Saturday, December 15, 2012

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.

I am recording this brief account because I want to comment on it.

  • A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
  • A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:
  • a woman in good health
  • at term
  • spontaneous onset of labour
  • good progress in labour
  • uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  
Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  ( )

Breastfeeding is an intrinsic part of physiological birth.
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:
Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded. 
How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.

Your comments are welcome

1 comment:

Elisabeth Saether said...

I agree with your final comment. The problem is, in USA and in Norway, where I practice, to get in touch with pregnant women before the doctors give them all the information about how safe a hospital birth is compared to a unmedicated birth. There are only a few women who are interested in undisturbed, uninterrupted birth before they have their first child. Pregnant women are not very strong opinion-leaders, I´m afraid. Perhaps the topic should be part of the school´s curriculum on reproductive health? And then we need to ask the women / couples who succeed having an unmedicated birth to promote this in their networks. The first battle is to give the women back their right to choose for them selves and their unborn babies.