Midwifery led care: risk management issues

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Midwifery led care risk management issues

• Soo Downe
• Risk management and medico-legal issues in
  women's health
• RCOG , London
• With thanks to all those who feature in the
  photographs, and especially to the women and
  staff in Blackburn, and to Denis Walsh

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.Risk was/is real..

• Childbirth in the late 19th century was both
  difficult and dangerous. Maternal mortality stood
  at around 500 per 100,000 births compared with
  approximately 12 per 100,000 today. Few women had
  access to trained attendants in childbirth and
  many of the poor had to depend on local untrained
  midwives.
• RCM website

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but birth is more than the physical..

• ...To anyone who thinks about it long enough,
  birth cannot simply be a matter of techniques for
  getting a baby out of ones body. It involves our
  relationship to life as a whole, the part we play
  in the order of things
• Kitzinger 1987

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Valuing wellbeing as well as risk avoidance

• Health is
• a complete state of physical, mental and social
  well-being, and not merely the absence of disease
  or infirmity
• WHO 1948

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Social safety in Brazil

• Project Luz has given many women the feeling
  of strong confidence in a safe delivery and in
  child rearingleading to self-transformation,
  which empowers them profoundly. Thisraises their
  concerns about society, their lives, and
  motivates their participation in community
  activities and development.
• Umenai T 2001

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Beware medical (midwifery) nemesis (Illich)

• -I had a woman who had a massive haemorrhage at
  home,
• so home birth/midwifery led care is inherently
  unsafe..

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Over-generalisation

• Risk management criteria tend to be based on
  population level evidence
• Clinical practice is about individual service
  users and clinicians working in complex and
  uncertain environments

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What do we mean by midwifery led care?

• Antenatal, intrapartum, postnatal?
• Team midwifery?
• Caseholding?
• One to one?
• Birth centres, integrated or free standing?
• Home births?

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Why manage risk specifically for midwife led care?

• Philosophical differences (and suspicions?)
  between systems and professionals
• Grey and underresearched boundary issues
• Alternative techniques and treatments
• Geographical distance
• Silo mentalities

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Elements of clinical governance

• Patient, Public and Carer Involvement
• Strategic Capacity and Capability
• Risk Management
• Staff Management and Performance
• Education, Training and Continuous Professional
  Development
• Clinical Effectiveness
• Information Management
• Communication
• Leadership
• Team Working
• http//www.cgsupport.nhs.uk/About_CG/

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Risk management through clinical governance

• Clinical governance is the system through which
  NHS organisations are accountable for
  continuously improving the quality of their
  services and safeguarding high standards of care,
  by creating an environment in which clinical
  excellence will flourish
• http//www.dh.gov.uk/PolicyAndGuidance/HealthAndSo
  cialCareTopics/ClinicalGovernance/fs/en

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Unpacking this

• System singular?
• Accountable level of accountability?
• continuously improving possible conflict?
• quality judged by?
• high standards of care for populations or/and
  for individuals?
• flourishing clinical excellenceclinical
  autonomy?

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Key risk issues in midwife led careClinical
governance in NICE intrapartum guidelines
(consultation draft)

• Focus is on risk management of place of birth
  (specifically out of hospital birth), and on EFM
• Booking criteria, transfer criteria and efficacy,
  poor outcomes
• Specific audit required of transfers that should
  have taken place (but not those that shouldnt
  have, or of bookings that should have been in an
  alternative setting?)

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Maternity matters

• by 2009all women will have choice in
• where and how they have their baby
• what pain relief to use...

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The transfer issue how can we avoid
disarticulation?

• Safety of mothers and babies is paramount..
• there needs to be absolute clarity around
  responsibilities and clear protocols governing
  transfers before, during and after labourso that
  women can transfer flexibly and in a timely
  manner between different levels of care p19

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Providers responsibilities (p28)

• adequate staffing levels
• audit and consequent action especially following
  poor outcomes
• environment, facilities, timelines of services
• transfer arrangements
• women-focused, family-centred care
• gather and report routine data
• development of the workforce, with training and
  continuous professional development
• regular board level reviews of the performance
  and function of maternity services

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Royal Colleges and Professional Bodies
responsibilities

• Define measurable standards for skills,
  competencies and regular continuing professional
  development
• Support the development ofpostgraduate education
  and training
• Facilitate multidisciplinary learning so that all
  clinicians train in a way that recognises each
  others responsibilities within the team to
  improve care and safety

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Elements of effective care

• 12 key factors in 4 Canadian units with low CS
  rates (selected five)
• Pride in low caesarean section rates
• Hospital culture birth is a normal
  physiological process
• Commitment to one-to-one support during labour
• Effective multi disciplinary teams (who liked
  each other)
• Effective (? transformational) leadership
• Ontario Women's Health Council
  www.womenshealthcouncil.com/ (NHS centre for
  improvement and innovation 2006)

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Changing systems doesnt always (often doesnt)
make much difference

• Simpson, Kathleen Rice James, Dotti C. Knox, G.
  Eric 2006
• .Nurses and physicians shared the common goal
  of a healthy mother and baby but did not always
  agree on methods to achieve that goal.

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Design

• 4 hospitals (approx 3000-6000 births
• Nurse managed labour predominant model
• 54 nurses, 8 focus groups
• 38 obstetricians, individual in-depth interviews.

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Areas of contention augmentation of labour and
interpretation of EFM

• They the physicians like that pit pushed and
  you'd better push it and go, go, go, otherwise
  they'll be hot, really mad if it's not going.
• I would be petrified if at 7 am they the
  physicians walked in and I didn't have the pit
  going. They'd yell at me and that's just an added
  stress.

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What did the doctors value in the nurse-midwives?

• The main thing is to have a nurse who is not
  afraid of pit, who can actively manage the labor
  and be aggressive in turning it up on a regular
  basis.
• When I hear I've got a nurse who will go up on
  the pit, I know it's going to be a good day.

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philosophical conflict that resulted in (covert)
resistance

• I increase the pit as I need to, but I'm not
  going to have contractions right on top of each
  other. I'm not going to cause fetal distress or
  injure a baby.
• Cf anterior rim, Annendales ironic
  intervention, apparent shifting in gestational
  age

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Problems of lack of trust and respect (subtle
power games)

• Sometimes I feel downright unwelcome when I show
  up on the unit to check my patient without being
  called. The nurses say 'What are you doing
  here? I didn't call you.'

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Lack of trust respect..

• Some doctors are a disaster so I make sure I
  don't call them for delivery until the head is
  almost out. That way I can try to prevent a
  vacuum or forceps, I don't have to deal with
  fundal pressure and I don't have to stand there
  while they sew up the inevitable fourth degree
  laceration. The patient is much better off and
  they don't even know what a favor I've done for
  them.

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And the consequence isworkarounds (Iedema et
al 2006)

• So it almost becomes like a battle where you
  think she the nurse should be doing this and
  she has other ideas but doesn't necessarily tell
  you. Instead of directing all your attention to
  the patient you end up having to worry about the
  pit. It doesn't serve the patient well where
  you're not working really together.

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Subtle rules of interactiona risk?

• If I really think she the patient needs a
  section and I want them the physician to come
  over, I use key words "going no where, head is
  sky high, she's stuck, not changing even with
  good contractions.
• When I'm busy in the office or in the middle of
  the night, I'm listening for key words or phrases
  that mean I have to come like fetal distress,
  lots of blood, prolapsed cord, ready for delivery
  otherwise I know they don't need me right away.
  I can't come in for every call.

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Nurses' views of "good" physicians

• not always in a hurry doesn't yell or scream at
  me
• professional courteous
• patient and kind to the patients
• understands the labor process knowledgeable
  keeps up to date
• doesn't call to tell me to push the pit or get
  her delivered at a certain time
• respects what we do asks my opinion trusts my
  judgment
• nice to the new nurses.

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Physicians' views of "good" nurses

• can predict when delivery will occur (I like to
  be called an hour before) anticipates my needs
  knows me well and knows when to get concerned
  and when to get serious and push the panic button
  and feed the information to the physician.
• proactive helps patients stay on the labor
  curve not afraid of pit
• loving and caring toward the patient
• wants patients to have the best possible outcome
  
• a selfless kind of attitude at the bedside
• older reliable consistent knowledgeable,
  experienced

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Beware false sense of security about teamwork.

• Physician participants had a more positive
  opinion of the state of teamwork than did nurses

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To manage risk effectively we need to move from
this.
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..to this
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effective multidisciplinary teams who like
(trust, respect, care for, constructively
challenge) each other

• Example one
• planned homebirth for woman with haemorrhagic
  problems, and previous caesarean section

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Example two managing intervention positively
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effective teamsLearning mutual trust and
governance with rather than governance of or
over

• Example three
• planning for the future together
• (midwives, obstetricians, GPs, paediatricians,
  managers, commissioners, service users etc)

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Essential components of risk reduction based on
reward not punishment..

• (properly) agreed updated clinical guidelines
  applied FLEXIBLY
• regularly tested clinical protocols for
  emergencies/sentinel event
• regular training in keeping birth normal as well
  as in EFM and other labour management skills
• for out of hospital birth, ALSO type training and
  skills
• rapid non-judgemental review of adverse events
  based on collegiate support and learning
• regular sharing of insights, novel experiences,
  and positive successes within and between
  disciplinary boundaries
• on-going audit and regular publication of
  clinical service user results
• celebration of success, innovation, and
  constructively critical debate

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and based on mutual respect, heedfulness and
error wisdom

• Before it can be effective, an organisation must
  dismantle its vicious cycles.(p63)
• The major hurdle is to remove the underlying fear
  of telling the truth (p 56)
• Each person must become a fully responsible
  autonomous agent who respects the rights of
  others to assume similar status. (p 66)
• Kelly Allison 1998

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And if we dont do this

• Agents, frightened of losing their positions,
  adopt threatening postures and tell 'white' lies
  to protect themselves. Afraid to report the truth
  as they see it, they don't provide full and
  accurate information. Decisions, made in
  ignorance, backfire, leading to mistrust. People
  learn not to entrust their individual survival to
  others in the group. Mistrust amplifies the fear
  and the cycle intensifies
• Kelly Allison 1998 p54

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What is the risk of loss of benefit?

• My life was devastated by my experience and it
  has made me a worse mother a barely functioning
  suicidal mother at times who was deeply wounded
  by the careless expression of never mind at
  least you have a healthy baby of course I
  mind!Of course I am delighted to have a healthy
  baby but my feelings matter too. Sarah
• Beech and Phipps 2004

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The risk of getting it wrong..

• the way a woman gives birth can affect the
  whole of the rest of her life - how can that not
  matter - unless the woman herself doesnt
  matter
• Beech and Phipps 2004

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And the advantages of getting it
right(particularly for disadvantaged women
babies)

• You have given me power in my life that I could
  never have dreamed of I have achieved something
  wonderful for the very first time and no-one can
  take that from me. Thank you
• (Carol 1st baby, from Walsh 2006)

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Midwives, doctors, and maternal mortality

• I found and it was not a finding I had expected
  that wherever (there was) a system of maternal
  carebased on trainedand respected midwives
  maternal mortality was at its lowest. I cannot
  think of an exception to that rule.
• Loudon 1992 p426-7

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George Bernard Shaw

• We are made wise not by the recollection of our
  past, but by the responsibility for our future.

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