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Must try harder

Louise Silverton, Director for midwifery
23 December, 2015

Must try harder

Over the past year a number of things have unsettled me. There has though been a common cause for my reaction:  that of missed opportunities, for example, if something had been done differently or better, the outcome may well have been different and an adverse outcome averted.

Just to put this into context, I am referring to the content of a series of reports. From the Kirkup inquiry into University Hospitals of Morecombe Bay through to the two recently published MBRRACE reports into still birth and maternal mortality. For me, this theme rings out. Cathy Warwick’s address to Conference sounded another warning bell that “we are all part of the problem” and that we can and must do better, this was further evidence of the need to examine our practice and with others across the maternity team, strive to do things better next and every time.

These reports have also led to me reflect on my own practice. How was I taught to do things? How did I ensure that my practice was up to date? What advice did I give to women? Did they understand what I said and how to act on it? Did I only inform the woman and not her partner? Did my actions or failure to act directly lead to poor outcomes?

So why am I asking myself these particular questions? The answer is in the report I found most disturbing; that of the MBRRACE investigations into term antepartum stillbirths. The lessons were both simple and stark and are there for everyone. If you haven’t read it, I urge you to do so if only to read the excellent infographics that can be found here. You may also want to see how your unit fared against others of similar type for perinatal outcomes and this can be found here. These figures are for 2013 but the ones for 2014 will be available alongside the main report next spring.

I want to focus on a three areas of the report.

Firstly, let’s reflect on the measurement of fundal height. How did I learn? I am not sure (it was a very long time ago), probably in the class room but with most of the learning taking place in clinical practice. Taught by a midwife or clinical teacher (we have mentors now); but did she teach me right? We know that midwives are individuals and that practices (good and bad), are handed down. For many midwives they continue to practice the way they were taught until they retire hence the importance of making sure you keep up to date and undertake regular CPD. It is clear that measuring fundal height is not as simple and straightforward as we thought and practice has changed over time.  Whilst I knew to start at the fundus and to use a tape measure, I always used it number side up and sometimes measured more than once.  At Conference this year a community midwife was brave enough to stand up and admit that it was a student midwife who taught her the current technique designed to increase accuracy. How I admire her for realising that she could do better and for taking action. Clearly accuracy is also increased with continuity of carer but we need to standardise what we do even then.

And it isn’t enough just to take accurate measurements, the growth monitoring chart is a key midwifery tool and must be used. I am not going to get into the argument around standardised versus customised growth charts, what is important is that the measurement is plotted and if growth slows then the woman is referred for further tests. The report highlights the fact that not all measurements are plotted and that actions were not taken or started early enough when growth slowed – a missed opportunity.

Now to something less straightforward, changes in fetal movements. Reduced movement was present in over half of the case examined in the report. The thinking about fetal movement has clearly changed over time, no more counting but encouraging women (and yes, also their partners) to be aware of the individual pattern for their baby’s movements and the need to report changes in a timely manner. The report showed that some women attended more than once with concerns over changes to their baby’s movements and that insufficient action was taken. As is well known, antenatal CTGs do not seem to be a way of guaranteeing that all is well, they are not predictive of fetal wellbeing and, even when performed to provide reassurance, a number of deaths still occurred.  Where a woman attends more than once additional input is needed, she may need an ultrasound scan or other investigations. Whilst far from simple, these missed opportunities and the vital necessity of listening to women and taking their concerns seriously, should strike a chord with every midwife, it certainly did with me.

My third disappointment with the stillbirth report was the issue of bereavement care. The RCM has campaigned over many years for improvements in these services and for there to be a bereavement specialist midwife in every unit. I thought that this was a problem that we had cracked but clearly not. Even at the launch event bereavement midwives spoke about how their posts were under threat or that their hours had been savagely reduced (they are not alone in this, many specialist roles are under review due to cost). The report also spoke about lack of availability of suitable accommodation for bereaved parents, another area I thought we had addressed. Bereavement care is not an optional extra but an essential for the future wellbeing of the parents. Whilst, thankfully, few couples need this care, for those who do, it is as vital a part of their care as taking the woman’s pulse. And, let’s not forget, these midwives are also a vital resource in supporting those midwives and maternity support workers who provide the vast majority of care for bereaved parents.

Looking forward, I wonder what other simple changes to our practice could improve care in the future.

Any ideas? 

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