print and distribute any of this, but please spell check
it first, as it would just be too embarassing for me other wise. But email
is so immediate thjat the mistakes get through. I would like to hear what
you think of all this as well.
>
>I am happy to talk more on my favourite subject. Hope all this helps.
Cheers, Trish
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