I am writing with deep sympathy for the family who lost their baby in late 2010, and for the midwives and doctors who attended the mother.
I am writing about this because the Melbourne Coroner is currently hearing evidence from the various parties. In time the Coroner's report will be published. The Coroner's job is to find out what happened, in a respectful and unbiased way. At present fragments of information have been published in newspapers and online news sites. Some pieces of the information circulating in the media are factual, while others are contested.
I am writing because this case raises issues that are similar to a case that I wrote about a couple of months ago.
It is difficult for me to write. I know the midwives; they are my colleagues, and we have shared in professional and personal journeys over the years. I know the hospital; I have been there with women many times over the years. I know the mother, who was a member of a peer support group I facilitated a few years ago.
The big issues as I understand this and similar cases are around a midwife's duty of care, a woman's decision-making, and the need for women to be able to feel respected in maternity hospitals.
The questions that I asked in my previous post are still pertinent:
"If a mother does not want to go to hospital, when overwhelming professional advice would want her to give birth in hospital, WHY?", and
"What can be done to make going to hospital a more acceptable choice for women for whom complex obstetric care may become necessary?"
I have many thoughts that I will not make public at present.
Showing posts with label private practice. Show all posts
Showing posts with label private practice. Show all posts
Wednesday, August 08, 2012
Sunday, June 10, 2012
Understanding what's behind an adverse outcome
Today I am recording a few of my personal thoughts in relation to the (lengthy) Coroner's report that was released this past week, in Adelaide. I have written about it from the perspective of Australian Private Midwives Association (APMA) at the privatemidwives blog.
Principles of accountability and transparency must be applied to professional practice. When something goes wrong in birth, our society wants to know, and has a right to know what happened. It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear? How must I act when a woman in my care understands her personal risk differently from the mainstream?
A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain. The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity. So, when I read in the SA Coroner's report that
The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.
This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:
I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result. The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation. She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]
Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive. The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives. The emergency code had been rehearsed, prepared for, and was called into action. Perhaps that group of midwives will be more ready and competent when it really is called for???
In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety. I cannot control another person's actions. I also cannot use these experiences as a reason to stay out of hospital in future situations. The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.
I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********
The Coroner's recommendations are listed at the end of the 106-page report. In this blog I am attempting to summarise the recommendations, for future reference:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."
Principles of accountability and transparency must be applied to professional practice. When something goes wrong in birth, our society wants to know, and has a right to know what happened. It's easy for me to say that the safety and wellbeing of mother and baby guide my professional advice and actions, but what about the times when things aren't clear? How must I act when a woman in my care understands her personal risk differently from the mainstream?
A considerable proportion of my practice in the past 20 years has been with women who would not be graded 'low' risk, yet they want to give birth spontaneously, without drugs to stimulate their labours, or to ameliorate pain. The most usual 'risk factors' that these women have include previous caesarean surgery, a previous large baby, a previous post partum haemorrhage, and grand-multiparity. So, when I read in the SA Coroner's report that
"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases, and were therefore not entirely unpredictable."I wonder if a similar judgment is being made of my practice, as though a midwife who agrees to attend women with recognised risk profiles is playing a version of Russian Roulette, and the midwife in South Australia was just unlucky?
The recommendations made by the Coroner in this instance appear to be an [albeit superficial] attempt to prevent similar occurrences in the future.
This course of action - the statutory authority using its considerable muscle to regulate and control the practice of midwifery - would appear acceptable to the majority of maternity care providers and academics. The suggestion is that:
- if a baby is known to be large, the birth should be facilitated (presumably by repeat caesarean, because it's not safe to induce a BAC labour);
- if the baby is known to be presenting breech, it would almost certainly be born alive by elective caesarean;
- if a woman is known to have twins, the babies will probably be born alive in the care of an obstetrician (most of whom will strongly advise elective caesarean)
I cannot ignore the fact that some women in my practice who have agreed to go to hospital, following my advice, have told me how they suffered as a result. The woman who gave birth spontaneously to twins in hospital told me she still grieved, several years later, that the first baby was taken from her, became chilled, and she deeply grieved that unnecessary separation. She told me she felt exposed and a lack of respect when she realised that a gaggle of unknown extra people had quietly slipped into the room to watch her breech baby being 'delivered' by the obstetrician. [It could be argued here that public hospitals are training grounds, and doctors and midwives have become deskilled in breech vaginal births, so ...]
Another woman who agreed to have an IV cannula when she gave birth in hospital to her third baby after a previous caesarean experienced the shock of being treated, without any discussion or consent, for post partum haemorrhage immediately after the birth, despite the fact that her blood loss was not excessive. The 'risk' factors - VBAC, multiparity, and large baby - seemed to precipitate an over-energetic response by the hospital midwives. The emergency code had been rehearsed, prepared for, and was called into action. Perhaps that group of midwives will be more ready and competent when it really is called for???
In each of these, and other situations, I have grieved my contribution to the 'harming' of women, even though what happened occurred as I tried to ensure wellbeing and safety. I cannot control another person's actions. I also cannot use these experiences as a reason to stay out of hospital in future situations. The safety of mothers and babies in my care is linked in complex ways with my own attitude towards the hospitals, my own ability to facilitate a spirit of cooperation between hospital staff, myself, and my client.
I look forward to the day when midwives will be free to practise (midwifery) without restriction in any setting; home or hospital.
***********
The Coroner's recommendations are listed at the end of the 106-page report. In this blog I am attempting to summarise the recommendations, for future reference:
1) legislation to outlaw unregulated midwifery services "without being a midwife or a medical practitioner registered pursuant to the National Law;"
2) legislation requiring reporting "the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication,"
3) That the woman who is reported in (2) will receive "advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, ..."
4) "establishment of a position known as the Supervisor of Midwives"
5) "establishment of alternative birthing centres" [note: not one of the three mothers of babies who died would have been eligible to go to 'alternative birthing centres']
6) education for public distribution on homebirths and risks
7) revised policy for Planned Birth at Home in South Australia "with an addition that current risk factors for shoulder dystocia be specifically identified;"
8) "That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician."
Monday, April 30, 2012
H+BAC=?
TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]
I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].
Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.
Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.
Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.
Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.
Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.
Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.
Q. And progressing without medical assistance - that happens best at home?
A. Correct.
Q. And that's where the midwife is experienced and competent?
A. Correct.
Q. So, why is homebirth contraindicated?
[But there's a hole in the bucket, dear Eliza ...]
Of course this little Q&A sequence is overly simplistic.
But the point I am trying to make is that 'home' is not the key issue. The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby. The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.
Achieving vaginal BAC is core business of midwifery. It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.
Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.
Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices. Either we continue to attend women with scarred uteruses professionally, or we refuse to do so. The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.
The central issue is not about the big 'H' - homebirth. The central issue is the midwife's right to engage in professional practice. A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions. In some cases that may mean going to hospital; in others it means staying at home. At all times the wellbeing and safety of mother and baby guide the midwife's professional advice. Home is only a setting. Healthy mothers and babies are the outcome we desire.
[H+BAC stands for Home + Birth After Caesarean]
I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].
Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.
Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.
Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.
Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.
Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.
Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.
Q. And progressing without medical assistance - that happens best at home?
A. Correct.
Q. And that's where the midwife is experienced and competent?
A. Correct.
Q. So, why is homebirth contraindicated?
[But there's a hole in the bucket, dear Eliza ...]
Of course this little Q&A sequence is overly simplistic.
But the point I am trying to make is that 'home' is not the key issue. The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby. The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.
Achieving vaginal BAC is core business of midwifery. It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.
Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.
Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices. Either we continue to attend women with scarred uteruses professionally, or we refuse to do so. The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.
The central issue is not about the big 'H' - homebirth. The central issue is the midwife's right to engage in professional practice. A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions. In some cases that may mean going to hospital; in others it means staying at home. At all times the wellbeing and safety of mother and baby guide the midwife's professional advice. Home is only a setting. Healthy mothers and babies are the outcome we desire.
Saturday, January 01, 2011
Plans for the new year
As the sun goes down on 1 January 2011 in our part of the world, others have just seen the New Year in.
I have noticed from the statistics function on this blog that a large number of the visitors to this blog are in the United States. G'day, folks! I am delighted to have you visit. I have wonderful memories of five winters in Michigan, and have attached a family pic, with me holding our first baby, that takes us back 37 years.
Twelve months ago, I and other Australian midwives were wondering if we would be able to practise legally, after 1 November. We are practising, and intend to continue. I won't say without change - anyone who is so set in their ways that they are not willing to change should not be practising. We must continue to change and grow in our understanding of birthing processes, while we adapt and work within the limitations of our own lives (such as ageing), and the law.
I have noticed from the statistics function on this blog that a large number of the visitors to this blog are in the United States. G'day, folks! I am delighted to have you visit. I have wonderful memories of five winters in Michigan, and have attached a family pic, with me holding our first baby, that takes us back 37 years.
 |
| New Year 1974, at our home in Biscayne Way, Haslett Michigan |
Twelve months ago, I and other Australian midwives were wondering if we would be able to practise legally, after 1 November. We are practising, and intend to continue. I won't say without change - anyone who is so set in their ways that they are not willing to change should not be practising. We must continue to change and grow in our understanding of birthing processes, while we adapt and work within the limitations of our own lives (such as ageing), and the law.
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