By Caroline Flint

In the second of her four articles on continuity of care for maternity patients, Caroline Flint, SRN, SCM, outlines scheme No. 1 involving a team of four midwives looking after 200 women a year

Continuity of care by midwives who are known to the mother would probably enhance the childbirth experience for women, possibly improve the quality of the relationship between mother and child and perhaps reduce the perinatal mortality rate.

At the same time, midwives in this scheme will experience continuity of caring, thus enriching their job satisfaction and encouraging more midwives to stay in the profession. The scheme would enable the art of midwifery to be practised to the full and would provide an efficient, humane and probably economical maternity service.

Four midwives would work together. One would be a senior sister or nursing officer who will service the team, and act as co-ordinator and administrator. But her more important function is to work as one of the team members when anyone else is on holiday or on sick leave.

I envisage the nursing officer as being able to service two teams at a time, but this may be too much. She will need to get to know all the women being looked after by the team and they will need to get to know her.

As for the other three midwives, they will have the great advantage of knowing their off-duty for at least six months in advance - it could even be worked out for a whole year - one of the greatest causes of distress among nurses and midwives would be alleviated.

The number of maternity patients who can be looked after by this team of four midwives is 200 a year.

The midwives on duty work one of the two shifts. One is on the on-call day when the midwife is on call from 07.45h -19.45h: an alternative might be from midnight to mid night.

This midwife will spend the day al home with a bleep and will be called in by the hospital when a `scheme' patient is due to come into the hospital in labour or when a scheme patient arrives at the hospital in labour; although all the scheme patients will be asked to telephone the hospital before they arrive in labour, so that the team midwife can be there ready to greet her on her arrival in the labour ward. Thus she will only be in the labour ward when there is actually someone in labour.

If no one is in labour that day - 200 patients a year means that in any one week there should be only four women in labour - the on-call midwife will come into the unit at about 18.00h and will do postnatal nursings on any patients who are part of the scheme and will generally spend the evening with them.

When she has settled them in for the night, she will either go home, where she is on call for any scheme patients who are admitted into labour, or she will sleep in an oncall room in the unit and look after any scheme patients who are admitted in

During the afternoon she goes to the antenatal clinic where she works for two hours and sees six patients. She will undertake the total antenatal care of each patient and it is estimated it will take 20 minutes to see each one. She will do each patient's blood pressure, weight, urinalysis, abdominal palpation and any blood taking that is needed, and will send the patient for ultrasound scanning or any other necessary tests.

The patient will not be seen by a doctor unless the midwife has any worries about her, when she will either be asked to come back to the consultant's clinic or the midwife will bleep the registrar on call and he will see her. This midwife will go off duty at 16.30h and will have the evening free.

On Wednesday no one has a day off. One of the midwives is working an antenatal and postnatal day and will, as usual, be in the antenatal clinic for the afternoon. The midwife who is on call will come into the hospital at 16.00h and will work in the antenatal clinic for two hours before going to the postnatal ward, as long as she is not with someone in labour.

The nursing officer /senior sister and the other member of the team will work from 13.00h - 21.00h and see 32 patients. They will give talks about the scheme, and hold discussions and teaching sessions with the patients and their partners about the scheme, about pregnancy and labour in general, breathing and relaxation, breast feeding and life with a baby. They will show films and give total antenatal care as on the other days.

It will be an opportunity for the midwives to see each other and give each other support and encouragement. One of the benefits of working so closely together will be that the midwives will become friends and be able to support each other, and even swap duties if necessary.

The midwives will work a 150-hour month (37.5 hours a week) and could care for 200 patients a year. For three weeks of each month the rota will be strictly adhered to. On the fourth week, the hours done by each midwife will be totted up and the rota adjusted accordingly.

Two teams of midwives could care for 400 patients a year - that is, six midwives and one senior sister. As far as the senior sister is concerned it might be more realistic to reckon on two senior sisters for every three teams which would mean that three teams could look after 600 patients a year using 11 trained staff. At a London teaching hospital I have recently been working in, we were usually under establishment but, even so, for every 600 patients we had 12.6 trained staff (not including any grade above sister). It might be worth considering how many trained staff below the grade of nursing officer most units employ, and how many midwives are being used for each 600 patients.

Women involved in this scheme have to be ` normal', that is, no previous obstetric complications, no diabetics and no cardiac patients should be included. But late bookers or previous defaulters might find the scheme attractive.

Patients would be invited to join the scheme at their normal booking visit- when the previous obstetric history has been ascertained in the case of multips - by a handout detailing the scheme. This stresses that the patients concerned would receive the greater part of their care from midwives and, unless any complications arose, would normally only see a doctor on booking, at 32 weeks and then from 40 weeks onwards.

The patients and their partners would be invited to meet the midwives on a Wednesday evening when all the midwives would be available to discuss the scheme. Every week, four new patients would be taken into the scheme.

How will the scheme work? Mrs A will come to the normal booking clinic, have her history taken and undergo a thorough medical examination. She will be given a leaflet with details of the scheme, inviting her to meet the midwives on any Wednesday evening. Let us imagine she visits on week one. She is 12 weeks pregnant. She meets midwives Liz and Emma and the senior sister, who explain the scheme to her.

Mrs A is still working and would prefer to attend after work, so an appointment is made for four weeks' time on a Wednesday evening.

When she comes this time, she will see Joan and Liz; when she comes for her appointment at 20 weeks she will see Emma and Joan; and as the weeks progress, she will get to know all three midwives and the senior sister.

If her pregnancy progresses normally, she will see the midwives throughout, except at 32 weeks when she will see a consultant obstetrician or a registrar. She will be seen again by the consultant at term.

If anything untoward should occur in her pregnancy, she will be seen by the registrar on call while she is in the building or she will be asked to come back to the consultant's clinic, depending on the circumstances. The midwives will need to be able to initiate urine tests, ultrasound scans, urinary oestriol collections, etc. Once Mrs A has left work and is attending fortnightly or weekly, she may attend during the afternoon to see a midwife who will have plenty of time to devote to her, and be able to really get to know the midwives and they her. They will note what she hopes will happen at delivery, whether she has strong feelings about drugs, enemata, shaving, etc.

Let us imagine that Mrs A, who is a primipara, goes into labour in Monday of week one. She rings the labour ward before she comes in, so that they can contact the scheme midwife. If she goes into labour on Monday morning or afternoon, Liz will be called in because she is on call. If Mrs A goes into labour on Monday evening or during the night, Liz will already be in the hospital.

Suppose she is admitted at 02.00h Tuesday morning, Liz is called from the oncall room where she is asleep, or from home.

She is with Mrs A until 08.00h, when she is due to do the postnatal nursings, and Joan is now on call. Liz will ring Joan, and between them they will decide whether Liz stays with Mrs A, and Joan will then do the postnatal nursings, or vice versa. By now Mrs A will have formed a relationship with Liz but, on the other hand, she also knows Joan well.

It is now Tuesday morning and Liz has decided to stay with Mrs A during labour. Joan, who is on call, will come into the unit and do the postnatal nursings. Mrs A is delivered at 16.00h so Joan stays on and sees the antenatal patients. As she is on call, she then does her normal on-call duties, which involves seeing the postnatal patients.

Joan retires to the on-call room at 22.30h and falls asleep, very tired. She is called at 02.00h when Mrs B arrives at the unit in labour. She may feel too tired to take on the case, so rings Emma who is not officially on call until 07. 45h, but who realizes she may be called any time after midnight. Joan arrives on the unit, and delivers Mrs B at 09.30h and is back home by 11.00h. Midwife Emma will stay at home or go out, but always with her `bleep'.

When Liz delivers Mrs A at 16.00h on Tuesday, she is due to go off duty. Joan arrives on the labour ward, takes over from Liz, transfers Mrs A to the postnatal ward and then starts the postnatal nursings on the other scheme patients as well as Mrs A. She will be cared for during the night by the normal ward staff. Joan will be doing postnatal nursings on Wednesday morning and Emma will be there on Wednesday evening and Thursday morning - Mrs A will know them all very well.

Mrs A booked early, but what of the woman who books late, or who has been an irregular attender at the antenatal clinics? I suggest that, for this woman, the intimacy and relaxed atmosphere these midwives could provide would help her to feel happier in the hospital environment, and she would also feel she was being treated as an individual - the waiting time for antenatal visits would be reduced and her other children would be welcomed also.

On starting the scheme, only one midwives and the senior sister, would be needed for the first five months. Let us imagine Emma starts working on the scheme in March. During this month she books four patients a week, who are all 12 weeks' pregnant. During April she books another four patients a week and also sees 16 patients who are now 20 weeks' pregnant. In May, June and July she will do the same. In August the second team midwife will need to join the scheme, because by now the original women booked are 36 weeks' pregnant, and by the end of August the third team member needs to be employed.

During these first five months, Emma will have much spare time which can be used according to the needs of the service. By September the scheme will be fully operational with the four midwives working together. The senior sister should be employed right at the beginning of the scheme; she can also be used according to the needs of the service during the early months.

This is a suggestion for a pilot study on continuity of care. I honestly do not envisage in a unit where there are 1800 deliveries annually, nine teams of three midwives plus six senior sisters because it is too complicated and because high-risk patients need more care by doctors. On the other hand, I think if one such pilot study were conducted, a great number of ideas would surface which could influence treatment of all patients in such a unit.

It has been suggested the scheme could make other hospital staff resentful of the 'exclusive ' midwives and their `exclusive' patients. In the same way that there is sometimes resentment towards community patients and often hesitancy in treating them because of their close relationship with their `own' midwife, this danger needs to be faced. But it is unlikely to occur if the senior sister is a good communicator and holds frequent meetings between hospital and scheme staff, and if she really listens to suggestions from her midwives.

December 9, 1981