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.  (http://www.mydr.com.au/medicines/cmis/syntometrine-solution-for-injection )

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

Women's rights in childbearing

I took a consultation paper on birth registration, and the latest issue of MIDIRS with me in the plane yesterday.  The flight from Melbourne to Brisbane takes about two hours, which fits well with my capacity to stay focused on a topic. 

The issues around women's rights in childbearing have been promoted by many writers and film makers.  A multi-disciplinary international conference on human rights in childbirth was held in the Netherlands a few months ago, spurred on by outrage at developments in Hungary with relation to  criminal proceedings against doctor-midwife Agnes Gereb.

Australian birthing activists are planning to meet in Sydney next month for a special meeting on Childbirth and the Law.

Who decides how and where a baby is born? Who bears the risks of childbirth? What legal rights do women have to choose how they give birth? These are just a few of the issues that will be discussed at the upcoming Childbirth and Law Forum on Friday 12 October 2012 at Riverside Theatre, Parramatta.

The Childbirth and Law Forum will begin at 2pm with presentations from  two speakers who will discuss the legal issues facing childbirth today in Australia. (Homebirth Australia press release)

It seems that women and childbirth activists in the UK are learning how to demand homebirth services within their public maternity care system.  Barrister Elizabeth Prochaska wrote:

A recent case of mine shows that it is worth fighting decisions to refuse to provide a home birth (even at a late stage in pregnancy).  A large London hospital suspended its home birth service for a month due to staff shortages and informed women who had planned home births that they would be transferred to hospital by ambulance regardless of whether or not they consented to transfer.  AIMS put a coupe in contact with me who had been promised a home birth by the hospital.  With only a few weeks before their baby was due, they decided to threaten legal action, relying on a legitimate expectation and the Ternovsky case. The hospital rapidly backed down and agreed to provide independent midwives to attend all the affected women at home. (Prochaska E. AIMS Journal, vol 24, no2, 2012, pp6-7.)

The debate around women's rights in childbearing are confused and complicated by the whole spectrum of risk and professional duty of care.  Women in Australia who are within cooee [an Aussie slang word for reasonable distance] of a publicly funded homebirth service will often experience extremely narrow definitions of wellness, or exclusion criteria, which make many ineligible for homebirth.  For example, a woman who declines a test, such as ultrasound, or glucose, or group B Streptococcus, may be unacceptable for homebirth.  Similarly a woman who indicates that she plans to decline active management of the third stage, can be excluded.

In these cases it seems fanciful to argue women's rights, when the hospital simply uses narrow risk management protocols to exclude them.  They are no longer 'low risk'.

Similarly, the options for women who have had one or more previous caesarean births, are woefully inadequate.  A woman planning vbac is ideally cared for in her home as her labour establishes, with a known and experienced midwife in attendance.  The decisions about home or hospital birth can be made as labour progresses (or doesn't, as the case may be). 

Midwifery services today use the term 'evidence based' without challenge.  The exclusion of women from birth centres and homebirth programs is considered 'evidence based'.  Rarely does anyone ask, "what evidence is that?"

A recent update of the Cochrane review , the centre of excellence in medical evidence, states:

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. ...

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. 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. [emphasis added] In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. 

An article in MIDIRS that prompted my thoughts today is titled Women's Rights in Childbearing, by Nadine Edwards.  Nadine is vice-chair of the UK maternity organisation AIMS, and a director of the Pregnancy and Parents Centre, Edinburgh.

In 'Women's rights in childbearing'  (Edwards, 2012), there is considerable focus on the rights of women to give birth at home unattended: free birth.  The article reports that  UK authorities support a woman's 'right' to give birth "without medical or professional help. ... it is legal as long as the birth is not attended or the responsibility for care is assumed or undertaken by an unqualified individual. ... the woman assumes responsibility for her birth."

Recently a young woman spoke to me about being asked by a woman to attend birth, as a doula, without a midwife being present.  The limits of responsibility in such a situation are in no way defined or clear.  It's clear to me that the Australian authorities will jump at the opportunity to close any opportunity for unregulated birth attendants, whatever they call themselves, to replace the highly regulated midwife.  Unfortunately it will take adverse outcomes to test the limits of women's rights.

old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

Midwives and the battle of the bulge

A new draft National Antenatal Care Guidelines has been released for public consultation. The consultation period ends on 27 June 2011. The guidelines can be found here.

Today's health care world relies heavily on guidelines, and this document is being developed with government funding under the AHMAC priority to "Ensure Australian maternity services provide high-quality, evidence-based maternity care."


If anyone has had an opportunity to read through these draft guidelines, you will find much that is accepted as good practice, presented clearly and referenced. However we need to read with our critical minds switched on: otherwise there's no point in reviewing the draft. Midwives and doctors who provide antenatal care need to ponder the impact on our practices that they might have when they are approved.

Routine weighing at each antenatal visit
Please take note of

Recommendation 4: Routinely weigh women at each antenatal visit. Excessive or inadequate weight gain may have negative effects on the woman and the baby. (p vii)

This recommendation is rated as Grade 'A', which means "Body of evidence can be trusted to guide practice."

I put a question out about this to colleagues, via a midwives' email list. "Do you routinely weigh women at each antenatal visit?" It appears that there is a general consensus in the group that midwives do not currently weigh women at each visit.


It’s clear that obesity in pregnancy is linked to poor outcomes, and the midwife’s duty of care is around promoting health through good diet and weight management. Obesity is the big current focus of health promotion. However it appears to require a great leap of faith to believe that routine weighing in pregnancy will result in better weight management, and better outcomes.

As I remember being pregnant in the ‘70s, when everyone was weighed at every visit, women were harming themselves in an attempt to control weight gain. Some women were restricting their intake to the point were they were nutritionally unbalanced, leading to a lot of fluid retention, and pre-eclampsia. The doctors (bless them) were prescribing a diuretic (Lasix) to get rid of the excess fluid, which did actually give ‘better’ weight gain, but at what cost? The routine weighing potentially led to adverse effects.


The Draft Guidelines Appendix D (p138) gives the UK National Institute for Clinical Excellence (NICE) recommendations, that Weight and height be measured at the first appointment, and BMI calculated. Then this second recommendation:
“Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]”


This second recommendation from NICE has been summarily dropped for the new Draft Australian guidelines, with some review discussion around ‘new evidence’ associated with a high or low pre-pregnancy BMI that has emerged since the NICE (2003).

It would seem wrong to impose routine weight monitoring on all women, when the new evidence, even if it is grade 'A' applies only to those at the ends of the spectrum.

It's good that maternity services seek to "provide high-quality, evidence-based maternity care." BUT, any guideline that claims to be evidence-based, with an A-grade "Body of evidence [that] can be trusted to guide practice." needs to be just that. In this case, there is no evidence that routine weighing of all women will do anything to address obesity and ill health, or under-nourishment for that matter, or improve maternity outcomes.

Comments from readers are welcome. If you refer to something in the Draft Guidelines, please quote the page.

ps
Readers will be interested in the Science and Sensibility blog entries and discussion on maternal obesity.  The writer, Pam Vireday's blog is Well Rounded Mama.