About a year ago I was bound for the MMBP, a bridging program for internationally educated midwives based in Vancouver and affiliated with UBC. In order to qualify for the Accelerated Stream, I had to prepare a portfolio that included narratives, reference letters, and evidence of my work-things like what I used for my documentation and pictures of my office space.
The outline for the narratives, provided by the program, was the “Framework of Professional Practice, a detailed description of competent midwifery practice in Canada. It is based on the Canadian core competencies with input from provincial/territorial regulators to ensure inclusiveness of jurisdictional differences.” (From the Accelerated Option Guide linked on http://cmrc-ccosf.ca/node/229) I wrote one to two page narratives on each of the twelve functions, as well as an overview narrative, on these topics:
1. Establish conditions for the provision of primary midwifery care, informed choice and continuity of care
1.1 Assure the availability of continuous primary care throughout the childbearing cycle, on a 24-hour on-call basis
1.2 Organize care to provide time for the development of relationships and to provide informed choice
1.3 Maintain complete and accurate health care records
2. Provide primary care, informed choice and continuity of care
2.1 Develop a relationship with the women in care
2.2 Enable women and their families to play a full role in making informed choices
2.3 Provide safe antenatal care
2.4 Provide safe labour, birth and immediate postpartum care
2.5 Provide safe postpartum care
2.6 Respond to increased risk
3. Establish and maintain current professional practice
3.1 Provide evidence-based care
3.2 Plan, implement and facilitate personal and professional development
3.3 Contribute to the effectiveness of the health care system
I’m going to selectively post some of these, the ones that aren’t repetitious or just plain boring. (Seriously, who wants to read about my record keeping?) I’ll start with what I think is one of the more interesting pieces, evidence based care.
That I think evidence based care is interesting is an important facet of my midwifery-ness. A few years ago, I saw on a message board, “If your midwife hasn’t explained all the possible outcomes, including the bad ones, of a certain decision, it is NOT true informed consent. It is just paternalistic practice, disguised in flowing skirts, hugs and peace signs.” It was written by a CPM.
I love the client relationship part of my job-the connection, the joking, the journey we take together. But you know what? My client didn’t hire me to be her friend. I have a job because she needs an expert advisor, in the same way I need to hire an accountant or a mechanic. The connection, the joking, and the journey are important facets of my care provision, much more important than with an accountant or mechanic, but it’s only one leg of the table, ya know?
My job, in part, is to stay current with the research and be able to share it with my clients as well as be willing change my practice when new evidence suggests it’s a good idea.
Anyway, here’s what I had to say last year. I’ve edited for privacy, to explain technical terms, and yes, storytelling.
“In this narrative I describe three examples of how I provide evidence based care. Two of these examples, routine urine testing at each prenatal visit and sweeping membranes, demonstrate how evidence has changed the way I practice. The third example, the management of a labor and birth with thick meconium stained fluid, shows how I used evidence to guide my decision making in a particular case.
Several years ago at an ACNM convention, one of the presentations was titled, “Prenatal urine testing: a sacred cow of obstetrics”. This lecture described how prenatal urine testing, a routine procedure in prenatal care, has become entrenched because it is simple, noninvasive, and inexpensive, making it difficult to stop doing. Indeed, it seems like “not a big deal” until one considers the unnecessary additional testing that may result from false positive readings, and that more sensitive and specific tests exist that look for the conditions that prenatal urine testing is supposed to identify.
In October 2009, I chose to stop performing this testing, instead following the recommendation of performing a urine culture and sensitivity at each new ob exam, and performing urine testing for indications only. The only unintended and undesired effect of this change is that if that initial culture and sensitivity is positive for beta strep infection, I am obligated under CDC standards to treat it in labor regardless of a later test being negative.
Sweeping membranes is an intervention I abandoned in 2002 but chose to begin offering again two years ago based on evidence. When I worked in a hospital based physician private practice, I cared for three patients in a row for whom I had swept membranes who subsequently experienced rupture of membranes without labor, all less than 24 hours post membrane sweeping. Furthermore, for two of them, several months later I received a notice from medical records that I needed to sign something in their chart. When I did so I read their placenta pathology reports, and they both read, “Cellular changes demonstrating chorioamnionitis are present.” Neither of them had fevers in labor or was treated for infection, but to me, the conclusion was clear: sweeping membranes leads to waters breaking, which is either a cause or an effect of infection. Either way, no more sweeping membranes from THIS midwife.
Two years ago, a few abstracts were distributed through my local ACNM listserv. One stated, in summary, that sweeping membranes may help to induce labor, and does not lead to premature rupture of membranes; the other concluded that while sweeping membranes did not appear to bring on labor, it did not lead to premature rupture of membranes except in a particular subgroup.
Since the n of both studies was significantly more than my three, I began offering these abstracts to my clients for review, sharing my story with them, and leaving the choice to them, though I recommended NOT sweeping membranes until 41 weeks if our plan is induction at 42 weeks.
My final example of my use of evidence to guide my practice is described in a particular labor and birth. At 40 and 4/7 weeks, “M” experienced rupture of membranes, and the fluid showed particulate meconium. We communicated by phone that morning and agreed to meet at my office for a non stress test and discussion of options. I did an online search for current information on management recommendations. I found an excellent MedScape review article that detailed facts about meconium, meconium aspiration, and meconium aspiration syndrome-each entity being more rare and more serious than the previous.
We met at my office, and the NST was reassuring. We reviewed the article and had a lengthy discussion of the risks and benefits of staying home vs. going to the hospital. I expressed that a risk AND a benefit of going to the hospital is that a pediatrics team would be in standby-whether or not the baby was born vigorous, the baby would very likely be evaluated, if not immediately, then within the first few minutes. The risk of staying at home is that I do not have experience with intubating and deep suctioning with an ET tube. Furthermore, the entire situation would be moot if she did not begin spontaneous labor within 24 hours-we’d be going to the hospital for induction at that point. I had, and expressed, every confidence that as long she entered spontaneous labor, she would progress well.
We had several factors supporting staying at home. One is that she was a second time mother who had had a quick first labor, which was the source of my confidence of a smooth labor. Another is that she was a repeat client and we had a deep degree of trust in each other. Also, her doula was a monitrice, a labor and delivery nurse of many years experience, who I also know very well and in whom I have a deep degree of trust. Finally, this was to be a home birth in an urban setting, where we have an EMS system with a documented four minute response time, and a hospital within five minutes of her house. If ANY of these factors had been absent, we may have made a different decision.
M entered spontaneous labor overnight and, as I predicted, had a speedy labor. When M began make grunting noises, I said, in my Boss voice, “OK, everyone, here are your jobs. M, you push her out and stand up as that happens. When I say stop pushing, STOP, and I will suction her mouth and nose. Then I’ll pass her between your legs and you put her on the bed. Tanya (monitrice), if need be, you listen to her (the baby’s) heartbeat. Lynne (nurse), you call out times and chart. J (M’s husband), you hold the cordless phone and if I say so, call 911. And stand here so you can see the baby come out. Let’s not forget to have fun, right?”
The birth deities smiled upon us. The baby’s heart tones stayed excellent throughout pushing, and when I suctioned her mouth after her head was born she grimaced. She cried lustily before she was fully born, and as she passed through my hands her tone was excellent. The baby nursed immediately and vigorously, easing any worries of respiratory distress, which we continued to watch for for the next few hours.
One of my cherished memories of this birth is Tanya saying to me soon after the birth, “Thank you for creating this space.” If I were a cartoon a question mark would have appeared over my head, followed by, “Oh. OK. You’re welcome.”
This is the part of my job that gets lost on me. In a perfect world, I’m not needed at all. But I, and my nurse and my equipment, are what makes any home birth possible. I, and midwives everywhere, help to create and hold the space.
Back to the mundane. In summary, evidence based practice is a very important part of my practice. I do not cling to evidence at the expense of patient autonomy, but when reviewing options, evidence is one piece of the puzzle to consider.”
I like evidence based practice because I like numbers and love informed choice. A secondary effect that is also important to me is interprofessional integration. I like to think, and have one piece of objective evidence supporting, that my interest in research and the science of midwifery increases my credibility with the bigger health care system in which I work. I can walk a woman through her fears and questions, AND I can speak the language of science with physician and nurse colleagues.
My primary objective is, and remains, having and using the tools at my disposal to be the best midwife I can be and deliver the best care that I can. Good interprofessional relationships are not an explicitly stated goal, but a secondary outcome of my primary objective.