By Caroline Flint

Is a split developing in the midwifery hierarchy, and if so why? Caroline Flint explores two recent incidents which provide cause for concern

What is happening on the Isle of Wight where a community midwife was told that all patients must be given Syntometrine (see Nursing Times News, January 14, 1987) is only an echo of what is happening throughout the country where the midwife's right to practise her profession is increasingly coming under attack.

In a report in 1983, Robinson, Golden and Bradley' alerted us to the fact that in a third of all consultant obstetric units the decision over when to rupture membranes was made by unit policy and not by the midwife relating to the individual woman's needs. The decision to carry out vaginal examinations had nothing to do with the needs of the individual woman or the professional judgement of the midwife, but was unit policy in 50 per cent of consultant obstetric units.

Reviewing the report, Pat Ferguson said, `The doctors, particularly the junior staff, see midwives as advisers rather than clinicians' and added, `it seems clear that the UK will shortly have an American-style system of obstetric nursing, rather than the high status midwifery practised in the rest of Europe".

In response to instructions that Syntometrine must be given to all patients, Royal College of Midwives general secretary Ruth Ashton said, `Our organization does not support any umbrella policies which take away the proper clinical judgement opportunities of anyone.' This underlines the Midwife's Code of Practice which states that, `each midwife as a practitioner is accountable for her own practice in whatever environment she practises'. (3)

The case about using Syntometrine came to light in the same week that I heard of an area where community midwives who stay on call voluntarily for women booked for a domino delivery, have also received notice that, `Midwives are not allowed to visit any patients in labour at home unless they are the midwife on call that day.'

Midwives' practice is being attacked on several fronts and who is responsible? The consultants? They are up to a point because to increase their own sphere of practice necessitates restricting the midwife's, but even more the attack is coming from senior midwives. They do not seem to ally themselves with their own profession but with the obstetricians - which is a direct result, I would suggest, of the hierarchical way in which we have arranged our profession. The effect is that the most senior midwives become isolated both from their fellow midwives and the women they care for, and in their loneliness turn to the only other group with which they have contact - the obstetricians.

So what should the senior midwife on the Isle of Wight have done when she was asked by a consultant to tell the midwife in question to use Syntometrine? Ideally, she should have refused and pointed out that this was a matter for the midwife's professional judgement. At the least, she should have agreed to say that the consultant 'recommended' the use of Syntometrine, but she should certainly not have issued an instruction to say that all women were to receive it. It is pleasing to learn that the health authority has now effectively acknowledged this point. (see News, p.8)

Likewise, what is the senior midwife in the case of domino deliveries thinking of when trying to change the established practice of midwives, which is obviously very much for the benefit of the women they are caring for? If midwives have been in the practice of seeing women in early labour at home even though the midwife herself is not on call, that practice cannot be changed without proper consultation. If the midwives refuse to change this practice because they believe that it is beneficial for women then nothing can be done about it.

The employer should be leaping up and down with joy that he employs people who are so committed that they are willing to go beyond the call of duty. This is expected of all professionals. The only obligation of the midwife who has been up all night is that she must be in a fit and proper condition to do her work when she is supposed to be on duty and this is her decision, not her employers. She can be challenged by her employer only if it is patently obvious that the midwife is not in a fit and proper condition.

As for the old chestnut that `You're not covered when you aren't on duty'- as a professional you are responsible for your own practice, so it is essential that you are covered by indemnity insurance either with the RCM or with one of the trade unions.

And to lonely midwife managers I would say, whatever you do affects us and ultimately the women we care for. You are in the difficult position of being the spearhead for midwifery, you must support our profession. It is you who can make or break us.

1. Robinson, S., Golden, J., Bradley, S. (1983). A study of the role and responsibilities of the midwife. London: DHSS.

2. Ferguson, P. (1984). 'Midwifery under threat.' Senior Nurse; Vol 1, p.27.

3. UKCC (1986). A Midwife's Code of Practice for Midwives Practising in the United Kingdom. London: UKCC.

4. Klein, M., Lloyd, I., Redman, C., Bull, M., Turnbull, A. (1983). `A comparison of low-risk pregnant women booked for delivery in two systems of care: shared-care (consultant) and integrated general practice unit.' British Journal of Obstetrics and Gynaecology : Vol. 90: 2, pp. 118-128.

February 4, 1987.