Chapter 1 The midwife’s role

INTRODUCTION

The formal definition of a midwife was first adopted by the International Confederation of Midwives (ICM) and the International Federation of Gynaecology and Obstetrics (FIGO) in 1972 and 1973, respectively. It was later adopted by the World Health Organization (WHO). The definition was amended by the ICM in 1990 and this amendment was then ratified by the FIGO and the WHO in 1991 and 1992, respectively:

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She has an important task in health counselling and education, not only for the women, but also within the family and the community. The work should involve antenatal education and preparation for parenthood, and extends to certain areas of gynaecology, family planning and child care. She may practise in hospitals, clinics, health units, domiciliary conditions or in any other service

The Association of Radical Midwives states:

A midwife is a specialist who is qualified to give total care to a woman and her baby during pregnancy, labour and after the baby is born. The midwife does not have to call in a doctor unless there is a potential or actual problem which requires medical assistance

(Association of Radical Midwives 2006)

The Royal College of Midwives (RCM) position paper 26: refocusing the role of the midwife states:

Currently, there are a number of developments, both external and internal to the profession that are creating change in midwives’ roles and working practices. These changes are not uniform across geography or practice settings. However, they have the potential to challenge midwives’ traditional working practices across the UK

(RCM 2006)

Midwives today are facing a dichotomy: at one end of the spectrum, they are constantly being asked to expand their role to incorporate new challenges, new ways of working, new screening programmes and develop new skills, and at the other end midwifery skills are being farmed out to support workers or nurses. It is inconceivable that midwives can be all things to all people, but embarking on change must be carefully thought out, measuring and weighing current practice and ensuring safety and quality to women in our care.

The role of the midwife, from whichever perspective, is diverse and encourages informed decisionmaking, working in partnership with other health and social care services in a wide variety of care settings, including low and high risk settings and working independently outside the NHS.

Many women have complications or underlying medical conditions that require specialist obstetric and multidisciplinary care during childbearing and midwives also play a pivotal part in this process, delivering the necessary care, providing continuity and support and linking directly or indirectly with all other members of the multidisciplinary team. Basic knowledge and understanding of medical conditions affecting pregnancy and childbearing is only a starting point for today’s professional midwife. The midwife has been educated to have a thorough knowledge and understanding of normal childbearing and this is her field of expertise. However, the midwife’s knowledge cannot be restricted, as this would be naive and unrealistic but her knowledge and understanding of complications and medical conditions of pregnancy should be slanted towards midwifery care. This is not less than medical care, just different.

There is still a hierarchical element within the National Health Service (NHS), and obstetricians are assumed to have final control. However, midwives must be prepared to be assertive and act as advocates for women when required. It is possible to develop a professional relationship with medical staff where there is mutual trust, and where each member of a team works harmoniously, benefiting from each others’ expertise. Midwives need to feel safe and valued as members of the team and management has to reverse the prevailing culture of fragmentation and put in place measures which empower midwives (Curtis et al 2006).

One of the most important attributes of a midwife is competence. Attaining competence is hard work; it requires effort, commitment, responsibility, preparation and above all motivation. Knowledge and understanding of conditions, their management and development of clinical skills leads to competence and fitness for purpose. Fitness for purpose demonstrates the ability and proficiency for practice. Women today require a professionally competent midwife, one who goes that extra step to learn, to hone a skill, or to communicate effectively. Clinical competence is only one facet of care.

Midwives who succeed in professional practice reflect on their care and fully embrace the concept of lifelong learning. They demonstrate qualities of empathy, enthusiasm and assertiveness in all aspects of care. They are professionally supportive of women and colleagues. This is of fundamental importance as all too often, midwives have shirked the professional responsibility of supporting their colleagues in both clinical and management roles, and nowhere is this more important than when caring for women with complications or medical conditions in pregnancy. Critical thinking and reflection in and on practice by every midwife is necessary to raise and maintain standards. Updating knowledge and understanding of specific conditions can be achieved through reading relevant articles, informal discussions, tutorials or fire drills during quiet periods.

Midwifery practice is governed by the Midwives Rules and Standards (NMC 2004b). These rules and standards are designed to protect the public, and also describe the standard one would reasonably expect from someone who is practicing as a midwife or is responsible for the statutory supervision of midwives. Midwives should be familiar with all parts of the rules and standards as they allude to, and define the parameters for safe everyday practice.

In caring for women with ‘high risk’ pregnancies, the midwife should pay particular attention to the following:

Rule 6 …

2. Except in emergency, a practising midwife shall not provide any care, or undertake any treatment, which she has not been trained to give.

3. In an emergency, or where a deviation from the norm which is outside her current sphere of practice becomes apparent in a woman or baby during the antenatal, intranatal or postnatal periods, a practising midwife shall call such qualified health professional as may reasonably be expected to have the necessary skills and experience to assist her in the provision of care

In essence, this means each midwife is required to personally ensure she develops the requisite skills in order to care for women within her particular sphere of employment. Employers have a responsibility to make provision to enable midwives to develop such skills. This also includes the administration of medicines. In an emergency, a midwife must call on any relevant person to aid her in care, for example a more experienced midwife, a doctor/obstetrician, anaesthetist or paramedic. The midwife is also required to call for medical aid where there is a deviation from normal circumstances.

If when requesting medical aid a doctor either fails to attend, or does not take appropriate action, this does not relieve the midwife of the responsibility to the woman or infant in her care. The midwife should contact another more senior member of staff and her supervisor of midwives.

In circumstances such as the above, it is essential that the midwife records the time of making a request for medical aid, and documents the time and the reason for the request in both midwifery and medical notes. In law, courts consider that if something alleged to be carried out is not documented, then it was not done.

The Nursing and Midwifery Council considers that record-keeping is fundamental to midwifery practice and helps safeguard the public by promoting high standards of care, communication of information, and an accurate record of care provided, enabling the identification of problems at an early stage (NMC 2005).

Good record-keeping also protects the midwife. If the midwife follows the guidance for record-keeping and documents factually, consistently and accurately as soon as possible following an event and where possible, written with the involvement of the woman concerned, and without abbreviations, jargon or alterations, then the midwife is demonstrating evidence of the care delivered.

It is in the midwife’s best interests to maintain good records. It enables her to logically and sequentially document the planning, implementation and evaluation of care, which will aid her to recall events accurately during reports or handovers to midwives or members of the multidisciplinary team and allow others to follow care even in her absence. In addition, logical, sequential and factually accurate recording of information can go far to increase the recognition of the midwife as a legitimate professional.

In order to provide a high standard of care, the midwife must scrutinize her practice to ensure that the care provided is not carried out routinely by habit or tradition, but as result of critically examining current research to identify the best available, current, valid and relevant evidence in order to provide evidence-based practice. This is important in caring for any woman, as well as when caring for women with problems or complications of childbearing, as in this situation, the woman’s health may already be compromised and sub-standard care could further undermine her health.

Supervision of midwives is provided to promote a safe standard of midwifery practice, in order to protect women and babies through a system of support and guidance for every practising midwife in the UK. Individual midwives who are eligible to become supervisors have to undergo a period of preparation. They have a wide remit and are involved in promoting best practice, preventing poor practice and intervening in unacceptable practice. One facet of their roles is to monitor practice through audit and ensuring midwifery practice and decision-making is evidence-based (NMC 2006). Additionally, they are available as experienced professionals to advise and support midwives in gaining the experience they require to care for those women who come into pregnancy with a pre-existing medical condition.