During a panel debate at last year’s RCM annual conference, CMACE chair Professor James Walker called for obstetric and midwifery teams to show greater trust and cooperation. It was a message which was welcomed by an audience that was well aware of how relations on the labour ward can be tested from time to time.
It’s sentiment is shared by another leading obstetrician, Professor Sir Sabaratnam Arulkumaran, newly recognised by the RCM as an honorary fellow.
Arul, as he is known, qualified as a doctor in 1972 in Sri Lanka. He worked there for six years, then spent the next two decades in the UK and Singapore. He settled back in the UK in 1995, firstly in Nottingham, then London: ‘During that time I’ve been doing academic research, teaching and clinical work. But I’ve also been involved in activities beyond the hospital, for example in Nottingham I was non-executive director of the Southern Derbyshire Acute Trust. When I came to London I was a council member of the RCOG, then vice president for two years and finally president. But my relationship with midwives has gone on for three or four decades.’
Arul is now based at St George’s University of London but even when based in Singapore he would regularly visit the UK for conduct lectures. He still travels around the country to talk, in the main, about fetal surveillance – the majority of his audience are midwives.
It may be an unusual, if not unique, occurrence for an obstetrician to be inducted as an honorary fellow by the RCM and Arul sees it as ‘a great privilege.’ He explains: ‘I’ve worked closely with the RCM for about five or six years in my capacity as an officer of the RCOG. I was able to stimulate a number of joint projects such as
Safer childbirth: minimum standards for the organisation and delivery of care in labour and other documents promoting joint working.’
More recently, he has been championing the latest joint RCM/RCOG project on electronic fetal monitoring, eFM, but reducing rates of intervention in birth is another area close to Arul’s heart: ‘It’s important to have as many normal births as possible because the woman will have less complications of surgery. Certainly the obstetrician will try very hard to normalise a birth as much as possible. Obviously there is a debate about the intervention rate, can we reduce it? One thing that has been shown to be beneficial to promote normal birth is one-to-one care in labour. So that always has to be kept in mind.’
Arul says three factors are driving the intervention debate – finance, law and access to health care. He describes how in certain countries, there’s a financial incentive to medicalise birth. Secondly, a legal imperative can create a sense of uncertainty in a doctor, worried that something might go wrong, which leads to court action. The third factor Arul speaks of is the availability of care: ‘In Brazil, for example, some women opt for caesarean section because there’s not enough staff to look after them unless they do. For a caesarean section they know there’ll be a doctor and midwife there. They think that’s a better way to do it.’
He points out that as there is no financial incentive in this country, the key is to talk to the midwife and the woman and see how much can be achieved by having normal childbirth and move away from the medical and legal implications.
‘We’ve been working with Cathy Warwick and the RCM jointly in having some more senior staff input into cases – a consultant presence. A consultant doesn’t have to see every case on the labour ward, but if the consultant is there, the junior doctor can ask and the senior doctor can reassure the junior doctor by saying don’t worry, everything will be ok. But if the senior is not present and the junior is calling on the phone, whatever the junior says, the senior has to imagine what is going on.’
Arul’s view is that if there is a good relationship, people talk about things, but he warns against situations being blown out of proportion.
‘Take the RCM and RCOG: we work together and will continue to work together. Usually the problem stems with two or three obstetricians and four or five midwives who are having some difficulties trying to get along and communication issues flare up.’
Arul’s view is that, for the most part, relations are fine but because it’s common it goes unnoticed, but whenever there is an issue between obstetrician and midwife or some relationship difficulty arises it is unjustly magnified.
However, he says that’s not to suggest there is complacency: ‘The colleges have been worried about that in the situation of training days. If a student midwife is not treated well by a doctor then she might not feel like continuing with midwifery. So the colleges have a couple of joint working parties to see how we can smooth some of these things.
‘Bullying and harassment is something found in every single field. There’s no question about that. But the issue is actually more sensitive because the person who will lose out in the end is the woman if the doctor and midwife quarrel about something.’
Guidelines to which the colleges are working are harmonised, and the multidisciplinary training is bringing midwives and doctors together. As this work builds, Arul wants its emphasis to be felt at college level as well as trust level: ‘We should make an extra effort to identify the difficult personalities in some way and try to talk to them in some way and draw the line somewhere. Get on and do the work.
‘I don’t think it’s a big problem, out of 200 there may be three or four who have some difficulties.’
Ultimately, his message to midwives and obstetricians alike is that teamwork and communications are the two key elements: ‘Be compassionate about the care you give, always devote yourself for the woman and do it as a team. Discuss and debate but don’t have fights in front of the woman or the couple. Discuss differences outside the room and come to a common under-standing.’
To watch a video of the interview with Arul, visit:
www.rcm.org.uk/midwives/videos
