By Caroline Flint

This article discusses what hospital midwives can do to improve their own clinics tomorrow, or next week, simple thoughts and ideas which wouldn't take months of consultation with obstetricians, nursing officers, policy making committees and procedure meetings

Having spent considerable effort and time persuading expectant mothers to crowd into centralized antenatal clinics in consultant obstetric units we are now faced with the task of trying to make these clinics less like cattle markets - less overcrowded, less noisy, less unpleasant. And to do this we need to reverse the whole process again by making them smaller, quieter, more personal, more intimate.

In this article I wish to set aside the whole philosophy of whether pregnant women have any place inside a hospital at all, unless they are diabetic or have serious cardiac conditions, and the fact that for most women it is much easier, therefore less stressful, to go to a health centre near their home. Midwives need to make their voices heard and need to be pushing for clinics in the community run by community midwives and GPs, and for home antenatal visits by community midwives.

How can we make our own clinics smaller, more intimate? How can we change things easily and simply? Firstly we need to work out when women in our own clinics are seen by a midwife and this may work out something like this - women having shared care with their GP and community midwife will be seen in the community at 16, 20, 24, 30, 32, 34, 37, 39 weeks, and maybe at the hospital at 12, 28, 36, 38 and 40 weeks. At 12 weeks they will have their history taken by a midwife and will then be examined by an obstetrician, in many hospitals the woman will have her 28 week consultation with the midwives because they can then give her the Certificate of Expected Confinement, and can arrange her parentcraft classes; she would therefore only see an obstetrician if the midwife was concerned about anything. The 36 week visit would be with a consultant obstetrician and the 40 week visit with a senior registrar, but many obstetricians are happy for the 38 week visit to be with the midwives so that the woman can discuss her final plans and wishes for labour, and can have a long discussion about the forthcoming labour with the midwife. Thus a woman going through the system of shared care like this, could expect to see a hospital midwife at 12 weeks, 28 weeks and 38 weeks. With the present system it is highly likely that the pregnant woman would meet different midwives at each of these appointments but this can be transformed if each midwife carries a diary with times when she can be consulted, i.e. her own appointment system, this does not necessarily have to be at the time of a consultant's clinic, it could even be at a time when she can find spare room with a couch, because in a consultant obstetric unit, if a doctor is required there are always several available on a bleep, and anyway the number of women needing medical referral will be very small.

Let us take Mrs Rhoda Phipps as an example - she is a primigravida who is having shared care with her GP and she comes to the hospital with her GP letter at 12 weeks where she meets Midwife Brown at the booking clinic who takes her history. When Midwife Brown has taken her history Rhoda will be examined by a doctor but before this she makes an appointment in her diary for February 14th when Rhoda will be 28 weeks pregnant and for 27th April when she will be 38 weeks pregnant. She writes these appointments on Rhoda's appointment card and also writes her name Midwife Lorna Brown on Rhoda's appointment card so that Rhoda knows who is `her' midwife at the hospital, if ever Rhoda needs to telephone the hospital she can ask to speak to `her' midwife and when Mrs Phipps has seen a doctor she can seek out Midwife Loma Brown to explain anything she doesn't understand and to make clear anything that has confused or upset her. When Mrs Phipps is in labour she can send a message to the antenatal clinic so that her midwife can pop up and see her.

With women who are not having shared care with their GPs far more of the visits a pregnant woman makes to the hospital can be with a midwife, with low risk women the Royal College of Obstetricians in their Report of a Working Party on Antenatal and Intrapartum Care' suggest that a woman should see an obstetrician at 12, 30 and 40 weeks and at other times (16, 22, 26, 34, 36 and 38 weeks) should be seen by a midwife or GP. If individual midwives carry a diary and make themselves responsible for a group of women - taking on each week as many as they can manage - several benefits accrue: the woman sees the same midwife throughout her pregnancy, the midwife has the pleasure of seeing an individual woman through pregnancy. The woman taken out of the system in this way could reduce the numbers crowding into consultants' clinics and so enable them to be less stressful and more efficient. Similarly, if a woman does not turn up for a Clinic she is far more likely to phone and explain, if she knows that she will actually be missed by someone who is interested in her progress. If you are thinking how much you should like to take on responsibility for a number of pregnant women but your clinic is short of room, remember that for an antenatal consultation all you need is a space with a couch or bed in it and preferably two chairs so that you and your patient can sit and talk to each other. The ideal - a consulting room with couch, desk and 2 chairs, the almost ideal - someone's office with a couch in it (ask your head porter if he has any spare couches), the fairly ideal - a labour ward with a delivery bed and two chairs in it and the not quite so ideal - a bed curtained off in the postnatal ward.

Most midwives can find a small space that they can use for `just this morning' or `just this afternoon' and in every hospital there are offices that are unused for periods, perhaps every Wednesday afternoon or for two hours on a Friday morning.

When obstetricians are approached by midwives wishing to make the provision of antenatal care to women more humane and pleasant they are invariably very supportive and enthusiastic and only too happy to go along with the RCOG Document' This is an opportunity for hospital midwives to practice fully as midwives and to gain and receive a great deal of pleasure both from and for the women they are caring for.

1. Royal College of Obstetricians and Gynaecologists (1982). Report of the R. C. O. G. Working Party on Antenatal and Intrapartum Care. September.

October 1984