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Recent events in the Isle of Wight suggest that midwives are being hampered in their role as practitioners and their right to use their clinical judgement. Caroline Flint argues that midwives are clinicians and that unless they are practising dangerously they must not be beholden to uniform directives from obstetricians The row in the Isle of Wight over the right of midwives to use their professional judgement', is not over. It is, however, heartening to read that the senior midwife involved has the support of her colleagues, as letters to this week's correspondence columns show. I'm so glad to hear that if they were not in agreement with unit policy these midwives would feel free to discuss their views with their nursing officer/ supervisor of midwives and obstetricians and that they feel confident their views would be given every consideration. It is the right of all employees throughout the land to have their views heard by their employer in relation to their work and conditions of service and to expect those views to be given every consideration. But these midwives appear to have missed the point of what this rumpus is all about - unlike the 29 people who have written to Mary Cronk to pledge their support and to tell her of yet more awful examples. They have recognized that this is about a practitioner's right to practise. A midwife is a practitioner, wherever she works. This is underlined in the World Health Organization's definition of a midwife: `A midwife ... must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postnatal period, to conduct deliveries on her own responsibility and to care for the newborn and the infant' (my italics). The status of a practitioner is different from any other employee in that a practitioner practises and uses her clinical judgement. What is happening throughout the country is that `unit policies' are being drawn up with defined clinical actions, and midwives are being expected to follow them unquestioningly. If they are employed as obstetric nurses with responsibility to the obstetricians, they can follow the policies quite happily. But if they are employed as midwives this is impossible for them to do; as midwives their responsibility is to provide the best care possible to that particular mother and baby. And this cannot be carried out with uniform policies because no woman is the same as any other woman, and, equally, no labour and no baby are the same as any other. So it needs clinical judgement on the part of the midwife to ensure that this mother and baby receive the best, the safest and the most supportive care appropriate to their needs; it cannot be pre-determined. This is not to say that guidelines cannot be written; for instance `Mr Rogers recommends that all his patients should be accelerated with Syntocinon if their cervix does not dilate at the rate of one centimeter an hour once labour is established' a guideline based on O'Driscoll and Meagher2; or `The supervisor of midwives suggests that all women who wish to breast-feed should be encouraged to put the baby to the breast within an hour of delivery and frequently (at least every two hours) for the first 24 hours following delivery)' as Salariya et al. (3) suggest; or `Miss Jones recommends the artificial rupture of membranes when the cervix of any of her patients reaches four-five centimeters in order to assess fetal condition' as quoted by O'Driscoll and Meagher (2). These recommendations and suggestions may be relevant for this particular woman. But then again, they may not. For example, the midwife has a woman in labour who is a patient of Miss Jones. The woman's labour is progressing well, the baby's heartbeat is strong and firm and regular and the midwife decides in this instance that artificial rupture of the membranes is inappropriate. When questioned she refers to Dunn on the hazards and disadvantages of amniotomy and the increase in perinatal mortality following its use, quoted in the Proceedings of the Sixth European Congress on Perinatal Medicine in Vienna and the World Health Organization' recommendation that ,artificial early rupture of membranes, as a routine process, is not justifiable". In her clinical judgement at this time artificial rupture of membranes is not appropriate for this woman. In retrospect she may regret this decision; there may be some reason why she wished she had ruptured the membranes earlier, but this is irrelevant. To quote O'Driscoll (2): `Medicine in real life does not include the luxury of wisdom after the event'. It is the duty of the midwife to do at the time, what she considers best in her clinical judgement. And because of this she cannot follow a prescribed route. This is the
reason that no midwife can be told: `always give Syntometrine' or `always
rupture membranes' or `always use electronic fetal monitoring'. The safety of the women in a midwife's care is safeguarded by the role of the supervisor of midwives. If the midwife is practising dangerously or not in accordance with the Midwives' Rules, the supervisor of midwives may then - and only then - intervene to check her practice. She cannot intervene merely because, in the exercise of her own clinical judgement, she would have done something differently. References 1. `Midwife wins clinical judgement battle' (News). Nursing Times. (1987). 83: 5,8. 2. O'Driscoll, K., Meagher, D. (1980). Active Management of Labour. London: W. B. Saunders Co. 3. Salariya, E.M., Easton, P.M., Cater, J.1. (1978). `Duration of breast feeding after early initiation and frequent feeding.' The Lancet ; 2: 8100, pp.] 141-3. 4. Dunn, PM. In: George Thieme (1979). Proceedings of the Sixth European Congress on Perinatal Medicine, Vienna, 1978. Stuttgart. 5. World Health Organization. (1985). Appropriate Technology for Birth. Geneva: WHO. March 4, 1987. |
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