March 20, 2004

The need for midwifery guidelines

It is encouraging that midwives in Britain are starting to write their own midwifery guidelines for the provision of maternity care. What usually happens in a hospital is that a Committee is formed, mainly composed of obstetricians, with perhaps a few token midwives, to draw policies up for the management of labour and birth in the unit. In the past, these were often a formal documentation of the doctor’s personal practise habits and preferences rather than evidence based guidelines. The midwives were told they had to follow them religiously, often with the threat of being censured if they deviated from them in any way.

Hospital administrations also felt they were covering themselves legally if the unit had documented procedures for the management of labour and stated that if everyone “followed the rules” then the risk of legal action was reduced (perhaps even eliminated). Senior midwifery managers backed up t he doctors and kept their staff in line. Midwives joining the staff were quickly inculcated into the policies of the unit, which were very likely different to those encountered elsewhere.

The availability of the Cochrane Library, the explosion in obstetric and midwifery research, the rapid increase in litigation, and the legal ramifications of “informed consent” have all had a huge impact, and “policies” are now becoming “guidelines” rather than rigid rules for practice. The importance of basing guidelines on clear evidence has been recognised, even though there are huge areas yet to be formally investigated and truly informed consent is rarely obtained from women undergoing any aspect maternity care.

Many of the policies are still being drawn up by the doctors in the expectation that midwives will follow them closely. Apart from being completely inappropriate for one professional group to be dictating the practises of another, few doctors will ever follow the hospital’s policies, even if they have been instrumental in drawing them up. Obstetricians have traditionally “done their own thing” and many birth suites maintain a book where specific practise habits of the various consultants are recorded, to avoid having to disturb them frequently about care plans. Thus one doctor may leave blanket instructions that “all of his women” are to have their membranes ruptured routinely at a certain point, or that they can be given a specified dose of pethidine if required without further consultation. It is a handy system, especially in the private hospitals (where doctors must be consulted about every aspect of the woman’s labour management), and it saves disturbing the doctor at inconvenient times.

It is high time that midwives stopped colluding with this charade of “informed choice” and took steps to individualise care to specific women’s needs. Midwives work differently from doctors, and this must be reflected in the guidelines that they follow. Where clear evidence exists is can be used to under pin these guidelines, where it does not a degree of flexibility should be acknowledged in their wording.

When I was in Norwich I was told about the new midwifery guidelines that the midwives were developing. It was exciting to hear of this development and to see midwives taking positive action to clarify their professional status and skills. It is time that all midwives began this process of exploring and writing up appropriate guidelines for their units - there is a lot of evidence available and the exercise of working on this important issue as a collective would be a useful step in encouraging co-operative teamwork within the unit.

Posted by andrea at March 20, 2004 12:53 AM

Comments

Hi Andrea I find it an endless frustration that it would seem women in the UK cannot give birth without a guideline. While I fully endorse evidence based practice and have myself been involved in developing midwifery guidelines I become frustrated with a system that still pays lip service to informed choice and individualised care. When are we going to acknowledge the uniqueness of a womans journey through pregnancy and birth and trust her to birth her baby when the time is right for both of them. It is her rite of paasage to motherhood and I feel passionately that as midwives our role is to enable women to develop the tools and skills necessary to be actively involved in the decisions they make about their birth jouney. While midwifery guidelines are an important step to providing women centred care we must critically appraise the evidence they are based on
and remember as you suggest a guide is all they are. Being with women remains at the heart of midwifery practice and guidelines need to acknowledge the individuality of each womens birth experience.

Posted by: Jill Hutchings on April 1, 2004 09:33 PM