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What can midwives do if they disagree on professional grounds with a procedure they have been instructed to carry out? Caroline Flint advises them to do their homework, and to have all the evidence at their fingertips to back their argument I am conscious of anger everywhere. Many women are angry because they feel that their bodies are being taken over, that they have no say in how they will have their babies, where they will have their babies and when they will have their babies. The anger of women is ignored at our peril - they are the guardians of the future. On their perception of their children's births hinges much of their mental health and wellbeing and, through them, the mental health and well-being of the community. Their protests seem to be getting shriller. We cannot afford to ignore what the voices are saying. There is another anger which I am very conscious of at the moment. That is the anger of midwives. I have spoken at several meetings recently and midwives ask me how to cope with having to do things against their will, things which they see as detrimental to women. Many midwives are unconvinced that women should have their membranes ruptured routinely at any particular stage of labour or that routine electronic fetal monitoring actually benefits everybody. They feel confused and treacherous because they feel they are foisting treatments on women which are not helpful and may be downright harmful. Why are these midwives doing things they don't agree with? Why are they rupturing membranes when they think they should be left intact? Why are they putting fetal scalp electrodes on women who are gravida 3, and 7 cms dilated, in a perfectly normal labour? They are intelligent women. Have they suddenly taken leave of their senses? No, they say, `it's hospital policy'- as if that explained everything, as if that was the reason night follows day or that falling toast always lands on the buttered side. What has my reply been to those midwives who have taken me aside and voiced the same deep concerns when talking to me in private places? What about hospital policy? What if your hospital policy laid down that when a woman comes into this hospital in labour the first midwife to greet her must then jump on her head? Would you do it? You know that you wouldn't - you know that to have her head jumped on would be detrimental to the woman and very detrimental to your career. You would not comply with that instruction at all. What is the difference between this instruction, which is obviously ridiculous, and the other instruction which may well be just as ridiculous for the particular woman you are with at this moment? A professional person has responsibilities and loyalties. Those are (in order):
If, in her professional opinion, the midwife feels she is being asked to do something which is detrimental to the welfare of her client, then she not only has a duty to refuse to do it on behalf of her client, she also has a duty to refuse to do it on behalf of her profession. What if she feels that the pressure is coming from the third in line of responsibility - her employer? One profession cannot change the practice and modus operandi of another. I could not issue a decree from Nursing Times to architects to say that in future all their plans must be drawn in green ink on recycled paper, even though plans might be much easier to read when written in green ink. If obstetricians also issued this decree to architects, what would happen? Would they instantly take up their green pens as you and I are taking up our amnihooks? To decline to do what one has been instructed to do needs courage, but above all it needs knowledge. One needs to be able to quote, or even better to produce relevant research on the subject under discussion. You could say, for instance: `No I haven't ruptured her membranes. I'm very influenced by the work of Dunn' who listed the hazards of amniotomy as being, among other things, the loss of isometric uterine contractions (when the pressure is the same throughout) which protects uteroplacental circulation. In addition, Donald' describes the assistance of the bulging bag of membranes to the rotation of the fetal head when the baby is in a posterior position. Robson' has shown that a woman has a 74 per cent chance of feeling indifferent to her baby if her membranes have been artificially ruptured, while Inch (4) lists many more reasons for and against amniotomy'. Go to your manager and give her all the up-to-date information on amniotomy. She is as concerned about the future of our profession as you are. She is also as concerned about the health and welfare of women as you are. Go to women such as the local National Childbirth Trust and the local AIMS group. Keep in touch with women you have looked after in childbirth. With knowledge (and with supportive friends) hospital policy, which is irrelevant, can be changed or discounted. References 1. Dunn, P (1979). 'Problems associated with fetal monitoring during labour'. In; Perinatal Medicine. Sixth European Congress, Vienna. Stuttgart: Georg Thieme, . 2. Donald, 1. (1966). Practical Obstetric Problems. London: Lloyd-Luke. 3. Robson, K M. (1982). 'Mother-baby relation ship: I feel nothing'. Nursing Mirror, Vol. 154: pp.24-27. 4. Inch, S. (1982). Birthrights. London: Hutchinson. April 2, 1986
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