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JOURNAL Being a delivery suite co-ordinator Informed consent and midwifery practice in New Zealand: lessons from the Health and Disability Commissioner A review of psychosocial predictors of outcome in labour and childbirth The vaginal examination during labour: Is it of benefit or harm? j o u r n a l 42 May 2010
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Editor
Contents
Journal 42 • May 2010
Joan Skinner
Reviewers
Jacqui Anderson Maggie Banks
6
Cheryl Benn Sue Bree
Norma Campbell Judith McAra-Couper Editorial The place of research in the quality and
Rea Daellenbach Rhondda Davies safety of midwifery care
Deborah Davis Jeanie Douche
Margie Duff Kathleen Fahy (Aust.)
Skinner, J.
Maralyn Foureur (Aus.) Lynne Giddings
Andrea Gilkison Karen Guilliland
Jackie Gunn Marion Hunter
7
Karen Lane Debbie MacGregor
Ruth Martis Robyn Maude
New Zealand Being a delivery suite co-ordinator.
Marion McLauchlan Jane Koziol-Mclean Research
Suzanne Miller Lesley Page (U. K.) Fergusson, L., Smythe, L., McAra-Couper, J.
Sally Pairman Jean Patterson
Elizabeth Smythe Alison Stewart
Mina Timutimu Sally Tracy (Australia)
Nimisha Waller
12
Philosophy of the Journal PRACTICE Informed consent and midwifery practice
Promote women’s health issues as they relate to ISSUE in New Zealand: lessons from the Health
childbearing women and their families.
Promote the view of childbirth as a normal and Disability Commissioner.
life event for the majority of women, and the
midwifery profession’s role in effecting this. Godbold, R.
Provoke discussion of midwifery issues. Support
the development and dissemination of New
Zealand and international midwifery research.
Submissions:
17
All submissions should be submitted electronically PRACTICE A review of psychosocial predictors of outcome
via email to joan.skinner@vuw.ac.nz For queries ISSUE in labour and childbirth.
regarding submission please contact:
Lesley Dixon Howarth, A., Swain, N., Treharne, G.
PO Box 21 106
Christchurch 8143
Fax 03 377 5662 or Telephone 03 377 2732
practice@nzcom.org.nz
21
PRACTICE The vaginal examination during labour: Is it of
Subscriptions and enquiries:
Subscriptions, NZCOM,
ISSUE benefit or harm?
PO Box 21-106, Edgeware,
Christchurch 8143 Dixon, L., Foureur, M.
Advertising:
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MS Media Ltd
Freephone 0800 001 464
Fax: 0800 001 444
Email mfisher@msmedia.co.nz
PO Box 33057, Barrington, Christchurch 8244
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The New Zealand College of Midwives Journal
is the official publication of the New Zealand
College of Midwives. Single copies are $7.00
ISSN.00114-7870
Koru photograph by Ted Scott.
Views and opinions expressed in this Journal are
not necessarily those of the New Zealand College
of Midwives.
EDITORIAL
The place of research in the quality
and safety of midwifery care
see the growth and dissemination of New demanding role of the delivery suite
Joan Skinner Zealand midwifery knowledge, reflecting a coordinator and how this role is experienced.
real growth in this particular tool for quality. We also have a practice reflection on the
place of the vaginal examination in labour
It is an interesting time for midwives in New The growth of the Journal has also which looks at the careful balancing act
Zealand at the moment (isn’t it always?) as necessitated bringing on some more support we as midwives must undertake as we
the Ministry of Health begins to develop and and I am pleased to be able to tell you that assess both the benefits and harms of this
implement a Quality and Safety Programme we have now appointed three new sub- procedure. We have two articles by non-
for Maternity Services. Many of us have editors. Ruth Martis, a midwifery lecturer midwives in this edition. Both have a real
recently attended the regional workshops that with Christchurch Polytechnic, Andrea interest in aspects of maternity care. One
the Ministry held throughout New Zealand Gilkison midwifery lecturer Auckland looks at how we as midwives might grow
and were able to provide input into what we University of Technology (AUT) and Jackie our understanding of how we manage
value and what we are hoping for. It is always Gunn midwifery lecturer and head of school informed consent, a challenging topic. The
great to be keeping an eye out on how we are (AUT) have kindly agreed to come on to article examines reports of the Health and
doing- not only to improve the outcome for the Journal team as sub-editors. I welcome Disability Commissioner and helps us learn
the women and the families for whom we care them with open arms and thank them for about what is expected. We also have a
but also to identify what we are doing well, their commitment. Apart from easing my review, from a psychologist perspective of
so we can support and promote this. There sometimes daunting work load this will also the psychosocial factors that are important
are lots of ways to do this and the quality mean that we can focus on really being able during the childbirth experience. It is
and safety programme will hopefully support to support more of you to get into print to great to see such articles submitted to the
what we are doing well and improve and share your research findings and practice journal. As midwives we have a unique
integrate the process so we can both be seen reflections. So do feel free to send me your characteristic in that we place a high value
to be providing high quality care and to be submissions knowing that we will endeavour on the importance of accessing and assessing
working on improving it. Another important to get your work ‘out there’. I would also
knowledge from many different perspectives.
way we work towards improving the quality like to welcome and acknowledge the work of
Along with the knowledge we generate
and safety of care is to undertake research Rhondda Davies who has made the kind offer
from our own research and reflections, we
and to reflect on how we are practising and of proof reading the Journal before it goes to
also value the knowledge we acquire from
to share the results of this. The Journal plays print. This is always a real challenge so it will
our own experiences and from those of the
an important role in our ability to share our be great to have a keen set of eyes to pick up
women for whom we care. But we also
thoughts and findings and thus is a key tool what needs fixing. Thanks to you all.
source knowledge from other disciplines
in our ‘quality and safety’ toolbox. I have
such as social science, neuropsychology,
been noticing lately how often articles from In this edition of the Journal we have four
epidemiology, bioethics, even architecture,
this journal have been cited by others writing papers. The first is a piece of midwifery
to name just a few. We value and make good
here. It is very gratifying and exciting to research that looks at the complex and
use of knowledge diversity. We are in a sense,
knowledge synthesisers, able to source and
make use of different ways of knowing and
Erratum understanding. It’s great that we are able to
acknowledge this role in the Journal, growing
We would like to apologise for typographical New Zealand College of Midwives Journal 41
our understandings of what is important as
errors made during publication of the paper: 20-26. In the paper Figure 2 was incorrectly
we seek to support and extend the quality and
Midwives care during the Third Stage of formated and caused errors in the text related
safety of the care we provide.
Labour: an analysis of the New Zealand to this figure. These errors have been corrected
College of Midwives Midwifery Database and an updated version of this paper has been
2004-2008 by Dixon, L., Fletcher, L., Tracy, placed on the NZCOM website in the Journal
S., Guilliland, K., Pairman, S., and Hendry, C. publications. Cinahl has also been supplied
published in the October (2009) edition of the with a corrected version.
6 New Zealand College of Midwives • Journal 42 • May 2010
NEW ZEALAND RESEARCH
Being a delivery suite
co-ordinator
INTRODUCTION the happenings during her shift so she can
Authors: anticipate and forward plan (Draycott, Winter,
The tertiary hospital delivery suite coordinator Croft & Barnfield, 2006).
• Lindsay Fergusson MHSc (Hons), RM, RN,
is not only an expert midwife she is also a
ADN. Midwife/Nurse Educator, Waikato
leader, a broker, a mediator and a peacemaker. BACKGROUND
Hospital, Hamilton.
E mail: wade.lindsay@slingshot.co.nz
Her workplace is one of the focal points within
maternity units where midwives, obstetricians, There are daily pressures on hospital midwives
• Liz Smythe PhD RM RGON and other staff come together as a team to whose work situations are influenced by the
Associate Professor provide the best care available to mothers current worldwide shortage of midwives.
Auckland University of Technology and babies. It is in this workplace that the At the time this study was conducted New
coordinator midwife acts as the ‘pivot’ or the
Zealand statistics revealed a national midwifery
• Judith McAra-Couper PhD RM RGON ‘hub’ for everyone and everything that happens
workforce shortage and an increasing national
Auckland University of Technology ‘on her watch’. The coordinator offers constancy
birth rate (Department of Labour, 2006;
during the shift, utilising her skills to influence
Ministry of Health, 2006; 2008a; 2008b).
the smooth and safe running of the unit whilst
The majority of women give birth normally.
she is in charge.
However the increasing medical, technological
Abstract
and pharmaceutical advances in reproductive
This paper offers 'a voice' to these experienced
This phenomenological study was conducted health impact on the provision of midwifery
midwives through the research findings
to reveal five midwives’ experiences of working care in tertiary hospital settings. Midwives
of a study that explored the meaning of
as coordinator/charge midwives in three are caring for women requiring increasingly
the experiences of hospital delivery suite
tertiary hospital delivery suite settings. The complex care with a small but increasing
midwives who work in charge of their shifts.
findings reveal the unspoken, taken-for-granted minority of women becoming critically ill
Five coordinator midwives from three North
personal experiences of the coordinators. They (Billington & Stevenson, 2007). Skinner (2005)
Island tertiary hospital delivery suites were
describe themselves as the ‘hub’ or the ‘pivot’ writes that “the midwife becomes a mediator
interviewed. The title of ‘charge midwife’ is
at their workplace. These midwives ‘know’ the between the woman’s risk framework, her
used in some hospitals. However to protect
unpredictability of childbirth and the challenge cultural position and that of the dominant value
anonymity the term ‘coordinator' has been
of managing escalating workloads. Their ability system, the technological approach” and goes on
used throughout this study.
to facilitate teamwork and their resilience in to observe “the authoritative knowledge stands
the face at times of seemingly insurmountable Readers are introduced to coordinators with obstetrics” ( p.273). The coordinator
obstacles shine through. descriptions of what it feels like being in their midwives in this study revealed their ability
leadership roles. One particular story will offer to mediate between lifeworlds and strived to
However much managers plan staffing and bed the reader specific insight into the challenges maintain a midwifery focus in their daily work
ratios, the nature of childbirth – and therefore and complexities of the role. While it may as they worked with colleagues. The challenges
the intensity of the workload - is unpredictable. appear a startling story of busyness, there were of increasing birth numbers and increasing
Recommendations from this study include other such stories within the study. Yet still the complexity in a tertiary hospital setting, without
consideration of strategic planning by District midwife coordinators were passionate about the necessarily an increase in staff numbers, impact
Health Board's (DHB’s) for when the acute role they played and committed to doing their on the role of coordinating a delivery suite and
clinical needs of women in a delivery suite very best to ensure safe practice. create hidden emotional work for coordinators.
outweigh the ratio of midwives available to
The coordinator is a leader. She is always Midwifery is a caring profession. The
provide care for women. The coordinator
‘on the floor’; forever present and accessible partnership philosophy of care, that of
midwife needs to be free to utilise her clinical
to everyone. She experiences the daily being ‘with women’ lies at the heart of the
skills ‘on the floor’ whilst a designated resource
unpredictability of childbirth as she encounters professional standards for practice for New
person arranges additional staffing cover for the
the “unknowness of the darkness” (Smythe, Zealand midwives (Guilliland & Pairman,
unit.
2000, p19) of childbirth whilst working both 1994; New Zealand College of Midwives Inc,
‘with time’ and ‘against time’ as events unfold, 2005). Hunter (2004) identifies the difficulties
sometimes at breathtaking speed. She reveals her for some hospital midwives who adopt a ‘with
‘need to know’ what is happening when she is woman’ style of practice which can result
KEY WORDS:
in charge and how she gains that information in an emotional struggle for the midwife.
Midwives, coordinators, clinical skills, teamwork in order to achieve a ‘helicopter view’ of Skinner (2005) questions whether hospital
New Zealand College of Midwives • Journal 42 • May 2010 7midwives become focused on “the demands of Midwifery practice encapsulates “skilled They were encouraged to tell stories of their
the institution”, rather than on the woman knowledge” and “emotional intelligence” everyday experiences. Interviews were initially
(p.261). Similarly, Hunter (2005) describes (Byrom & Downe, 2008, p.4). The hospital transcribed then crafted into stories. The original
the reality for midwives in her study who delivery suite is an environment where emotions transcriptions and stories were returned to
worked in a way that ensured the needs of the run high and as Davies (2007) poignantly participants which gave them the opportunity to
institution were met by deployment of workers writes “you bear witness not only to the baby’s change or delete data. One participant deleted
and resources, in order to facilitate the efficient emergence but to the emergence of the mother, portions of stories which she felt could identify
“passage of women and babies through the father and family” (p.45). Amidst all the her. All data returned were brought together and
maternity care system” (p.257). Organisational challenges of working as a coordinator midwife themes were revealed by delving deeply into the
constraints which impinge on midwifery is the huge significance of the experience of stories through a process of writing and re writing
work are reinforced by Walsh (2007) who birth for each family on her shift. and “moving dialectically between the part and
identifies factors including the pressures of the whole” (Koch, 1996, p.176). This process is
time, institutional constraints, regulations termed "phenomenological reduction" (Caelli,
and bureaucratic power differentials both
RESEARCH DESIGN 2001, p.276).
between professional groups, and also between The findings reported in this article are
professionals and women within the hospital from a study which used an interpretive Ethical approval for this study was granted
system. The coordinator midwife thus phenomenological, hermeneutic approach by Auckland University of Technology Ethics
holds the tension of preserving a midwifery guided by van Manen (1990). Van Manen Committee in February 2008
philosophy of care amidst a system that writes that phenomenology “attempts to
demands efficiency. explicate the meanings as we live them in our
everyday existence, our lifeworld” (1990, p.11).
FINDINGS
Within this work environment where there is Phenomenology does not seek to generalise Insights from this study are presented firstly as a
uncertainty and risk, positive relationships and meanings, rather it reveals the life experiences series of similes that participants used to capture
effective communication are vital. Hierarchical of those interviewed and seeks to articulate the the nature of the role, and then through a story
issues exist in the delivery suite setting and
“any particular decision may be the subject of
dispute, negotiation and occasionally pulling
of rank” (Lankshear, Ettorre & Mason, 2005, WITHIN THIS WORK ENVIRONMENT
p.374). Isa et al., (2002) offer an example of
the responsibility and confidence required when WHERE THERE IS UNCERTAINTY AND RISK,
a midwife challenges a consultant’s decision.
They explain that “it takes one with a strong A POSITIVE RELATIONSIP AND EFFECTIVE
sense of confidence in her own practice and
decision making ability, and to be absolutely COMMUNICATION ARE VITAL
within boundaries of safety. It would take only
one mistake to undo years of gain and we are
always very aware of that, consequently we nature of ‘how it is’ to be. Van Manen charges that reveals the busyness that can arise within
must be certain of our decision making” (p.26). the researcher to choose a study which requires the birthing environment.
As a result, a midwife with less experience and commitment and interest and this means
confidence is less likely to voice her opinion the researcher inevitably holds pre conceived
(Timmins & McCabe, 2004). The issues of ideas about the phenomenon. In keeping
‘Being’ a coordinator
communication that surround decision making
with his methodology the primary researcher
midwife is like:
during her shift are a daily challenge for the
initially had a tape recorded interview with her For the participants in the study being a
coordinator midwife.
supervisors, which was transcribed. The primary coordinator midwife is an experience of
researcher then analyzed and interpreted her complexity in a context that is ever changing.
Management of emergency situations is a
beliefs in order to address and be mindful New admissions can arrive at any time.
regular part of a hospital midwife’s professional
working life. Thompson (2003) describes the of her assumptions before she commenced Emergencies, threatening the life of mother
negative impact of emergency situations when participant interviews. Throughout the study, a and baby, happen. There is often not enough
“caregivers spend the majority of their focus reflective journal was maintained by the primary staff to meet the demands. It is this uncertain,
on the people directly involved and impacted researcher to stay focused and true to the potentially chaotic set of circumstances that the
by the incident and fail to pay attention to methodology. coordinator is challenged with while managing
their own needs” (p.1). There is literature her shift. The coordinators described in a variety
which describes support available for midwives Participants from three North Island tertiary of ways what the experience is like:
(E.A.P., 2009; Smythe & Young, 2008; Weil, hospital delivery suites were recruited using
2008). However, Deery (2005) writes there purposive sampling. As phenomenology requires
detailed descriptions from a small number of Being ‘the Hub’
is minimal research which addresses how to
alleviate the burnout and stress which exists participants, five coordinators who offered a Being the coordinator feels as though I am the
within the midwifery profession. Coordinator large volume of experiences were interviewed hub and I am in the centre of a circle with
midwives require resilience to stay working in once, with the interviews ranging from 60-90 the multidisciplinary team who surround me
such an environment. minutes. Each was assigned a pseudonym. each doing their jobs.
8 New Zealand College of Midwives • Journal 42 • May 2010By coordinating I am giving directions and how Alice reacts to this persistent pecking and a sense evoked that babies have just ‘fallen out’
receiving directions. Directions travel in sustains herself that reveals her leadership skills as with ease in her workplace where women often
and out of the circle. I am at the interface a coordinator. require intervention and assistance for birthing.
when directions come into the circle and as a
coordinator I send directions out. It is a constant Jane offers a story when she has time to sit and
‘Solving the puzzle’
in out interplay of communication with discuss forward planning with a registrar and
colleagues about a variety of topics ranging from Sally uses a different analogy for describing anaesthetist about the care of a woman with
clear instructions to practice directives to positive her work: complications with the 'luxury of time to discuss
reinforcement. The coordinator is constantly in things' and reflects:
I like coordinating because I enjoy being in
the middle of everything that is going on (Irene).
control and seeing all the mess come together.
It was good because we had a three way
As the coordinator, Irene is pivotal to the smooth I enjoy having a great big puzzle that I
discussion about how it was going to be safest
and safe running of the delivery suite during can fix and bringing everything together
for the woman. It was nice to have the time
her shift. There is a sense of fluidity in her work at the end of a shift, then knowing it all
to know that the three of us, each with a
and of weaving threads together to make things came together really well. Where I work, the
different focus could sit down and talk about
whole. Effective communication skills are the difficulty is the staffing shortages and when
what could be the best outcome.
the puzzle just doesn’t fit together.
basis of her management style. Her ability to
listen and respond appropriately shines through The unhurriedness of the shift gave Jane the
Sally enjoys being in charge, being “in control”
in her descriptions of working with colleagues. gift of time to focus on collaborative planning;
and being a decision maker. This is not ‘just’ a
She gives and she receives with no sense of a this was a luxury rather than the norm for her
puzzle; rather it is “a great big puzzle”. Fixing a
power play conveyed in her interview. and something to be valued. Like Alice, her
puzzle takes resoluteness, patience, determination
‘good day’ is also when there is no sense of
and persistency. It is only at the end of her shift
‘Being the pivot’ time constraint, with time ‘flowing’ rather than
that she is able to reflect and feel the satisfaction
‘racing’, where midwives and colleagues have
Alice speaks about ‘being the pivot’: of fixing the puzzle, in the knowledge her
time for each other, where there is nurturing,
achievements directly relate to safe practice for
caring, teamwork and fluidity in the day and an
You try to make the system work and I think staff and safe delivery of care for clients. These
absence of undue tension.
you are a very pivotal person in that respect. puzzles are not easy and sometimes the pieces
I was saying the other day “what do I really are not all there; she does not complain, rather
like about my job?” because I do nothing but she reflects on the ‘difficulty’ she faces when the In the Eye of the Storm
moan about it. I like being a pivotal person puzzle does not fit. Something that is difficult to Coordinators know they are working in a high
that things happen around; I get a buzz out fix is not necessarily impossible and that is her risk environment with the unexpected often
of that I suppose. enjoyment factor. revealing itself with no warning. Storms are
unavoidable parts of life experiences to which
There is almost a sense of love/hate feelings we each react differently. Irene remarks:
Experiencing ‘the plop, plop, plop
for her job such are the swings of emotions
of a good day’
for Alice. She identifies her work as ‘people It makes me think about a movie I once saw
management’ in what is often a stressful Within the phenomenon of lived space for
about a storm. Part of me always remains
environment. At the same time, she is the coordinators, Alice describes how it feels on a
in the centre of the storm even though there
professional who is central to everything good day:
may be times when I am weaving in and
happening in the delivery suite, which is out of the storm with everybody around me
A good day is when you’ve come away feeling
exhilarating and stimulating for her. moving too.
good. When there have been lots of deliveries,
they’ve all been normal, there’s been lots of
‘Feeling the peck, peck, peck’ midwife led deliveries around the place and Irene’s analogy fits well as she describes partly
it’s all just been straight forward, plop, plop, being centred in ‘the storm’ but in reality, never
Alice continues:
plop and the midwives are all happy because still as she multi tasks and moves in time to the
There’s the phone, and then people at you they’ve had nice midwifery care. It’s not been rhythm of the happenings of the unit and the
the entire time, peck, peck, peck of being the too busy so everyone’s had a chance to sit colleagues she works with. Smythe and Norton
pivot. Some days it’s fine but when you’re in the coffee room and have a laugh and a (2007) write “thinking leaders live a back-and-
busy it becomes hard to deal with and gets cup of tea which is important. When things forthing, drawn to lead and pulled back to
frustrating especially when it’s not necessary. have flowed, there have been lots of normal follow, to being with and then to being alone,
deliveries and nothing bad has happened or prompted to act and cautioned to wait” (p.76).
How Alice reacts to people and situations is if it has, if there has been an emergency, it’s Irene has no control over what ‘is’ or what ‘may
critical to the smooth running of the shift and been dealt with well; that’s a good day. be’, rather she is a player in life’s events as they
ultimately reflects on safe care for mothers and unfold in her workplace.
babies. Her description of being ‘pecked’ is Everybody needs good days. In tertiary delivery
effective and conjures up an unpleasant sense of suites every day is unpredictable. Irene spoke
A PARTICULAR SHIFT
being worn down by the persistency of people, about the need to look at the positives and here,
each with their own agenda. However there is Alice describes the positives that help to make All of the experiences described above come
also a sense that this is an integral part of her her and her staff feel good. Her description of together as parts of the whole in Jane’s story.
role and something she has to manage. It is good days is when there is normal birthing with Her story was chosen because it reveals her
New Zealand College of Midwives • Journal 42 • May 2010 9level of multi tasking, her skill base and the she arrived, so I cared for her because the The LMC has the right to hand over care just
‘knowing’ she utilised to manage the challenges LMC hadn’t arrived. as her client has the right to an epidural but
that confronted her that shift. Midwives know neither are realities on this shift. Jane knows
the unpredictability of childbirth. Just as they Amongst this I was worried about my this and has to manage this reality the best way
experience quiet shifts, so they experience placenta praevia client who was bleeding. I she can in trying circumstances. Jane knows the
relentlessly unexpectedly busy shifts which hadn’t checked on her or the baby’s wellbeing consequences of torrential haemorrhage with a
stretch them to their limits. This is the nature because I was busy with the lady who was placenta praevia and reveals her team approach
of tertiary hospital childbirth. This is a dramatic trying to push her baby out. None of the other to forward planning the ‘what if’s’. She knows
story, a day remembered because it was so three midwives had had a break all night she has no option but to care for the woman who
busy and so taxing, similar to those described because I had my own patient load and I has arrived on delivery suite in the second stage
by other participants. It is included not to couldn’t relieve them. They were entitled to of labour and is actively pushing. She knows she
argue “this is how it always is” but rather as breaks but didn’t get them. should be checking on her own client but staffing
a reminder that this is how it can be. It is shortages make this impossible. She knows no
By 6.30 am everything fell apart. The registrar
offered to encourage thinking as to the kind of one has had breaks all night which impacts on
had completed the caesar, the LMC’s client
strategies that could be put in place to address safe practice but there is nothing she can do about
who had been pushing needed assistance and
such situations: this. The pace remains frenetic. It is her knowledge
I agreed so the registrar went in there and
ventoused that baby. Unfortunately there was base, based on her experience as a coordinator,
On Sunday it was a twelve hour night shift,
no paediatric support for an instrumental which helps her anticipate potential problems. She
staff sickness on the antenatal floor, post
natal was busy, and delivery suite staff had delivery so that was me again. Fortunately I is ready to resuscitate the baby who has birthed
sickness. There were two off sick, so it’s the had asked the anaesthetist to stay around. Just by ventouse, she recognises the need for assistance
situation of how many inpatients have they as well because the baby came out rather flat from the newborn unit and she responds to the
got in the ward and who I can pinch to and took a couple of minutes to pick up, so we postpartum haemorrhage situation by transferring
cover. I had four midwives plus a registered got the newborn unit down to assist. Just as I the woman to theatre at speed.
nurse on delivery suite which was a luxury. had the nurse practitioner from the newborn
Jane is working in the midst of great complexity.
But, we ended up with all admissions being unit and the anaesthetist helping me with
She knows her limitations and reveals her fears
previous caesars (sic) with their midwives not that baby, the LMC had arrived for her client
of the ‘what ifs’ of her job. She has no control
accompanying them. who was fully dilated and pushing by that
over the unexpected; all she can do is respond
stage. She double belled from her room so I left
I ended up coordinating, three midwives and utilise her knowledge to make the situation
the anaesthetist and NNP [Neonatal Nurse
‘specialing’ women in labour, one on synto as safe as possible under the circumstances.
Practitioner] with the baby, and jumped into
(sic), one with an epidural and one with Heidegger (1927/1962) writes of thrownness,
that room. The woman had quite a major tear,
synto and an epidural, and I cared for a where one is thrown into a world where one
so she was rushed straight down to theatre.
twenty nine weeker with placenta praevia. must respond, with all the understanding of
Then the day staff arrived and said “We’re
how the situation could get even worse, and all
So I had a patient load as well as ready for a handover, do you think you could
the anticipation of possibilities still unrevealed.
coordinating and ensuring safe staffing for come?” “Yeah, sure I’ll find time”.
One struggles to manage the unknown,
the night for the block. Once it was sorted especially when there are no extra resources to
When I have enough staff to cope with
out you start thinking ‘I hope nothing comes employ. When one is stretched beyond capacity
everything I enjoy coordinating. The times
in overnight because I don’t have anybody
I don’t enjoy it is when you know there is one deals with what ‘is’, responding to the most
else to give’. Then of course an LMC [Lead
absolutely nothing, nothing, nothing left and if urgent, yet always knowing an unsafe situation
Maternity Carer] wanted to hand over at
one more thing comes through the door it would may be unfolding with no one there to see.
around 4am for an epidural for her client. I
didn’t have anyone and had to say “you are tip you over the edge. I just hate those times
Coordinator midwives are all too familiar with
going to have to explore other choices for your because I’m really frightened that something
the unsafe situations they and their colleagues
client because an epidural is not a choice”. awful is going to happen because there is no one,
can find themselves in. It is nobody’s fault.
absolutely no one to care for the woman.
Nobody could have predicted such a busy shift
Then my client started to bleed, with the
Jane’s story reveals the busyness and the with so many at risk situations. Everybody
complete praevia at 29 weeks. Is she going to
complexities of coordinating on delivery suite. does their very best, often under stress and
come unstuck, bleed and then deliver? Where is
the best place for her to be delivered? So I am Her decision making and her prioritisation is exhaustion. On most occasions enough safety
working through these scenarios with the registrar based on her knowledge and experience. Her is maintained to get through, but the fear
and anaesthetist as to what is safe for the woman. first task when she starts her shift is to know the remains. Yet, there is always the potential that
staffing situation of the entire unit and the skill the coordinator finds herself in a situation
By 6am just when we thought we had got mix. Despite the busyness of the unit she has the stretched beyond what she knows is safe care.
through the night quite well one woman added challenge of having to provide midwifery Such is the nature of the work.
had to go for a Caesar(sic) which was okay care for a woman in a high risk situation.
because she already had a midwife and our The midwives in this study were all very aware
RN[Registered Nurse] would scrub. But Jane’s decision making reveals her ‘knowing’ of the huge responsibility they carried, and their
at the same time, the woman who couldn’t that there is huge uncertainty with women in commitment to the birthing women. Irene sums
have the epidural started pushing and labour and that she always needs to be prepared up her sense of ‘being’ a coordinator midwife
continued for quite some time. An LMC to manage the unexpected. She knows what where despite the busyness of the delivery suite
rang to say she had a lady coming in who might happen, she will never know everything environment, her focus remains on the woman
was going quite fast. The woman was fully that could happen, however Jane reveals in her 'who has to carry the canvas of her experiences'.
dilated and pushing on the doorstep when story that she is continually thinking ahead. She sums up her pivotal role when she remarks:
10 New Zealand College of Midwives • Journal 42 • May 2010I am not 'just' a midwife. I am a midwife technology work environment, increasing Caelli, K. (2001). Engaging with phenomenology: Is it
more of a challenge than it needs to be? Qualitative Health
and that is my expertise.......my midwifery is complexity of provision of care required by Research, 11(2), 273-281.
inside me and if I don't bring it out it will be women with co- morbidities, staffing shortages,
Davies, L. (2007). The art and soul of midwifery. Edinburgh:
invisible; I practise by example. skill mix challenges, managing 'what is' and the Churchill Livingstone.
unpredictability of ‘what may be’.
Being a midwife is about supporting women Deery, R. (2005). An action-research study exploring
midwives’ support needs and the effect of clinical
and families to have safe, empowering birthing It is the unpredictable nature of the delivery supervision. Midwifery, 21, 161-176.
experiences. However frenetically busy or suite workload that presents challenge. Even the
Department of Labour. (2006). Midwife: Occupational Skill
luxuriously quiet the delivery suite may be, the most competent practitioners cannot maintain Shortage Assessment. Wellington: New Zealand.
strength of these coordinator midwives lies in their safe care in situations when there is not enough Draycott, T., Winter, C., Croft, J., & Barnfield, S. (2006).
commitment to work with their midwifery, medical, staff to ‘be there’ in every situation that Practical Obstetric Multi-Professional Training Course
and nursing colleagues to achieve that aim. demands close watchful attention. There is no Manual. PROMPT Foundation: Bristol NHS Trust, UK.
way of predicting workload in terms of numbers Employee Assistance Programmes: EAP. Retrieved February
or complexity for any given shift. Coordinators 27, 2009, from http://www.eapservices.co.nz/employee-
DISCUSSION assistance-programmes
need a mechanism whereby they can send a
Guilliland, K., & Pairman, S. (1994). The midwifery partnership.
This study reveals the ability of the five message that extra midwives are needed ‘now’ New Zealand College of Midwives Journal, 11, 5-9.
delivery suite coordinators to work alongside to someone not responsible for the ongoing
Heidegger, M. (1927/1962). Being and time. Oxford: Basil
people, to work ahead of time and to clinical management of the unit, yet able to Blackwell.
project themselves into worlds of unknown make that ‘happen’. The unpredictability of
Hunter, B. (2004). Conflicting ideologies as a source of
possibilities over which they may have little or workload needs to be addressed with strategies emotion work. Midwifery, 20, 261-272.
no control. There exists an underlying level of that are immediately responsive to meet the
Hunter, B. (2005). Emotion work and boundary maintenance
excitement, adrenaline rush, ‘buzz’ and sense of required standards of safe care. in hospital- based midwifery. Midwifery, 21, 253-266.
achievement in their experiences and how they
Isa, T., Thwaites, H., McGregor, B., Gibson, E., Earl, D., &
manage their shifts. Finally, research is required on the resilience McAra-Couper, J. (2002). The Middlemore practice paper.
of coordinator midwives, the skills required Paper presented at the 7th Biennial National Midwifery
These women have the fortitude to manage to undertake the role, the support needed Conference, New Zealand.
‘what is’, their emotions of stress and angst to maintain it and the sustainability of their Koch, T. (1996). Implementation of a hermeneutic inquiry in
disguised as they maintain a professional role long term. Consideration of access to nursing: Philosophy, rigour and representation. Journal of
Advanced Nursing, 24, 174-184.
demeanour. They return to work shift after professional support for coordinators is
shift with extraordinary commitment to a job Lankshear, G., Ettorre, E., & Mason, D. (2005). Decision
required as part of coordinator midwives’
making, uncertainty and risk: Exploring the complexity of work
which poses immeasurable challenges. They are employment contracts. processes in NHS delivery. Risk and Society, 7(4), 361-377.
seen to be ‘doing’, ‘directing’ and ‘facilitating’
Ministry of Health (2006). Midwifery workforce. Wellington:
to get things done, always with the safety of Being a midwife is the springboard from New Zealand Health Information service.
the woman and baby paramount. They seem to which these women leap. Van Manen (1990)
Ministry of Health. (2008a). Maternity Action Plan 2008-
have the ability to cherish the good times when writes that it is our sense of purpose in life 2012: draft for consultation. Retrieved November 11, 2008,
all goes well yet also be anticipatory of situations which sustains us. It is my hope that this from http://www.moh.govt.nz.
which offer no forewarning. study offers coordinator midwives ‘a voice’ Ministry of Health. (2008b). Midwifery Workforce Summary
and will lead to an increased awareness and Results from the 2008 Health Workforce Annual Survey.
The challenges for coordinators include staffing Wellington: Ministry of Health.
understanding of their work experiences
shortages and skill mix anomalies in their which in turn will foster strategies to New Zealand College of Midwives Inc. (2005). Midwives
Handbook for Practice, Christchurch: New Zealand College
workplaces. Further, the nature of childbirth maintain safe staffing levels, ensure staff of Midwives.
means that however prepared they may be, development, appropriate remuneration
Skinner, J. (2005). Risk and the midwife. Unpublished
there is always the potential for the unexpected and give attention to coordinators’ personal doctoral dissertation, Victoria University of Wellington,
to present itself and for them to be stretched wellbeing. A profoundly rich ‘heart and soul’ Wellington, New Zealand.
to their limits or beyond; this is the nature of of midwifery and a true intent to offer the Smythe, E. (2000). “Being safe in childbirth: What does it
being a coordinator. best and safest of care to mothers and babies mean? New Zealand College of Midwives Journal, 22, 18-21.
shone throughout this study in spite of the Smythe, E., & Norton, A. (2007). Thinking as leadership /
Within this study, coordinators offered little numerous and often daunting challenges the leadership as leadership. Leadership, 31(1), 65-90.
insight into how they manage the relentlessness coordinators encountered. Smythe, E., & Young, C. (2008). Professional supervision:
of working under such conditions and more Reflections on experience. New Zealand College of Midwives
questions than answers emerge. Is their work Journal, 39, 13-27.
sustainable long term? Do coordinator midwives Thompson, R. (2003). Compassion fatigue: The professional
possess resilient personalities? What and who liability of caring too much. Paper presented at the 8th World
Accepted for publication March 2010
Congress on Stress, Trauma and Coping. International
are their support systems? Do they need or want Critical Incident Foundation Inc.
professional support as a result of their experiences? Fergusson, L., Smythe, L., & McAra-Couper, J. Timmins, F., & McCabe, C. (2004). Nurses’ and Midwives’
(2010). Being a delivery suite co-ordinator. New assertive behaviour in the workplace. Journal of Advanced
Nursing, 51(1), 38-45.
RECOMMENDATIONS AND Zealand College of Midwives Journal, 42, 7-11.
CONCLUSION van Manen, M. (1990). Researching lived experience. Ontario:
The Althouse Press.
Experiences of coordinator midwives working References Walsh, D. (2007). Evidence-based care for normal labour and
birth. London: Routledge.
in tertiary hospital delivery suite settings Billington, M., & Stevenson, M. (2007). Critical care in
childbearing for midwives. Oxford, UK: Blackwell Publishing. Weil, S. (2008). Experienced midwives and their voluntary
have not been previously studied. This study
Byrom, S., & Downe, S. (2008). ‘She sort of shines’: engagement in professional supervision. Unpublished research
reveals the pivotal role coordinators play when midwives’ accounts of ‘good’ midwifery and ‘good’ paper, Graduate Diploma in Supervision, Waikato Institute
faced with a rising national birth rate, a high leadership. Midwifery, 26 (1), 126-137. of Technology, Hamilton, New Zealand.
New Zealand College of Midwives • Journal 42 • May 2010 11PRACTICE ISSUE
Informed consent and midwifery
practice in New Zealand: lessons
from the Health and Disability
Commissioner
Rights (the Code) may guide midwives in the birthing and must uphold a woman’s right to
Author: challenging area of informed consent. Firstly, free, informed choice and consent throughout
a search of the literature highlights potential her childbirth experience, while accepting that
• Rosemary Godbold, R.N. PhD
Senior Lecturer, Health Care Ethics
barriers to informed consent in midwifery women are responsible for the decisions they
National Centre for Health Law and Ethics practice. A background to the Code is then make (NZ College of Midwives, N.D.). While
AUT University provided and the Rights relating to informed all ten rights in the Code relate to facilitating a
Email: rosemary.godbold@aut.ac.nz consent are considered. This includes an client’s autonomous decision, Rights 5, 6 and
examination of selected cases which show how 7 specifically address effective communication,
the Health and Disability Commissioner (the access to information and informed consent.
Commissioner) applies the principles relating
to informed consent to possible breaches of the
ABSTRACT Code in the midwifery context and how the
Barriers to informed
Commissioner’s opinions might inform practice.
consent in midwifery
Informed consent appears to be a challenging practice
and sometimes problematic area of practice This paper concludes by evaluating what can be
for midwives. It is not always clear, for learnt from the Commissioner’s investigations. Despite this emphasis on women’s autonomous
example, what amount of information decision making rights in professional guidelines
is required to be supplied to women to and in the law, the proportion of midwifery
Autonomy and informed
ensure fully informed consent. Similarly it complaints investigated by the Commissioner
consent
is unclear whether midwives can provide - which relate directly to informed consent -
unbiased information, and what midwives’ In the current consumer focussed health care suggest that this area of practice may be one
communication responsibilities are when other environment, there is an ethical obligation for of the most problematic. While the number
health care providers become involved in care midwives to facilitate the autonomous choices of complaints was very low overall, of the 41
and treatment decisions. This paper examines of mothers. As Mill famously declared in 1861, opinions published by the Commissioner
the Code of Health and Disability Services autonomy is the right of individuals to self- relating to complaints about midwifery practice
Consumers Rights and selected Commissioner’s determination ‘over himself, over his own body received after 2000, 21 investigated potential
opinions which consider potential breaches and mind, the individual is sovereign’ (Mill, breaches of the rights relating to informed
of the Code in relation to informed consent. 1972, p. 78). For a choice to be autonomous, it consent (www.hdc.org.nz as at 26.8.09). The
Case analysis demonstrates how the principles must be intentional, made with understanding, 2008 Midwifery Council report also highlights
relating to informed consent are applied in without controlling influences and be made a lack of informed consent and communication
the midwifery context, and examines how the voluntarily (Beauchamp & Childress, 2001, p. with clients as two of the themes from the
Commissioner’s opinions can offer practical 59). This highly prized ethical principle finds 35 complaints they received that year about
guidance to midwives. expression through the competencies for entry professional conduct (Midwifery Council of
to the Register of Midwives. It is also embedded New Zealand, 2008, p. 25).
in the New Zealand College of Midwives
KEY WORDS: (NZCOM) Code of Ethics, and is given legal A search of the international midwifery
Informed consent, autonomy, midwifery, Code weight through the Code of Rights. Registered literature highlights the difficulties in this area
of Health and Disability Services Consumers' midwives must respect and support the needs of practice. Skirton & Barr (2007) conducted a
Rights. of women to be self determining, provide up systematic review of the literature on antenatal
to date information and support women’s screening and informed choice in the United
informed decision making (Competencies Kingdom. Their main finding was that there
INTRODUCTION 1.7 and 1.10, Midwifery Council for New was a danger that parents and professionals
This paper examines how New Zealand’s Code Zealand [N.D]). Midwives must accept the regarded screening tests as routine and
of Health and Disability Services Consumers' right of women to control their pregnancy and therefore not requiring a decision. Additionally,
12 New Zealand College of Midwives • Journal 42 • May 2010midwives were not always sufficiently prepared midwife’s bias; fear of litigation; and the power
RIGHT 1 Right to be Treated with Respect
in terms of their knowledge, skills or attitudes imbalance between patients and midwives.
to offer screening in ways that facilitated RIGHT 2 Right to Freedom from
She urged midwives to take into account the
Discrimination, Coercion,
informed choice for parents. More recently quality of the evidence on which they base Harassment, and Exploitation
Skirton and Barr (2009) surveyed both parents their practice. Patronising approaches to RIGHT 3 Right to Dignity and
and midwives and found that although parents women (Kitzinger, 2006), the language and Independence
wished to have information about screening at terminology used to transmit information RIGHT 4 Right to Services of an
an early stage, many parents did not perceive (Hunter, 2006) and midwives’ perception of Appropriate Standard
their second trimester scan as a method of risk (Tupara, 2008) have all been implicated RIGHT 5 Right to Effective
antenatal screening. Also, midwives lacked in undermining women’s autonomous birthing Communication
accurate knowledge about screening and the choices. In addition, commonly used methods RIGHT 6 Right to be Fully Informed
conditions for which it is offered. for sharing information and promoting RIGHT 7 Right to Make an Informed
informed choices, such as leaflets, birth plans Choice and Give Informed
In his discussion about the roles of midwives Consent
and education classes have been identified in
and obstetricians in informed consent in the RIGHT 8 Right to Support
the literature as insufficient (Deave & Johnson,
modern era, Longmore (2004) questioned the RIGHT 9 Rights in Respect of Teaching or
2008; Lothian, 2008; Kitzinger, 2006;
value of antenatal education, suggesting that Research
Longmore, 2004; Schott, 2003; O’Cathain,
‘informed compliance’ may be a more realistic RIGHT 10 Right to Complain
Walters, Nicholl, Thomas and Kirkham, 2002;
outcome than informed choice or informed
Bradley & Schira, 1995).
consent because of the way information Figure 1: The HDC Code of Health and
is promoted. He challenged whether the There is a paradox that while midwives fear Disability Services Consumers' Rights
information given in prenatal education is Regulation 1996
of litigation has been cited as a barrier to
non-biased. Using the example of the risks of informed consent (Stewart, 2006 and Austin www.hdc.org.nz/the-act--code/the-code-of-
pelvic injury from vaginal delivery, he asked: & Benn, 2006), problems with inadequate rights/the-code-(full).
“Are women ever informed of these risks?” informed consent can themselves become the
(Longmore, 2004, p. 7). Longmore raised focus for complaint or litigation. An added informed consent contributed to poor ethical
other important issues about when information tension for midwives is that they have a dual practices and a failure to deliver acceptable
is delivered and who is responsible for giving professional responsibility to both the mother treatment (ibid.). In response to the Report, the
information to enable informed consent. He and the unborn child. The law in relation to Health and Disability Commissioner Act 1994
asks if medical professionals can assume that the status of an unborn child in New Zealand (the Act) was passed. The Act was also necessary
women already have information from other has been described as “unpredictable” (Peart, because New Zealand's unique "no fault"
sources (i.e. through antenatal education) and 2006, p. 464), although a fetus does not accident compensation scheme (ACC) leaves
whether fully informed consent is possible when “generally become a person in the eyes of health and disability service users with restricted
a woman is in labour. the law until it is born alive” (ibid., p. 452). recourse to the courts and there was no formal
This is contentious and further discussion complaints mechanism for consumers (Dew &
When investigating the influences on decision
is available elsewhere (see Peart, 2006). A Roorda, 2001). The Act’s / Code’s purpose is
making about induction of labour in New
significant body of research demonstrates that to promote and protect the rights of all health
Zealand, Austin & Benn (2006) echo concerns
women who participate in decision making and disability service consumers ensuring fair,
about the lack of consensus on what constitutes
experience greater satisfaction, reduced labour simple, and speedy complaint resolution when
informed consent. This seems justified given
and postpartum adjustment (Martin, 2008). consumers’ rights are infringed (The Health and
their research findings. In their New Zealand
Although it may be controversial to suggest Disability Commissioner Act, 2004).
study they interviewed 74 Lead Maternity
Carers (LMCs) and 79 women in the birthing that women should always have complete
The Code was developed by the Commissioner
suite prior to an induction of labour and autonomy over their birthing experiences
and enacted in 1996. Unlike the Health
found that the women had limited knowledge (see for example Douche’s 2009 paper which,
Practitioners’ Competence Assurance Act,
about the negative effects of induction using a poststructuralist lens, examines the which applies only to registered health
and that their participation in decisions to construction of a ‘natural caesarean’ where professionals, the Code applies to “any
induce labour was minimal. They also found women may elect caesarean regardless of need), person or organisation providing, or holding
disparities in the reasons cited for induction in New Zealand, they have legislated rights to themselves out as providing, a health service
between women, the LMC and consultant effective communication, to be fully informed to the public or a section of the public
obstetricians. Fears of litigation, and even the and to make informed choices. whether that service is paid for or not.”
hospital booking system were influential when (www.hdc.org.nz/theact/theact-thecode). It
decisions were being made to induce labour. Background to the HDC confers ten rights on all consumers of health
These findings raise significant questions about Code of Rights and disability services in New Zealand and
poor communication, professional anxiety and places corresponding obligations on providers of
hospital systems as barriers to informed consent. It is now over 20 years since the Cartwright those services (Figure 1).
Report investigated poor research practices
Other writers add to this list of issues. In for women with cervical cancer at National The Commissioner’s role is to investigate any
considering the challenges for midwives in Women’s Hospital in Auckland (Cartwright, complaint or action that is, or appears to be, in
New Zealand Stewart (2006) identified the 1988). The Report highlighted violations of breach of the Code (Section 14 (1) (e) of the
following factors that may influence informed fundamental patients’ rights, concluding that Act). Providers of health services are not in
consent: contradictory clinical guidelines; the clinical freedom, peer supervision and a lack of breach if they have “taken reasonable actions in
New Zealand College of Midwives • Journal 42 • May 2010 13You can also read
