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Hello everyone - I agree with Mary and
Caroline... we are pressured to conform to the expectations of
other clinicians, and their wishes often conflict with the woman's wishes and
inner knowledge of her body, her baby, and their
wellbeing.
My last two cases have required me to negotiate this
difficult path. I described the overdue baby case recently. She was
born exactly 21 days from her u/s due date, and although "L" had one ctg at
my request to conform with the supporting GP/ob.'s expectations, I followed
this woman's wishes throughout, with a lovely outcome.
This weekend I've cared for my
client (Primip, no partner) with prolonged ROM. I monitored her very
carefully, and her labour was long and gentle. All was well, however
I was aware of the time ticking away and after 48 hours sought a CTG and AB's to
satisfy the Homebirth Policy and Guidelines for risk management. Around
that time her labour pain increased and I felt she was now in active
labour. After being turned away from the hospital she was booked into as a
backup because it was closed to admissions due to staff problems(!!!), we went
to the next hospital where she had to be admitted to obtain the AB's
etc. A GP/ob ordered them by phone (refused to order IVAB, ordered IM),
and CTG was fine. VE performed by hospital midwife at doctors request
confirmed 6cm dilation, station at spines, ROL. The woman decided she
wanted to go home to complete her labour and birth, and signed herself out
"against medical advice". Three hours later she stated "this is not
working, something's wrong". My VE confirmed baby was now ROP, and still
at spines. She was exhausted and wanted to go back to the hospital, so
that's what we did. She was examined by a different midwife who
confirmed OP position on VE, and -1 station, stating "obstructed".
She then advised my client that a CS had been booked for her by the doctor (who
still had not seen or met her), for 15.45hrs. Although my client
agreed with this plan quite readily, I felt it was odd that a CS would occur
like that without either the GP/ob or the ob. performing the surgery even
assessing the woman, but that is what happened. I didn't challenge the
decision because the client was OK with it. During the surgery it was
clear the baby's head had come out of the pelvis and was facing outwards
(OP) when viewed thru the incision. All was fine.
Then came all the pressure for the IMAB's for this
"terribly compromised baby" due to prolonged ROM. They threatened "N"
(once all family and I had left) that she would be transferred to Perth if she
did not comply with the paed's order for IMAB's.
She complied with the first IM dose, and then negotiated oral ab's
from this am, while awaiting results of swabs. She's a strong,
intelligent young woman, and I'll be there for her whatever occurs over the next
few days. I feel these two cases really reflect the pressures
which we experience as we support women in their birthjourney, as discussed by
Mary and Carolyn. The bottom line is how the woman feels about the
process and outcome - as Carolyn so wisely stated:The point of the story for me is that in a midwifery model
of care, which is inherently women centered, the women lead the
care. The joy of programs such as CMP Freo style and the NMAP is that
more women can access midwifery care and, with the development of the
relationship, gain the huge benefits that care for the human spirit and the
emotions, as well as the physical body, brings.
Thanks for allowing me to "debrief". Regards,
Lois
---- Original Message -----
Sent: Sunday, August 11, 2002 8:24
PM
Subject: RE: [ozmidwifery] Pressure re
ctg's etc
Mary
has highlighted some deep, complex and important issues here
regarding the pressure faced by midwives when working in a systems model,
however that model is configured.
The
collective sense of responsibility, the political pressure, the need to defend
the 'unorthodox', our protocol bound profession and the need to be 'doing the
right thing' by the mainstream are all powerful considerations at any time.
Mary's comments have had me thinking all afternoon as I juggled the various
aspects in my head and heart. My guess is that it comes back to woman centered
care, how the woman is feeling and what she in her head and heart wants to do.
If the woman feels safe and certain in herself, then she will
know what is right for her. If she is uncertain/fearful, then that is
what is needed to be taken into account, no matter what the model of care is
or who or what is directing the management of the model.
Women know themselves better than any so called expert. If a woman is
worried, I'm worried. If they are not worried and they are clear and definite,
It is easy to support their decisions. I use questions to discover what
is happening for a woman, as it is often the strategically
positioned question that can lead to insights and understanding for
both/all of us.
There is a story which comes to mind and it may illustrate my
thinking here.
I
had the immense pleasure and privilege of being midwife for a midwife
colleague. She was having her second child. The pregnany was traumatic, her
relationship with her husband ruptured during the pregnany and she became
quite anaemic. She did everything to get her Hb up. At 40 weeks, she had a
breech baby with cord around it's feet in the pelvis (cord presentation
diagnosed on scan done when baby became breech). She was offered a caesarian
and refused. She agreed to be admitted to hospital and whilst lying there on
her back, stroking the baby, pondering life, the universe etc as one does at
these times, she felt the head and gave it a gentle push towards the correct
position. The baby turned easily, flipping to head first. She rang me
immediately, concerned and anxious, worrying that she may
have caused a cord compression. She had an immediate scan and CTG which showed
a head first baby, cord well and truly out of the way. The CTG was great. She
chose to go home, despite being cautioned about unstable lie etc. She
finally went into labour at 43 +2 days, there was absolutely no interest in an
induction. She "wasn't ready" she told me. Liquor volume/movements etc were
fine. She screamed all through her labour, which she assured me was nothing to
do with any physical sensation, she was releasing her emotional pain.
Gave birth intact to a beautiful 8 something pound baby with clear
liquor. Her birth notice in the paper included the words, "a screaming
success".
What's the point of the story in this context? The point of the
story for me is that in a midwifery model of care, which is inherently women
centered, the women lead the care. The joy of programs such as
CMP Freo style and the NMAP is that more women can access midwifery care and,
with the development of the relationship, gain the huge benefits that care for
the human spirit and the emotions, as well as the physical body, brings.
thanks Mary for the opportunity to discuss these issues.
warmly,
Carolyn Hastie
After replying to Joy's message I was thinking about where that
"pressure in my head" came from. It wasn't because I was afraid about
the baby. The movements were more than adequate, on palpation there
was plenty of fluid. All other obs were perfect. Both of us felt
that the baby was o.k. I think that the pressure comes from a
collective sense of responsibility when part of a larger birthing
community. The Community Midwifery Program is always under political
pressure from the doctors to not put a foot wrong. Always defending us
for our "un-orthodox"(ie non-interventionist) practice. My
daughter is a client of that program and I am a midwife contracted to that
program. Because of that it is always important for us to be seen to be
doing the "right" thing. I felt that we were more or less obliged to
do what is assumed to be "right" by the mainstream community. (except for
being induced at 7-10 days which is fast becoming the rule at our large
teaching hospital). It is something for you all to think about when
contemplating NMAP. The gains outweigh the losses, but for midwives
there is ALWAYS that loss of true autonomy, for the client a trade of a free
homebirth, for some subtle pressures, increased protocols and that
sense of responsibility to make sure the Program itself is not damaged, for
the greater good. On the whole the existance of the Community Program has
been just wonderful and I urge you all to work towards it, but these are
some of the drawbacks. Cheers, mary
M
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