|
|
Exciting things are happening in midwifery in South London. Some mothers at St George's are able to opt for total midwifery care from booking clinic to post-discharge follow-up in a 'know your midwife' scheme. Over the next few weeks, the midwives involved, the researcher and some of the mothers describe what it is like to be part of the scheme. Here Caroline Flint, the scheme's prime mover, explains how the system works At St George's Hospital, Tooting, we are evolving a new breed of midwife, neither a community midwife nor a hospital midwife, but a midwife who is equally at home in both environments. I think that this is the midwife of the future; someone who uses the best of both environments for the comfort, happiness and safety of pregnant women. A woman who comes to the normal booking clinic at St George's has a medical and social history taken and she is examined by a doctor. A further appointment is made for her next consultation. After each booking clinic, I go through all the notes, discarding those where women are having shared care with their GP and those women who would obviously be classed as high risk. Then, one of the senior registrars and I agree whether these women are suitable for almost total midwife care, Our criteria are:
The notes of mothers designated as suitable for midwife care are stamped and then left for our research assistant who pins envelopes on them. Inside half the envelopes is a piece of paper which says ' know your midwife scheme' and in the other half is a piece of paper which says `control group.' The women who have been randomized into the know your midwife group then receive a letter from us which details the scheme. It tells them that if they want to come on the scheme they will be looked after by this group of four midwives throughout their pregnancy (except when they see their consultant obstetrician at 36 weeks). When they go into labour they will be looked after by one of the midwives, and after they have had their baby they will be visited by the midwives from the team. When they go home the midwives from the team will look after them there. They are sent a new appointment for the know your midwife antenatal clinic. This service is offered to 20 women a month. Most of them return our tear-off slip accepting the scheme. A few women do not want to be looked after by midwives only - they prefer more medical care - but the vast majority are eager to join us. (Actual numbers will be given when our research is published in a year's time.) Throughout her pregnancy the woman (and often her partner) will come for antenatal consultations with the four midwives. We hold clinics every afternoon and on Wednesday evenings until 9pm. On Friday afternoons we do not usually hold a clinic but do antenatal consultations in the women's houses. We discuss the woman's choices about when she will leave hospital after the baby is born, and what she should get ready for her homecoming. When the woman goes into labour she rings the hospital and asks the switchboard to bleep the know your midwife on call. Whoever is on call rings the woman back and discusses when she should come into hospital. If the woman sounds as if she is in very early labour, the midwife will sometimes go to her home to assess whether she is in established labour or not. Women find this immensely reassuring. (Discontinued, October 1984). If the midwife and the woman have decided that it is to early for her to go into hospital they keep in touch on the telephone. They usually arrange a time when they can meet at the hospital. The on-call scheme midwives are not necessarily in hospital; they have long-range bleeps which give them a great deal of freedom, and may be at home or out shopping. The scheme midwife tries to reach the hospital before the woman so that she can arrange a room and prepare the notes ready for the reception of the mother-to-be and her partner, or partners and friends. While the woman is in labour, her midwife is with her. The scheme midwives refer straight to the registrar on duty in the labour ward and, for most of their cases, work with just a medical or midwifery student. The student midwives who are in their free allocation period at the end of their training are also beginning to work with the team. Otherwise, the team looks out for any students who happen to be allocated to the labour ward. The women are usually happy to have a student with them as long as one of the midwives they know conducts the delivery. The scheme midwife conducts the delivery, or if the woman has a forceps delivery she assists with that. She then transfers the mother and baby to the postnatal ward when they are ready to go. During the woman's stay there, one of the team visits in the mornings, and the midwife on call (unless she is in the middle of a delivery) calls again in the evening. On discharge, the team visits the mother and baby daily if they live within the Wandsworth health district. They are visited daily until the tenth day, then about every four-seven days up to 28 days, as appropriate. As a midwife, working this way is delightful. It gives us great joy to be able to be with a group of women all the way through their pregnancy, labour and puerperium and experience is gained quickly and easily because of the continuity of care we are able to give. If a woman develops complications we can still go on caring for her because we are hospital-based, and she has a midwife with her anyway. Thus, we can scrub for her Caesarean section, attend her during her trial of labour, and top up her epidural. The system breaks down at times. In 15 months we have had four occasions when we have had more than one woman in the labour ward. We have then had to rely on labour ward staff to help us out. They are very willing to do this, because as they say: `They are all hospital patients and it's so nice to have an extra pair of hands when a scheme midwife comes in with a woman.' One of the staff midwives in the labour ward keeps a count of our statistics for us, and we have been touched by the welcoming attitude of most of the staff. In the postnatal ward we rely on the regular staff a great deal as we attend to our women in the mornings and evenings only. They have indeed been marvellous, treating us as a bonus. After the regular staff have been allocated a number of women for the day, they say that it is helpful when a scheme midwife comes in and offers: `Don't worry about Mrs ..., I'll look after her.' The research findings will be important for midwives every where because they will show whether it is safe to let midwives look after low- risk women almost entirely. The midwives we work with appreciate this and we have been overwhelmed by their support. It is not all hunky-dory of course. There are times when we are very tired- about every six weeks we work a very long span of duty. Midwives who have not experienced bearing the full responsibility for their practice before, sometimes find it can be very heavy.One of the loveliest aspects of working in a small team is the support we all gain from each other. A real bond of affection has grown up between us; we try and help each other out when someone is tired, or if someone's child has an event at school. We feel relaxed with each other and we are able to be open with each other without feeling threatened, knowing that the other person will understand. Weekly meetings are an essential part of the scheme. We hold them on Wednesday afternoons when we have a break of two hours in the antenatal clinic. The scheme midwives do one of two spans of duty. On early shift (E) the midwife comes on duty at 8.00am, nursing the postnatal women in the postnatal ward on the scheme. She then goes into the community to nurse women there, returning at lunchtime and for an antenatal clinic in the afternoon (for five or six women), except at weekends when she has a half day. On call (OC), the midwife is in call from 7.45 am one day until 7.45 am the following day. She comes into the hospital only for labouring women, except from 6.00pm - 9.00pm when she nurses the scheme women who are in the postnatal ward. On Wednesdays there is another span of duty from 1.00 - 9.00pm, when the midwife spends all that time in the antenatal clinic seeing scheme women, except from 4.00 - 6.(X)pm when she and the others are having a meeting. The midwives tot up their hours of duty each month. They should do 150 hours every 28 days. If they have done too many these are adjusted every few months and they have extra days off, of if they have done too few hours (rare) we just wait and they catch up. The present off-duty is shown in Fig 1. This scheme seems to give women the continuity they have been wanting so much for so long. For midwives, the scheme allows them to know their off-duty months in advance, and it gives them the joy of being able to look after women in a very satisfying way. At the moment, the rota can be demanding and it seems to me that in the future it will beneficial to have teams of six midwives who will be able to look after 300-350 women a year. Because the team is bigger there will have to be more effort in helping the women to meet all the midwives, and with this aim in mind, in the rota I have included tea parties and coffee mornings (Fig 2). I have also included times for antenatal classes given by the team. Like the previous rota for four midwives (which has only three lines), the specimen rota has only five lines even though it is for six midwives. This is because the six midwives will have 42 weeks' holiday between them and study periods, and the sixth midwife fits in there (she is marked as * on the rota).In this rota, on-call is from midnight to-midnight. The early shift is as before, there is late duty of 1.00-9.00pm and I envisage the midwives on this shift working in the postnatal ward or in the clinic when there is an evening session. We now have our evening clinics on Wednesdays and these would fit in on that day. If two teams were to work in this way and the rata was staggered so that when one team was on week 1, the other team was on week 2, the postnatal ward would be covered by a know your midwife all the time except for Friday and Saturday evenings and night duty. This would make the teams much more self-sufficient than at present; 12 midwives could look after 600-700 women a year plus the midwives needed to staff the postnatal ward at night and the part-time midwife working Friday and Saturday evenings. One of the most important parts of the scheme would still be the regular weekly meeting for all the midwives - a source of great comfort and strength.
Because we have been given freedom to develop, we have been able to respond to the needs of the women we serve and to our needs as midwives, as mothers and members of our families or social environments. The person who has given us the freedom to develop is the same person who has financed the scheme and who has found us office space and equipment, our director of midwifery services. The other people who deserve our thanks are the midwives, enrolled nurses and nursery nurses in the rest of the unit. We may see ourselves as the midwives of the future, but at the moment we are an anomaly which does not always fit in with the normal functioning of the unit. But, because of the generosity of our colleagues, the women are looked after to the best of everyone's ability, and a great many of them write to extol the scheme and to commiserate with their less fortunate sisters who have to have their babies `the ordinary way'. Reproduced with kind permission from Nursing Times, January 30 1985 |
|
