Critical incident analysis: informed consent and the use of vaginal examinations during labour
This article is a reflection on a critical incident that occurred during a student placement. It outlines the facts of the incident and analyses the implications of the actions taken.
Midwives magazine: August 2003
Reflection is beneficial to all practitioners, as it allows them to focus on their skills and feelings (Woods, 1998). Varying types of practice can be identified and analysed, which should ultimately, help each of us define our roles within practice and therefore direct us toward becoming highly skilled, competent midwives. This paper reflects on and analyses a critical incident that occurred during a student placement. With the application of Gibbs' reflective cycle (Gibbs, 1988), the main components of the incident are identified and analysed, with reference to relevant literature.
Through retlection and analysis recommendations are made to aid and direct future practice. Confidentiality has been maintained throughout in accordance with NMC (2002) guidelines.
Description of incident
Ms Jones, a 24-year-old para 1, was admitted into hospital in spontaneous labour. On Ms Jones' initial assessment at 07.00hrs, a vaginal examination was performed, which indicated spontaneous rupture of membranes and cervical os dilatation of 4cm. Ms Jones was transferred to the delivery suite, where her care was taken over by a midwife and student. At this stage Ms Jones was coping weil and appeared to be very much in control of her labour.
Four hours later, and in accordance with the hospital policy, a further vaginal examination was performed in order to assess progress in labour. Cervical dilatation was estimates at 7cm to 8cm and the presenting part was -2cm in relation to the ischial spines. The cardiotocograph (CTG) showed that the fetal heart rate had a baseline of 145bpm, variability of 5bpm to 15bpm, one early deceleration was noted and regular uterine contractions were present. The midwife in charge was informed of progress and entered the room, looked brietly at the CTG reading and ordered the midwife to erect a syntocinon infusion. Half an hour later the midwife in charge re-entered the room and performed two vaginal examinations within 45 minutes. No informed consent was obtained or an abdominal palpation performed preceding the examination. During the second vaginal examination Ms Jones was in obvious pain and distress and lost contro!. The midwife in charge continued with the procedure and requested Ms Jones push down on her fingers to help dilate the cervix further. From this point on Ms Jones became increasingly distressed and emotional to the extent that the midwife in charge held her onto the bed for the delivery of the baby. No documentation was made regarding the last two vaginal examinations.
Feelings and thoughts
The rationale for choosing this incident was due to the negative feelings experienced while observing this situation.
While recognising that as a student, personal knowledge and experience in midwifery practice was limited during this clinical placement, it was still feit that this particular situation was inappropriately managed.
The first incident that provoked feelings of discomfort and anger was the manner in which the midwife in charge entered the room and took over the management of Ms Jones' care. There was minimal communication with Ms
Jones or the other two members of staff. This disruption in the continuity of care was inappropriate and the communication skills were inadequate. 1twas a contradiction to some of the recommendations of Delivering Choice (Department of Health (DH), 1994), as there was an obvious lack of respect shown to Ms Jones as an individual.
Ms Jones was in obvious pain and discomfort and, while recognising the need for advocacy, as a student it felt difficult to assert an opinion that would challenge the decision of the midwife in charge. This lack of assertiveness led to feelings of frustration and personal disappointment.
As a novice, entering a new profession, it was very disheartening to witness what appeared to be poor practice. There was a lack of communication and respect that should, ultimately, be at the care of every midwife's practice.
As a student midwife, much of the focus of preregistration education is on enabling a normal, safe delivery, with minimal intervention. Furthermore, the emphasis is on respecting the mother as an individual, who has a right to personal choice, continuity of care and control of her care (DH, 1993). In view of this, the main components of the critical incident have been identified as the issue of informed consent and the use of vaginal examinations during labour. It is beyond the scope of this paper to discuss any components other than these.
The purpose of vaginal examinations, during labour, is to give a detailed picture of progress and should always be preceded by an abdominal examination to correlate findings (Bennett and Brown, 1999). Vaginal examinations can estimate the dilatation and effacement of the cervical os, confirm the presenting part, estimate the level of the presenting part, diagnose the position of the fetus, determine whether the membranes are intact, and can exclude cord prolapse (Bennett and Brown, 1999; Warren, 1999).
A vaginal examination is also an invasive procedure that can introduce infection into the body (Marshall, 2000). There is also a risk of latex allergy, although this is rare, occurring in less than 1% of the general population and in 5% to 17% among healthcare workers (Warren, 1999a). In conjunction with this, research has indicated that vaginal examinations can have a significant psychological effect, in many women, leading to post-traumatic stress syndrome (Walsh, 2000).
Before proceeding with a vaginal examination, consent should be obtained. The midwives' Code of Professional Conduct stipulates that: 'As a registered midwife you must obtain consent before you give any treatment
or care' (NMC, 2002).
Symon (1997) highlighted that carrying out a procedure without consent, can be construed as a trespass or an actual assault. This was supported by Kean et al (2000), who stated that assault in civillaw is to subject a pregnant woman to any kind of examination, intervention, or treatment without consent. Consent requires three elements to be valid: the person must have the mental capacity to consent, must be given sufficient information and, finally, must give voluntarily consent (Kulkielka,2002).
In view of such information it is both justifiable and objective to suggest that this critical incident was indeed negative. Although the midwife in charge may have obtained information from the examination to determine progress, no abdominal palpation preceded the vaginal examinations. Ms Jones' risk of infection was increased and no informed consent was obtained. However, the positive aspect of this incident is that it generated reflection. The benefits of reflecting upon the experience have been identified as a useful learning tool that helps to unite practice and theory (Cameron and Mitchell, 1993). Through reflection, professional performance within the context of this incident, can be analysed to
enable potentiallearning (Chesney, 1996). In this instance it has caused reflection on the issues of informed consent and the use of vaginal examinations during labour. In conjunction with this, this situation prompted reflection on personal roles and areas of personal practice that need improvement, such as the need for assertiveness and being a stronger advocate. However, it is unfortunate that Ms Jones was subjected to this experience to enable learning to take place.
The optimal frequency of routine vaginal examinations in labour is unclear and policies vary from unit to unit (Clement, 1994).
According to Stuart (2000), there is a deficit in research-based evidence recommending the frequency and value of vaginal examinations and that it has become part of the strategy of the management of labours today.
Nolan (2001) suggested that midwives perform routine vaginal exarninations because the protocol says so, as opposed to it being required. However, based on the fact that midwives should provide evidence-based practice (NMC, 2002), it is therefore difficult to justify the practice of routine vaginal examinations during labour. Bennett and Brown (1999) have reinforced that there are occasions when it is imperative that a vaginal examination is made to obtain crucial information. However, with reference to the critical ineident, there was no apparent indication for two vaginal examinations to be carried out within a 45-minute period and no documentation was made as to why they were preformed.
Symon (2000) has suggested that there is an increase in investigations due to the prospect of litigation. Symon further highlighted that such defensive practice, in light of litigation, has serious implications for standards of care, as people are no longer treated as individuals. This is supported by Kirkam and Stapleton (2001), who believe that the fear of litigation is a major factor influencing the way in which choices are presented to or withheld from patients. This could be the reason why Ms Jones received no explanations prior to the procedures.
With reflection on the critical incident, it could be speculated that perhaps the midwife Student feature in charge performed the vaginal examinations, as she perceived progress in labour to be slow.
However, a senior member of staff was consulted, who studied the details of the incident and concluded that there was no indication that labour was slow or that a vaginal examination was required.
Furthermore, if fear of litigation were the motive for the vaginal examinations, then it would be plausible to suggest that the midwife in charge would have documented the findings in the notes.
Nolan (2001) has suggested that there are alternative methods of assessing progress in labour that could be used. For example, assessing the patterns of uterine contractions and the descent and flexion of the fetal head determined by abdominal palpation (Stuart, 2000). Hobbs (1998) describes the progression of a 'purpIe line' up to the natal cleft that is associated with cervical dilatation. However, there is no empirical research to support its reliability. It could be postulated that midwives do not use these other, less invasive alternatives, due to a lack of confidence in their diagnostic ability (Tilley, 2000), and perhaps, due to a lack of skills and knowledge (Stuart, 2000).
However, it is each rnidwife's responsibility to ensure that she keeps her '...knowledge and skills up to date throughout her working career' (NMC, 2002). In doing so, there should be an avoidance of providing care that may be outdated or harmful- psychologically, emotionally or physically (Judge, 1997). On observation, Ms Jones appeared to be in obvious distress and discomfort during the second examination performed by the midwife in charge. Studies have reported that women do find vaginal examinations to be traumatic, distressing, embarrassing, uncomfortable and can trigger off issues of sexual intimacy, especially if a mother has been sexually abused (Menage, 1996). It is unlikely that a midwife will know if a mother has been sexually abused unless it has been disclosed. Therefore, each midwife should treat every mother with sensitivity and respect. It could be postulated that the rnidwife in charge has become desensitised to the intrusive nature of vaginal examinations and has become unaware of the consequences of her actions. However, as Walsh (2000) pointed out, vaginal examinations are 'intimate, private and sexual: which highlights the need for midwives to be sensitive to the potential distress a vaginal examination can cause. Communication skills are the key factor to implement this.
Clement (1994) highlighted the importance of building up a relationship of trust between midwife and mother to ensure that the procedure is less traumatic. In this instance, Ms Jones did not know the midwife in charge and had not developed a relationship or rapport with her. Changing Childbirth (DH, 1993) reinforced the need for the provision of holistic, women-centred care, which enables women to enjoy pregnancy and childbirth as a positive experience (Clement et al, 1997). Yet, Ms Jones was provided with no psychological support or consideration from the midwife in charge. In order to provide holistic care, psychological factors need to be incorporated into midwifery care.
Nolan (2001) further highlighted that estimated cervical dilatation is an 'impressive measure' of how labour progresses and there can be variations and inaccuracies between each midwife's estimation. This was indicated
in a study by Tuffnell et al (1989) who found that two thirds of a sampie of healthcare professionals were inconsistent and often inaccurate in their estimation of cervical dilatation. Both midwives in this incident may
have had differing estimations of cervical dilatation and, therefore of how Ms Jones' labour was progressing. Continuity of care may have been more beneficial to Ms Jones and resuIted in less intrusive interventions, less anxiety, increased control and satisfaction with care (SandeIl, 1995).
Regardless of the indication or necessity for the vaginal examination performed on Ms Jones, the lack of informed consent can be identified as aseparate issue. Informed consent is a legal concept that can be obtained verbally or as a written document (SpindeIl and Suarez, 1995). Furthermore, empowering women by respecting them, providing information and offering choice is the essence of good midwifery care (Harrison, 1997), which would suggest that informed consent is both a legal and ethical necessity (NMC, 2002).
Marshall (2000) identified two duties that informed consent imposes on the midwife.
First and foremost, the midwife should disclose the nature, purpose, benefits and material risks of any proposed intrapartum procedure to the mother, using comprehensive terminology. Second, the midwife must obtain consent before proceeding with the treatment or investigation. The midwife in charge adhered to neither of these duties during the critical incident, therefore, the vaginal examination performed could be classified as an assauIt (Harrison, 1997).
Furthermore, the midwife in charge was not adhering to the Code of Professional Conduct, which stipulates the requirement for informed consent (NMC, 2002). Midwives have a professional responsibility to ensure that all their actions are within the remit of the code. The code emphasises personal and professional accountability that should be used as a yardstick by which to judge one's actions (White, 1998).
While acknowledging that issues such as policies and protocols, and professional accountability can govern informed choice (Judge, 1997), women still have the right to refuse treatment (Robinson, 1995).
It is insufficient to suggest that the midwife in charge was acting paternalistically. Ms Jones was a competent adult capable of receiving
information and making adecision, which has been identified as a requirement for consent.
Furthermore, Changing Childbirth has identified the receiving of information as being a patient's right (DH, 1993). However, it has been argued that midwives feel that the provision of too much information during labour can lead to irrational fear and, therefore, illogical decision-making (Spindel and Suarez, 1995). This can be further influenced by the pain and anxiety experienced during labour (Judge, 1997). This viewpoint challenges the idea that the mother is competent enough to make adecision and, therefore, can give informed choice.
However, prior to the vaginal examinations performed by the midwife in charge, Ms Jones appeared to be in control and coping well with her labour. In light of this argument, it could be suggested that the practice of good antenatal care could eliminate this problem. The provision of information at the appropriate time ensures that women are capable of making informed choices (Rodgers, 1999).
Although birthplans are not consent documents that give rise to any legal rights (Eddy, 1999), they can hold information from the mother, which should help direct midwifery practice during the intrapartum period (Harrison, 1997).
Marshall (2000) believes that women tend to be guided by the ethical principles of beneficence and non-maleficence during labour. This may lead to compliance to all interventions, as they are perceived necessary for the safety of the baby. Midwives are, therefore, in a powerful position to influence the choices mothers make regarding their care (Gilbert, 1995). This power is further enhanced by uniforms, identity badges, the environment and routine of the labour ward (Tilley, 2000). It may cause intimidation and, therefore, create an atrnosphere in which the mother finds it difficult to assert herself (Symons, 1997). In contrast, the presence of a midwife in uniform may be reassuring to many mothers, as they associate the title, uniform, and the badge, with a qualified and experienced person who is in complete control of the mother and baby.
However, in this situation Ms Jones may have felt intimidated by the fact that the midwife performing the vaginal examination was in charge and, therefore, in a position of authority. In view of this, it could be suggested that the other midwife and the student failed to act as an advocate for Ms Jones. Advocacy implies a fundamental ethical principle of beneficence (Richards, 1997), where the midwife and the student should have assisted Ms Jones in exercising her own autonomy. As the Code of Professional Conduct stipulates: 'You are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients' (NMC, 2002).
It could be suggested that while acknowledging that there are occasions when it is imperative that a vaginal examination is performed, there are other methods of assessing the progress of labour. It has been suggested that these methods are not used because midwives are not competent in their clinical skills and knowledge, thus indicating the need for the encouragement and promotion of continuous professional development and education throughout a midwife's career. In conjunction with this, the literature has highlighted the sexual issues surrounding childbirth. An awareness of such issues should be incorporated into pre- and post-registration education in order to improve psychological and emotional care of mothers (Devane, 1996).
Vaginal examinations are performed with regularity and frequency and appear to be accepted as routine procedures. The lack of evidence-based practice highlights the need for empirical research to ascertain if there is a rationale that justifies routine use of vaginal examinations in practice. In conjunction with this, vaginal examinations are intrusive procedures
that require informed consent. Informed consent is based on same fundamental values - women have a right to information and should ultimately, be the primary decision makers about what happens to their bo dies during labour (Mander, 1993). If midwives are to implement such holistic, women-centred care as recommended in Changing Childbirth (DH, 1993), midwives need to be educated on how to facilitate and respect individual choices while remaining professionally accountable for their practice (Symons, 1996).
The value of retlecting on this particular incident, by using Gibbs' (1988) reflective cycle has aided both personal development and professional practice. From a professional point of view, reflection has generated learning about the issues of vaginal examinations and informed consent that should help direct clinical practice, and has created an increased awareness about women's rights regarding decision-making and the legal implications of informed consent.
It has also highlighted the need to ensure personal skills and knowledge are adequate to provide a high and safe standard of care. In conjunction with this a personal area of weakness was identified through reflection.
There was a lack of assertiveness skills that should have been used to safeguard the wellbeing of Ms Jones and question the standard of care being provided (White, 1998). Both the student and staff midwife were professionally accountable in that they should have acted as an advocate for Ms Jones in accordance with the Code of Professional Conduct (NMC, 2002).
The incident that has been critically analysed has highlighted various factars that could be changed and implemented to improve future practice. Previous discussion with Ms Jones or the use of a birth plan could have helped establish her wishes regarding frequency and timing of vaginal examinations. This would have provided both the midwife and student
with a strong basis on which the actions of the midwife in charge could have been questioned.
By improving assertiveness skills, the midwife in charge could have been questioned and asked to justify her reasons for performing the examinations, and requested to document the same. Finally, it would have been beneficial to speak to Ms Jones postnatally in order to identify any emotional or psychological issues that needed attention.
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