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The sorts of clinical issues dealt with in this section are those of the everyday interactions between women and their midwives. The nature of `ordinary' midwifery practice and the issues it raises have been the focus of Caroline's attention. Whilst American midwives like Ina May Gaskin and Elizabeth Davis have written books and articles exploring the experience of midwifery, British midwives have been slow to examine midwifery through the actual experiences of its practitioners. Caroline is an exception and her book Sensitive Midwifery, published in 1986, had both midwives and mothers as its subject. Midwives are players in the drama of birth and not just the stage managers they seem in other textbooks of the time such as that of Margaret Myles. They may only be the support cast but their personalities, words and actions can have a profound effect on the main characters and are therefore worthy of attention. In the articles making up this section, Caroline does not divorce clinical practice from its practitioners but always presents the words, actions and attitudes of midwives as integral to her consideration of clinical issues. This is an area in which midwifery has developed further than medicine: in medical journals clinical issues are still treated as though they exist in a realm uninhibited by actual people. Most of Caroline's articles by contrast are peopled - peopled by the women she's cared for, met or heard about, and peopled by her colleagues and herself. The `clinical issues' discussed in these articles deal with breast feeding, breech babies, the spontaneous and artificial rupture of membranes, Caesarean section and postpartum haemorrhage. One article explores the labour ward environment and six explore (under various guises ranging from ethical issues to the risks of HIV infection for midwives) unit policies and guidelines for practice. The criticism of routine interventions in normal labour runs as a thread throughout, particularly electronic fetal heart monitoring, artificial rupture of the membranes, the use of fetal scalp electrodes, restricted mobility and unnecessary episiotomies or vaginal examinations. Privacy for clients and the need for clinical autonomy for midwives, together with greater continuity of care are Caroline's prerequisites for improving both the physical and the emotional outcomes of maternity care. Caroline is what is often termed `a physical person'. This can be alarming. Hugging and kissing are an occasional rather than day-to-day part of midwifery care for most midwives and their clients (`Care Plan or Talisman?), and even Caroline has a touch more restraint in person than in print. Nevertheless the breaking down of lay/professional barriers that hugging and kissing represent are central to her vision for midwifery and not simply a frivolous suggestion to annoy the Disgusted of Tunbridge Wellses of the profession (although they have not been without effect in that quarter). Two of the articles provoked an outcry when they were originally published (`Ethical Issues Facing Midwives' and `Postpartum Haemorrhage at Home'). The strong feelings underlying `Ethical Issues Facing Midwives' are apparent in the language used. The scenarios presented were felt by some to be too extreme and to portray rare examples of the very worst obstetric practice. Caroline was upset by the haranguing she underwent as she felt that there was nothing in the article that had not or did not happen. The incidents cited were based on those directly experienced by her or her colleagues and, whilst the presentation of them in such concentration may have made the article somewhat unpalatable, Caroline had thought that this was some dirty laundry which would benefit from public airing. The criticism levelled at `Ethical Issues Facing Midwives' was minor compared with the problems which had arisen earlier that same year following the publication of `Postpartum Haemorrhage at Home'. Whilst the Supervisor of Midwives directly concerned with the birth in question had a frank but friendly discussion with Caroline about her management of the problem, other Supervisors decided to pursue the matter further. Unable to suspend Caroline from practice for failing to call for medical aid because they had no authority in the area where Jane and Harry lived, a group of Supervisors nevertheless made a formal complaint to the then Investigating Committee of the English National Board for Nursing, Midwifery and Health Visiting (ENB) about the article. They claimed that the article had brought the midwifery profession into disrepute by publicly displaying a disregard for the Midwives' Rules. Caroline was informed only that a complaint alleging professional misconduct had been formally lodged about her in relation to the article and duly spent three months trying to ascertain what the charge against her was. Twenty years of marriage to a lawyer rendered her acutely aware that the whole situation was a travesty as far as the concepts of British legal rights and justice were concerned. As her letters and those of her solicitor made clear, she had a right to know with what she was charged. Caroline was at that time an appointed member of the ENB and having to work closely with some of the bureaucrats implicated in the tardiness and secrecy surrounding the complaint against her. After three months of tension and anxiety she was informed that it had been decided that there was no case for her to answer. The incident was another shameful episode in the Supervision of Midwifery in the UK. More of the issues surrounding and arising from the episodes are explored in many of the articles in section four `Rules, Laws, Autonomy and Justice'. The fact that `Postpartum Haemorrhage at Home' had been a serious and honest attempt to discuss Rule 40 of the `Midwives Rules' within the context of a not unusual clinical event was largely forgotten, but like many of the other clinical issues covered in this section, is still worthy of current debate. |
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