Reflection
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Clinical Study – Water for Labour and Birth.
The use of water to ease pain in childbirth has been known for centuries. Midwives have often encouraged women to get into baths for pain relief. The idea of relaxing in a pool of warm water, in restful surroundings, is very appealing to many women, and increasingly, women wish to use a pool (Lawrence Beech, 1998).
In 1992 The Winterton Report recommended “that all hospitals make it their policy to make full provision whenever possible for women to choose the position which they prefer for labour and birth with the option of birthing pool where this is practicable."
For The Midwifery Studies module I wanted to examine the role of the midwife with regards to birth choices and in particular the promotion of labour and birth in water as a viable option. I will be reflecting upon my experience of a water birth class using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
I observed a water birth class run by a hospital and community based midwife at a local hospital. There was a good attendance of 25 pregnant women and their partners. The video “A Guide to Water Birth” (Burns, 1993) was shown. Which described the basics necessary for a water birth:-
- Constant temperature of the pool between 36.5-37.5ºC
- Large pool (deep enough to cover the abdomen)
- Thoroughly cleaned between uses
The video then showed a normal delivery conducted in water throughout including a physiological third stage in water.
The midwife talked through a patient information leaflet called “The Birthing Pool” which explained:-
- Only “low-risk” women were allowed to use the pool
- That it was recommended not to enter the pool before the cervix was 4-5cm dilated, as this is thought to slow labour.
- That the woman may need to leave the pool for periods to be monitored.
- That the only form of pain relief available while in the pool was Entonox (nitrous oxide 50% and oxygen 50%).
- That staying in the pool to give birth should be discussed with the midwife at the time and will be decided depending on the condition of the baby.
- That the hospital requests leaving the pool for the third stage of labour, for the purpose of estimating blood loss and to avoid the theoretical risk of water embolism.
There was then a short tour of Labour ward, a viewing of the pool room as it was empty and a chance for questions to be asked of the midwife.
After a previous positive experience of being with a woman who had laboured in water, I became interested in the use of water for labour and birth. I found the water birth class to be a valuable experience. I was surprised by the large attendance; we had to change rooms to accommodate all of the women and partners. I spoke to many of the women present to gather information on why they were interested in water birth. Many were interested in the use of water for pain relief in order to avoid pharmacological methods. Others believed it led to more “natural” childbirth with less interference and perceived a reduced risk of episiotomy.
I felt the class was valuable to the women and partners as it put minds at rest, looking at the pool gave familiarity and the knowledge of this option gave more choice to the women a greater feeling of control and well being.
I was surprised at the popularity of the class as the pool is not used a great deal, which led me to question why of these women who were very keen to use water for their labour and birth very few of them would actually get opportunity to try water.
I feel the class could have given more information on the benefits of water birth rather that just the contraindications and what would happen. There appears to be excessive emphasis on the ‘risks’ of water birth, whereas pharmacological procedures such as epidural and pethidine appear more ‘acceptable’ as their risks are not stressed.
Lawrence Beech (1998) suggests that doctors have a much greater interest in reporting any adverse incident which may be connected with a water birth, even though it may not be a causal relationship. They are far less enthusiastic about reporting incidents relating to fetal scalp electrodes, prostaglandin inductions, oxytocin augmentation, epidurals, and other medically recommended procedures.
I feel it would be appropriate to promote some of the benefits of water so that women have faith in their choice. The supposed benefits of water for labour and birth are extensive and include less trauma for the baby (Leboyer, 1991) loss of inhibitions (Odent, 1983), ease of movement and comfort (Napierala, 1994) and change in pain perception (Balaskas and Gordon,1990) to name but a few.
Although immersion of the body in warm water is used primarily for relaxation and pain relief, it may also shorten labour and decrease the need for augmentation (Stables, 2000). The warmth of the water relaxes the muscles and enhances a state of mental relaxation thus natural endorphin release is increased (Milner, 1988). There may be a decrease in the release of the stress hormones such as catecholamines resulting in better uterine perfusion and more efficient contractions (Schorn et al; 1993).
Women who use water for labour and birth are significantly less likely to require pharmacological analgesics than control groups (Burns and Greenish, 1993). This is supported by a study that looked at a group of primigravidas, researchers found that only 24% of those who laboured in water needed pain relieving drugs, compared to 50% of those who did not use water (Burns and Greenish, 1993).
A reduction in the use of pain relieving drugs not only benefits the mother (who will be more alert and responsive after the birth) but the baby will also benefit considerably (Chapman, 1994). A study by Rosenblatt (1981) demonstrated how babies whose mothers had epidural anaesthesia were still showing adverse effects of the drug up to six weeks later. Several studies by Jacobson (1990) suggested that 25% of mothers giving birth to children who subsequently became addicts had been given opiates (morphine and pethidine), barbiturates, or both, in labour compared with only 16% for controls. The authors concluded that imprinting at birth could be the mechanism by which some young people are trapped into addiction after trying drugs, whereas others are not.
Using water may also reduce episiotomy rates. One study reported that of 541 women using a water pool during 1994/96 there were three episiotomies performed on primigravida and two episiotomies on multigravida women (during 1996 there were no episiotomies). Just under half the women had intact perineums, and 53 women had first degree tears, 83 had second degree tears and two women suffered a third degree tear (Brown, 1998).
If we perceive the role of the midwife to be the guardian of ‘normal’ childbirth, midwives should be promoting ideas such as water birth because they provide non-pharmacological methods of pain relief and distraction. Water birth is available in many units but is often under promoted, with pools remaining empty most of the time and the ‘risks’ of water being over emphasised (Marchant, 1996). For example, at the hospital in question, a woman with meconium stained liquor is not allowed to labour in water (due to the difficulties for monitoring) but will be offered pethidine and epidural anaesthesia, which I would argue holds significantly more risk for the compromised fetus.
The role of the midwife includes provision of education and a “complete preparation for childbirth” (UKCC, 1998, p26); surely this must include any information that would increase the likely hood of a normal labour and birth with minimum intervention. At present midwives are not doing enough to promote options such as water birth. Agencies such as the National Childbirth Trust (NCT) and Association for the Improvement in Maternity Services (AIMS) are doing most of the work promoting normal birth, birth without intervention and the choices that are available to women but about which they are not adequately informed.
Resources such as NCT and AIMS have developed because there is a need for them, women want them and in the past midwives have not been providing all the services women require. Midwives should be looking at the services offered by these other agencies and be remodelling and expanding their practice to meet the needs expressed by women. A decade since The Winterton Report (1992) and it is still not clear if women are getting what they want in childbirth, it is only through audit and research based practice that things will change.
To conclude, it is my personal experience that the risks of water for labour and birth are greatly emphasised, while the benefits go unmentioned. From my review of the literature it would appear this is the case in many areas. It seems that the reluctance to accept water comes from those who have medicalised childbirth and do not wish to relinquish their power.
I feel determined not to hold such biases within my own practice and to discuss honestly the benefits and risks of every intervention and birth choice within my sphere of practice. I realise to do this I must read more widely to gain a full picture of each intervention and always to question my own practice and that of others and not allow it to become routine.
I realise it is my responsibility as a midwife to educate women about active birth and to give them every tool necessary to have the birth they desire, including my unbiased support. I understand currently other agencies such as the NCT are educating women and providing services that midwives are not, thus these services are not available to all women. I plan to observe the organisations that arise as these often reflect the needs of women that are not being met, and to incorporate that knowledge into my practice. In order to provide holistic care for all women I must realise I am not the expert and that there is something to be learned from every woman.
ReferencesBalaskas J and Gordon Y (1990) Water Birth, The concise guide to using water during pregnancy, birth and infancy Thorsons London
Brown L (1998) The tide has turned: audit of water birth. British Journal of Midwifery 6 (4), 236-43
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Burns E (1993) Video – A Guide to Water birth, John Radcliff Maternity Hospital, Oxford Medical Illustration.
Burns F Greenish K (1993) Pooling Information. Nursing Times 89 (8):47-9
Chapman V (1994) Waterbirths: breakthrough or burden? British Journal of Midwifery, Jan Vol 2 No 1 17-19
Jacobson B (1990) Opiate addiction in adult offspring through possible imprinting after obstetric treatment. British Medical Journal 301: 1067-70.
Lawrence Beech B (1998) excerpt from the AIMS booklet, "Choosing a Water Birth". http://www.aims.org.uk/choosewater.htm accessed 04/03/2002Leboyer F (1991) Birth Without Violence. Manderin London
Marchant S (1996) Labour and birth in water: national variations in practice. British Journal of Midwifery 4 (8): 408-412; 429-430.
Milner I (1988) Water baths for pain relief in labour. Nursing Times 84(1) 39-40.
Napierala S (1994) Water Birth A midwife’s Perspective Bergin & Garvey London
Odent M (1983) Birth Underwater. Lancet 24-31 December: 1476-7
Rosenblatt D (1981) The influence of maternal analgesia on neonatal behaviour: II Epidural bupivicaine. British Journal Obstetrics & Gynaecology 88:407-13
Schorn M McCallister J Blanco J (1993) Water immersion and the effect on labour. Journal of Nurse-Midwifery 38 (6) 338-342
Stables D (2000) Physiology in Childbearing with Anatomy and Related Biosciences Bailliere Tindall London p456 Immersion in Water
United Kingdom Central Council (1998) Midwives Rules and Code of Practice UKCC London
Winterton, N (1992) House of Commons Health Committee, Second Report - Maternity Services.
Learning Outcome 1
- Demonstrate an understanding of effective communication and how to use this within a clinical area, and within professional groups.
As part of clinical practice, students have been assigned mentors and also become part of that mentors team. When I began my clinical practice in November a new team had just been formed and I was part of it. Thus I was approached by the team leader and invited to the first team meeting. I will be reflecting upon my experience of communication within the context of these team meetings using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
The meeting allowed all members of the team to meet each other. The first items on the agenda were 1) a team name 2) a mission statement and 3) the possibility of compiling a team leaflet. After some discussion, I volunteered to put together the leaflet (See evidence 1). The team has been meeting on a 4-6 weekly basis since November. Over that period we have gathered together photos of the team members and compiled a basic philosophy of the team. The leaflet is now complete and is given to women in the care of the team.
The leaflet is designed so that women can get to know the members of their team, in order to promote continuity of carer. The idea is that if a woman’s known midwife is unavailable then a member of the team should be available to provide care. So that the woman will at least see a face familiar from the team leaflet.
The leaflet represents an important attempt at communication with women prior to admission to labour ward. An attempt at providing some continuity in a situation where many midwives work solely in the hospital and have no chance of meeting women in the ante or post natal periods.
Attending to Feelings
Although initially apprehensive about attending team meetings as I did not feel like a ‘true’ member of staff. My personal experience of the team is they have helped me to integrate into and feel a part of the hospital staff. I felt very much an outsider when I began clinical placements but I now feel I am a valuable member of the team. I have received a great deal of support and encouragement from all team members and feel I have made a contribution by compiling the team leaflet.
I feel the team meetings have been a great aid to communication for me. Without them I would not have had the opportunity to forge relationships with team members. Through attendance of the meetings I have learned a great deal about the structure of the hospital how the teams work, and the midwives anxieties and triumphs. Meetings have allowed me opportunity to reflect upon my own strengths and weaknesses and to gain support and feedback from a wide range of experienced professionals.
Evaluating Experience
Communication with the client, colleagues and other professionals is an important potential area of risk (Williams, 1999). Providing opportunities for communication such as informal meetings reduces this risk.
Communication is a fundamental part of midwifery. As practitioners we often focus on our communication with the women in our care, but we should note that our communications with other professional are just as important and often neglected. Team meetings provide an opportunity for professionals to get together and voice opinions, problems, ideas and to support each other. It provides time, space and opportunity for effective communication, which often cannot be found in a busy maternity unit.
The meetings also provide an opportunity for midwives to get to know each other socially and to build a team spirit and a nurturing atmosphere. Meetings also provide a mechanism to give feedback to the management committee. The team leader attends a team leaders meeting once a month and expresses the needs and concerns of her team, providing feedback to the team at the next meeting.
The team leaflet is a direct attempt at communication with the women in the care of the team. Its main aim is to provide continuity and to make women feel more involved in their care that in a sense they are part of the team and can gain access to information and advice at any time.
Assessment of Competence
I feel that my skills of communication have been enhanced by attending team meetings. I have gained confidence in working with midwives and can learn more effectively as I feel part of a team, and not an unwelcome student. I feel the relationships I have forged with team members have given me a secure environment in which I can reflect upon my strengths and weaknesses and gain feedback and support.
Now that the team leaflet is complete and has been well received I plan to develop a team website which will incorporate much more detailed information. It will give information about each midwife, and areas of parent craft such as pain relief, positions for labour etc.
I believe if the team continues on the path of self improvement, through leaflets and web sites. It will foster a sense of team pride and also set an example to other teams. The team is excited about the progress and feels it is an excellent way to communicate with a growing proportion of the clientele.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Williams J (1999) Risk management in midwifery (Chapter 7) In Bennett V and Brown L (Eds) Myles Textbook for Midwives London Churchill Livingstone
Learning Outcome 2
- Demonstrate a professional approach in relation to care of women and their families.
A professional approach encompasses the many concepts including accountability, informed consent, and advocacy (Etuk, 2001). I will be reflecting upon my experience of these concepts using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
During my clinical placements I have been involved in several inductions of labour, where the indication has been that the woman is around 10 days post-dates. In one experience the woman was a primigravida in her early thirties who desperately wanted a natural birth without interventions and possibly without pain relief. She had attended active birth and yoga classes, and had hired a TENS machine which she was using when I arrived.
Sarah (false name) had been given 1 milligram of Prostin (prostaglandin gel inserted into the posterior fornix) which had been successful in inducing labour. Her cervix was 1cm dilated, 50% effaced and she was contracting moderately 2 in 10 minutes. The fetus was showing no signs of distress and observations were normal. Sarah was walking around, using breathing exercises and a birthing ball, and coping well.
After 4 hours Sarah was due for a vaginal examination (performed 4 hourly in inductions). Sarah’s cervix was 3cm dilated and an artificial rupture of membranes (ARM) was performed as is routine in inductions. Immediately the pain of Sarah’s contractions increased and she found them harder to cope with the frequency of the contractions remained the same, but Sarah now had to kneel and focus her concentration on dealing with the pain. Sarah was continuously monitored by cardiotachograph (CTG) from this point, and her movement was severely restricted although she did stand or kneel by the bed. Sarah tried Entenox for pain relief but disliked the sensation of being drunk and found it made the pain harder to deal with.
The midwife was reluctant to augment the labour with syntocinon (Oxytocin) immediately and hoped Sarah’s body would begin to contract more frequently. 2 hours later contractions were strong but still only 2 in 10 minutes so a Syntocinon drip was put up to augment the labour. When Sarah’s contractions were 4 in 10 minutes she found it impossible to cope with such intense and constant pain and requested an epidural.
My shift ended shortly after this but I saw Sarah the next day in the postnatal ward. She had been satisfied with her epidural anaesthesia, and had laboured for a further 8 hours and had a ventouse delivery for a prolonged second stage. Sarah had a lovely baby boy was breast feeding successfully and seemed pleased with the outcome.
Attending to Feelings
I was initially very disappointed and angry for Sarah, as she was having an induction of labour at 10 days postdates with no medical indication. I felt it was an unnecessary intervention, which was likely to lead to more interventions. As Sarah particularly wanted a natural birth I felt this was unfair. As the labour progressed through the artificial rupture of membranes to augmentation I was increasingly distressed for Sarah as her pain became artificially increased and became sure she would not have the type of birth she wanted. I felt powerless to stop the cascade of interventions that had begun, and tried desperately to support Sarah in what ever she wanted to do.
When Sarah so vehemently disliked Entenox, I explained to her that she also may dislike pethidine which can lead to similar sensations while only reducing the perception of pain a small amount, but that an epidural would not have the same effect. In retrospect I felt that this influenced her decision to have an epidural and I felt guilty initially. On further reflection I am sure if Sarah had used pethidine she would have found it an intensely unpleasant experience, as she so disliked the feeling of being out of control. I feel it could have been a traumatic experience and that I gave unbiased advice based on my knowledge of the pain relief methods.
Evaluating Experience
Induction of labour is indicated when the benefits to the mother or fetus are increased by ending the pregnancy (Shiers, 1999). As term delivery occurs over a period of 37-42 weeks it is arguable as to whether induction should take place before 42 weeks when there is no medical indication, especially when dating is often inaccurate.
When the hazards of ARM and the hazards of oxytocin are taken into account, I would argue that the risks of induction on a woman only 10 days post dates are far greater than allowing the pregnancy to continue.
I felt that Sarah had not been given an informed choice about induction of labour, she had been told that there was risk to the baby if the pregnancy continued and this was not necessarily true. She had not been adequately informed however, about the risks of induction of labour. Sarah much desired a natural birth without interventions and she had been led to believe that this would not be a problem if she was induced. She was not informed about the labour being considered abnormal and her being restricted, nor was she informed about the increased likelihood of requiring pain relief (Shiers, 1999). By the time I met Sarah I felt it would be unwise to discuss these subjects as it was too late to stop the induction and I did not want Sarah to loose confidence in her care.
I felt I could not act as an advocate for Sarah as she had already consented to induction and this was following its usual pattern as defined by hospital policy. I was unsure of the research around the subject and felt I did not have enough power to argue her case as a student. On one occasion I did feel in the position to act as an advocate for Sarah, when she was offered a scalp electrode, to monitor the baby. I feel I supported her in her wish to refuse.
I as a student was not accountable for the care Sarah was receiving, as I did not make any decisions and had minimal input, only taking observations and giving support (Etuk, 2001). Had I have been accountable I do not feel I could have supported an induction of labour in these circumstances. My accountability did extend to confidentiality and I feel I have never had a problem maintaining this for any client.
Assessment of Competence
I feel within the limitations of my student status I am developing a professional approach. I am certainly aware of the concepts of informed choice, advocacy, accountability and confidentiality and apply them whenever I have opportunity.
I must further develop my confidence so that I can act as an advocate for women, and keep expanding my knowledge base so I feel I can argue my case well. I must develop the habit of routinely questioning interventions and never allow myself to become brainwashed by the medical perspective on childbirth. I must maintain my pride in the profession of midwifery and see its strengths rather than its limitations.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Etuk E (2001) Professionalism and accountability: what do they mean in midwifery practice? The Practicing Midwife 4 (7) 28-30
Shiers C (1999) Prolonged pregnancy and disorders of uterine action (Chapter 26) In Bennett V and Brown L (Eds) Myles Textbook for Midwives London Churchill Livingstone
Learning Outcome 3
- Demonstrate the ability to undertake and interpret clinical measurement to:
1) Recognise normal parameters of health in the mother
2) Recognise normal health in the baby
3) Recognise normal progress in ante-natal, intra-natal and post-natal period but report to significant other.
I will be reflecting upon my experience of antenatal and postnatal examinations and the partograph as a tool for monitoring health and progress in the mother and fetus, using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
In the community I have had a great deal of experience undertaking antenatal examinations. A standard examination includes: -
- Urinalysis – to test for glucose and protein
- Blood pressure measurement
- Abdominal examination – inspection, palpation and auscultation with a Pinard’s Stethoscope and a sonicaid, and also measurement of syphysis-fundal height
- May also include history taking (at booking)
- Information giving i.e. on screening tests
On the postnatal ward and in the community I have undertaken examinations of mother and newborn. Standard checks include:-
Mother
- Breasts – to check for problems i.e. soreness, thrush, mastitis
- Legs – to check for deep vein thrombosis, thrombophlebitis
- Uterus – to check involution
- Wound or perineum – to check healing
- Diet – to ensure healthy food is being consumed
- Rest – to promote resting during the day when baby is asleep
- Pelvic floor exercises – to prevent incontinence
- Bowels and bladder – to ensure all is functioning well, to prevent constipation
- Lochia – to observe for any change which may indicate infection
Baby
- Skin – observe for rashes, infections
- Colour – observe for jaundice
- Cord – observe for separation and infection
- Bowels and bladder – ensure adequate nutrition
- Eyes – observe for infection, cataracts
- Mouth – observe for patency, thrush
- Feeding – ensure feeding well established
Throughout my experiences on labour ward, one of the major tools I have used for identifying and monitoring health and progress in the mother and fetus is the partograph. In using the partograph I have developed a methodical logical process of taking observations and recording them in a meaningful way. The charts of the partograph allow for monitoring at fifteen minute intervals including:
- Fetal heart rate
- Maternal temperature
- Pulse
- Blood pressure
- Details of vaginal examinations
- Strength of contractions
- Frequency of contractions in terms of the number in ten minutes
- Fluid balance
- Urine analysis
- Drugs administered (Cassidy, 1999)
As soon as a woman begins labour, the chart is used to record the progress of her labour, in particular the rate of dilatation - or progressive opening - of her cervix and the pattern of contractions. Progress of labour is monitored at four hourly intervals. General observations, such as taking the heart rate of mother and baby, are made more frequently. In this way, midwives can determine whether labour is progressing normally (World Health Organisation {WHO}, 1994).
Attending to Feelings
At first I was uncomfortable taking clinical measurements such as blood pressure, pulse, urinalysis and filling out important documents such as the partograph. The responsibility of the measurements was worrying and I often had my mentor double check my work for the initial weeks. Over the clinical placement I have gained competence and confidence and now feel more at ease with clinical measurements.
Evaluating Experience
I feel I have achieved the competences required by the module. I feel confident in recognising normal and abnormal clinical measurements in the mother and fetus and understand the procedures involved if the situation becomes abnormal. I feel I understand what constitutes normal progress in the antenatal, intranatal and postnatal periods. I understand as stated in the Midwives Rules and Code of Practice (NMC, 2002 p17) that “where there is a deviation from the norm” outside my sphere of practice that a qualified health professional who is expected to have the required skills must be called.
The partograph is a graphic recording of progress of labour for both the mother and the fetus. The information acts as an early warning system, detecting labour that is not progressing normally, indicating when augmentation of labour is appropriate, and recognising early cephalo-pelvic disproportion. It also improves the quality and regularity of all observations on the fetus and mother in labour (WHO, 1988).
I have found the partograph to be a useful aid to learning as it clearly shows what observations need to be taken what has already been done and any deviations from the norm. The Partograph identifies a normal progression of labour; both mother and midwife are reassured. One of the WHO's concerns is that caesarean sections may be used unnecessarily in many health facilities. Rates of caesarean delivery have been going up around the world, increasing health risks to women but showing little evidence of better rates of fetal survival. According to the WHO the Partograph has potential not only to reduce fetal and maternal mortality and morbidity but also to reduce the rising tide of caesarean deliveries. The Partograph is an inexpensive, low technology tool which requires basic, though vital, midwifery skills to save lives (WHO, 1994)
Assessment of Competence
I feel confident I have achieved the outcomes of this module in relation to clinical measurement. I feel my skills in taking measurements such as blood pressure and auscultation of the fetal heart have developed immensely. I am aware of the need to develop certain skills such as vaginal examination. I have not had much opportunity to develop this skill as not all women are willing to allow a student to make an assessment, as it needs to be verified by a midwife and the examinations are uncomfortable.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Cassidy P (1999) The first stage of labour: physiology and early care Chapter 21 in Bennett V R and Brown L K (Eds) Myles Textbook for Midwives. London, Churchill Livingstone
World Health Organisation – WHO (1988) The partograph: a managerial tool for the prevention of prolonged labour. Section 1: the principle and strategy. Geneva WHO
World Health Organisation - WHO (1994) WHO partograph reduces complications of labour and childbirth. Geneva WHO.
Learning Outcome 4
· Demonstrate a basic understanding of pharmacology and safe administration of drugs.
I will be reflecting upon my experience of administering drugs in a simulated setting during the Objective Structured Clinical Exam (OSCE) and in practice using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
For the module Midwifery Practice 1, skills in pharmacology and drug administration had to be developed. These were to be examined both in an OSCE and by gaining competences in clinical practice. The OSCE consisted of five work stations on the following components:
1 Hand washing technique prior to the handling of drugs
2 Administration of oral medicines
3 Intramuscular injection
4 Administration of a rectal suppository
5 Pharmacology questionnaire and self-evaluation
I prepared for the OSCE by studying pharmacology and drug administration, using ‘Skills for Midwifery Practice’ (Johnson & Taylor, (2000) ‘The Midwife’s Pharmacopeia’ (Banister, 1997) and ‘Guidelines for the administration of medicines’ (Nursing and Midwifery Council {NMC}, 2002). I learned the route, dose, indications, side effects, contraindications and interactions of the drugs commonly used by midwives. I also learned abbreviations for route, legal issues for controlled drugs and safe procedure for administering drugs.
I had little opportunity to administer medicines in practice prior to the OSCE although I did give a subcutaneous injection of Fragmin to a woman two days post lower segment caesarean section (LSCS).
The OSCE took place and I attempted to complete each station to the best of my ability. After the OSCE I had opportunity to administer intramuscular injections of pethidine and Syntometrine, and a rectal suppository of Paracetamol to women in labour and post partum.
While caring for women in labour and during parentcraft sessions, I have had a great deal of experience providing information about pharmacological and non-pharmacological methods of pain relief for labour and also about drugs such as Syntometrine and Vitamin K so that parents can make an informed choice. I have also spent time explaining drugs to women who are to self administer.
Attending to Feelings
I was initially very worried about drug administration, particularly giving intramuscular injections. Like many people I have a slight fear of needles and the idea of having to give injections was daunting for me. I feel the practice I had on dummies in the skills lab helped me to prepare for giving injections to real people. My first experience of giving an injection was a subcutaneous injection of Fragmin, which came ready prepared and had a very short needle. This gave me the confidence to give intramuscular injections which was a scary and exhilarating experience. After conquering my fear I felt much more positive about my ability to become a midwife.
I was very nervous before and during the OSCE, I felt under pressure to perform in a strict time frame (5 minutes at each station) and felt I did not perform to the best of my ability. I am aware I made silly mistakes such as not checking an expiry date of one of the drugs. Which I do not feel I would have made in practice, I was disappointed with myself for not performing well under pressure.
Evaluating Experience
I was trying to achieve greater knowledge of pharmacology and some degree of competence in the administration of medicines. I did not allow my fears to hold me back and I gained every experience I could in the practice setting.
I gained a great deal of knowledge from the NMC (2002) publication Guidelines for the administration of medicines (page 6). Which provided the basis for the OSCE examination and the grounding for my safe administration of drugs in practice. I feel I am now aware of the therapeutic uses of the medicines I have administered, including dosage, side effects, precautions and contra-indications. I am aware of the need to be certain of the identity of the patient to whom the medicine is to be administered. I consciously check that the prescription is clearly written and signed. I understand dosage, method of administration, route and timing of the administration. I have learned to check the expiry date of the medication to be administered, and check that the patient is not allergic to the medication. I always make clear records and get them countersigned by a registered midwife.
I am aware that when giving drugs to women in labour it is sometimes difficult to fully obtain consent, as they are in pain and not always completely aware of their surroundings. I will always ensure that full consent for drugs such as Syntometrine is obtained, in the antenatal period if possible or in the early stages of labour. Other drugs such as those for pain relief should also be fully discussed as early as possible to allow informed decisions to be made.
Assessment of Competence
I am happy I have achieved the outcomes set out by this module, and would like to develop my practice in the following ways:
Some drug administrations can require complex calculations to ensure that the correct volume or quantity of medication is administered (NMC, 2002). I am aware of my own uncertainty with drug calculations and plan to practice extensively and improve my confidence in this area.
Many women are using complimentary and alternative therapies in labour, and may often ask for advice. The NMC (2002) states that unless qualified in the use of these therapies we a not in a position to recommend of administer them. I would like to expand my knowledge in this area, particularly so I have something to offer women who would like to try non-pharmacological methods of pain relief
I feel it is important for me to have a clear understanding of my responsibilities in regard to administration of medicines. So that I may meet the recommendations of Changing Childbirth (Department of Health, 1993) to provide midwife-led care without the involvement of medical practitioners.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Banister C (1997) The Midwife’s Pharmacopeia Oxford Books for Midwives
Department of Health (1993) Changing Childbirth Report of the expert maternity group HMSO London
Johnson R Taylor W (2000) Skills for Midwifery Practice London Churchill Livingstone
Nursing and Midwifery Council (NMC) (2002) Guidelines for the administration of medicines London NMC
Learning Outcome 5- Keep accurate and legible professional and personal records.
I will be reflecting upon my experience of record keeping using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
As a requirement of my clinical midwifery placements, I engage in many kinds of record keeping. From filling out women’s hand held notes, hospital records for labour care and hospital birth registers. For my own requirements, I must keep details of deliveries, and care undertaken by myself to provide for fulfilment of European Union requirements for midwives. After a short time on placement I began to realise the importance of having more detailed personal notes in order to remember accurately events in practice and also for the purpose of auditing my experiences and eventually auditing my own practice. I purchased the ‘Midwives Birth Register’ from the Royal College of Midwives (RCM), but did not feel it provided enough scope to record some of the information I was particularly interested in. Thus I adapted the register and began recording information anonymously using only the hospital number as a means of identification.
Attending to Feelings
I was initially apprehensive about making entries into records, especially labour records as they are important documents and I was fearful about making errors. After reading what midwives had written and gaining experience, I began to feel more confident in making records. When I first began undertaking births on clinical placement, it felt as if I would never forget the details of those life changing experiences. It soon became apparent that I was forgetting details and that even the notes I had been making were not prompting me to recall everything I would have liked. Since developing the birth register I am more aware of the need to take more detailed notes.
Evaluating Experience
I feel I have learned a great deal about the importance and skill of record keeping throughout this module.
The Midwives Rules and Code of Practice (NMC, 2002b, p18) states:
“A practicing midwife shall keep as contemporaneously as is reasonable detailed records of observations, care given and medicine or other forms of pain relief administered by her to all mothers and babies” Record keeping is an integral part of midwifery practice and is essential for providing good care for women and their families (NMC, 2002a) Record keeping is essential to promote, continuity, effective communication between professionals, an accurate account of events, detection of problems and a change in condition.
The quality of record keeping is indicative to the quality of practice, excellent record keeping being essential to safe practice. The RCM recommends keeping a birth register to audit practice. They suggest keeping a register allows for reflection and if necessary changes in practice. Good practice can only be achieved if midwives monitor their practice and ensure that it is based on reliable current evidence (RCM, 2002).
Clinical audit is about improving practice and providing a better service for clients. Midwives should measure and demonstrate the effectiveness of the care they provide and one way to do this is clinical audit (Beresford, 1999). Clinical audit is an effective way to realise evidence-based practice.
Assessment of Competence
I intend to keep excellent contemporaneous records as part of my practice, as I feel this is a cornerstone of good practice. At present my record keeping skills are in their infancy, but I hope to develop them through further reading and practice.
I hope eventually to use my records to audit my practice to ensure that it is evidence based, and remains so as medical knowledge progresses.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Beresford G (1999) Quality assurance in maternity care (Chapter 8) In Bennett V and Brown L (Eds) Myles Textbook for Midwives London Churchill Livingstone
Nursing and Midwifery Council (2002a) Guidelines for records and record keeping NMC London Reprint of UKCC document published 1998
Nursing and Midwifery Council (2002b) Midwives Rules and Code of Practice NMC London Reprint of UKCC document published 1998
Royal College of Midwives (2002) Midwives Birth Register. RCM London
Learning Outcome 6- Demonstrate skills and knowledge of health and safety at work.
I will be reflecting upon my experiences of health and safety during this clinical practice session using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
During the Midwifery Practice 1, clinical practice module I had many varied experiences of health and safety issues. When we arrived on the unit for the first time there was no type of induction planned for us as there would be for other new members of staff, so for the initial shifts I was unaware of fire exits, the location of the CRASH trolley, how the emergency bells worked and general safety procedures. I managed to gain knowledge of these procedures through asking questions of the midwives I worked with. As I worked set days and not nights I did not get to spend time with my mentor within the hospital, so I had opportunity to work with several midwives and experience their varied ways of doing things.
The midwives had a diverse approach to universal precautions, with some regularly using plastic aprons, keeping nails short and polish free and removing jewellery and others not doing any of these things. All midwives were regular hand washers and wore appropriate gloves. Often there was not a health care support worker available on labour ward and the midwives would clean the rooms after a delivery. There were inevitably bodily fluids on the bed and on the floor, and these were not always cleaned thoroughly. The undersides of the beds had dried blood splashed onto them and had not been cleaned for a significant period of time. There seemed to be no obvious policy with regard to universal precautions although I did look in the policy book.
On one occasion the hospital fire trainer came to labour ward to see if anyone was available for a fire training session. I attended and learned the different fire alarms and procedures for getting patients out of the building. We also learned the types of fire extinguisher and the types of fire each is suitable for and where to congregate in case of fire.
During the placement a baby was abducted from a Midlands hospital which led to a review of security and a reiteration of procedures. Throughout the placement security consisted of visitors always being questioned before they were allowed in, babies being securely tagged and mothers and babies being kept together as far as possible.
Manual handling was not often used in the sense of lifting or moving patients as most of the women were mobile and able to move themselves. Although some women did expect to be moved although they were well and able to move themselves. Many midwives reported back problems and experienced discomfort when trying to assist breast feeding or position themselves at delivery. I personally found standing all day very tiring, and suffered lower back pain and sore feet for the initial few weeks although I tried to be aware of my posture and sit whenever possible. This discomfort subsided as I got used to standing on a regular basis.
Attending to Feelings
I was initially quite disoriented on labour ward and it would have been useful to have an official induction, to learn useful things such as the bell system, location of fire exits and CRASH trolley. Other members of staff had official inductions and I feel as students we were overlooked and expected to find our own way.
I found the differing practice techniques of many midwives interesting and confusing. I needed more guidance on simple health and safety issues such as how to apply sterile gloves and when to wear an apron. At the time I was not entirely aware of the lapses in universal precautions that were taking place but on reflection I note some of the procedures were dubious. On cleaning the rooms I was appalled at the level of cleanliness on surfaces that were not immediately in view and that even when large volumes of blood were present no specific chemical was used to clean it.
I found the fire safety training very useful but it was purely a case of being in the right place at the right time that I got to attend. There seems to be no structured way to train staff and the system is very ad hoc. As far as I am aware only one other student managed to attend fire training and the others are still lacking in important knowledge, with no apparent plan to get them up to date.
I feel the security system for mothers and babies worked very well as everyone took security very seriously, even before the much publicised abduction. Although the system was by no means foolproof, and I feel anyone determined to remove a baby from the unit could have done so. I initially felt very anxious answering the bell for people coming into the unit as I was worried I would let someone in by mistake. I have become more confident in questioning people and going to the door if I am unsure about them.
Evaluating Experience
During this placement I was trying to achieve a greater knowledge of health and safety and to incorporate good practice into my general routine. As practice was so varied I attempted to gain knowledge from books and research and to develop some general ideas about security, manual handling and universal precautions.
Williams, (1999) suggests that a security policy should be based on the following principles
- Raising staff awareness
- Raising visitor and parent awareness
- Use of an identification system
- Controlling entrance and exits
- Use of alarms (e.g. electronic tagging of babies)
- Video cameras
- Security problems reporting system
On reflection, I felt the security system was of limited effectiveness and that an electronic tagging system would be appropriate. Although staff were well aware of security procedures clients and guests were not, so I developed an information poster to inform mothers to be displayed in the postnatal ward (see evidence 6).
Research has shown that midwives are at risk of back injury (Williams, 1999). Risk factors are positions adopted when assisting breastfeeding and at delivery especially if delivery if off the bed (Hignett, 1996). Although this appears to be an undisputed fact there is little provision for midwives to get into safe positions to assist women. I have learned not to be a martyr and to always put the safety of my back first, although I feel this has been frowned upon by some of the midwives I have worked with.
I feel my knowledge of universal precautions has increased, and I have endeavoured to practice safely even if the midwife I am working with has not. I produced a universal precautions leaflet based on Chapter 8 of ‘Skills for Midwifery Practice’ (Johnson and Taylor 2000). Which I displayed in the unit, to remind myself and other midwives of good practice (See evidence 6).
Assessment of Competence
I feel I have achieved the objectives of the module with regard to health and safety. I have increased my awareness of:-
- Manual handling
- Fire safety
- Universal precautions
- Security
- & legislation surrounding health and safety
I hope to further improve my knowledge by reading more widely and updating skills such as manual handling. I feel that a health and safety induction on clinical placement would be beneficial for all students.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Hignett S (1996) Manual Handling risks in midwifery: identification of risk factors. British Journal of Midwifery. 4 (11) 590-596
Johnson R Taylor W (2000) Skills for Midwifery Practice London Churchill Livingstone
Williams J (1999) Risk management in midwifery (Chapter 7) In Bennett V and Brown L (Eds) Myles Textbook for Midwives London Churchill Livingstone
Health Promotion – Reflection
I will be reflecting upon my experiences of health promotion during this clinical practice session using a model for reflective practice adapted from Boud, Keogh and Walker (1985).
Returning to Experience
During the clinical placement I attended Parentcraft classes. The classes were run on Monday nights 7-9pm and were in groups of 3 covering the following topics
- Labour and pain relief
- Infant feeding
- Looking after a newborn and coping with parenthood
On evaluation of the sessions some individuals indicated they had not received enough information on infant feeding, particularly artificial feeding.
It is not uncommon in parentcraft classes for someone to discuss information they discovered on the internet. I thought it would be useful to have a website that would compliment the parentcraft classes.
I searched the internet for childbirth resources and focused particularly on infant feeding. I found the sites were often very pro breastfeeding or very information based, and didn’t provide information that allowed women to make an informed choice. I could not find any sites run by midwives.
I am in the process of developing my own website, it is currently online and has a breast feeding page (Southam, 2002) (See evidence 7) and is awaiting further development.
Attending to Feelings
I feel that parentcraft sessions are very useful, but are limited in what can be covered in the time frame. It is important to give people the information they need but not to overwhelm them. It is difficult to provide information to take home without giving lots of leaflets. I feel strongly that the internet could be an effective way of communicating with a growing population of parents, and providing them with information in a media that they can easily search to glean the information they require.
I felt we had failed in some way when evaluating the classes and it was expressed that more information was required on artificial feeding.
Evaluating Experience
I learned a great deal through parentcraft and by designing the website. The internet is in my opinion a good way to assess the concerns of the population as sites appear according to the interests people have.
The definition of a midwife (Nursing and Midwifery Council, 2002, p 25) states “She has an important task in health counselling and education, not only for the women, but also within the family and the community”.
Thus it is important we educate families about all aspects of parenting and to show no bias in education on infant feeding. Although it is a midwife’s duty to promote breast feeding as a healthy option there is no excuse for ignoring the artificial feeding population.
Assessment of Competence
The internet is a cheap, accessible way to provide information to families and it is currently being underutilised by midwives as a health promotion tool. I intend to further develop my website and also to develop a team website for the midwifery team I belong to and to use them as a vehicle to get information to the women in our care. I hope also to get women involved in requesting what information they would like on the sites by a feedback form. I feel the process will be positive for me, the other midwives and the families involved as it demonstrates a team approach to family centred care.
References
Boud D Keogh R Walker D (1985) Reflection: Turning Experience into Learning London Kogan Page
Southam M (2002) Breastfeeding www.geocities.com/childbirthresources/breastfeeding.htm Accessed 27/07/02
Nursing and Midwifery Council (NMC) (2002) Midwives rules and code of practice London NMC
Copyright © 2003 Michelle Southam. All rights reserved.
This site was last updated 03-04-2003
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