Oxford Handbook of Midwifery (16 page)

of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospi- tals, clinics or health units.
’

(Adopted by the International Confederation of Midwives Council meeting, 19 July, 2005, Brisbane, Australia. It supersedes the ICM ‘Definition of the Midwife’ (1972) and its amendments of 1990).

This definition tells us that midwives have a very diverse role and it is one that is expanding to meet the needs of modern society.

There are a number of little known facts about what midwives do and these are just a few examples from the Association of Radical Midwives:

• The midwife is the senior professional attendant at over 75% of births in the UK.
  
• Midwives can give total care to mother and baby from early pregnancy onwards, throughout childbirth, and until the baby is 28 days old.
  
• Midwives may legally set up in practice and advertise their midwifery services, either alone or in partnerships.
  
• It is not necessary to be a nurse in order to become a midwife, although many practising midwives also hold nurse qualifications in addition to their midwifery registration.
  
• Midwives are the only professionals concerned solely with maternity care. The only other people legally allowed to deliver babies are doctors (who need not have had specialist training in this field).
  

  1
  International Confederation of Midwives. Core documents. Available at: M www.
  internationalmidwives.org/Documentation/Coredocuments/tabid/322/Default.aspx (accessed 10.3.10).
  

  ROLE OF THE MIDWIFE
  

  5‌‌
  

  Role of the midwife
  

  The role of the midwife can be summed up in just two words: ‘delivering babies’! This is the common view of the public and other professionals of what midwives do.
  

  The Royal College of Midwives (RCM)—our professional organization— dedicated to promoting midwifery, and supporting mothers and babies by helping midwives in their professional sphere, says the following about the role of the midwife:
  

  ‘A midwife does more than just deliver babies. Because she is present at every birth, she is in a position to touch everyone’s life. A midwife is usually the first and main contact for the expectant mother during her pregnancy, and throughout labour and the postnatal period. She helps mothers to make
  

  informed choices about the services and options available to them by pro-
  

  viding as much information as possible.
  

  The role of the midwife is very diverse. She is a highly trained expert and carries out clinical examinations, provides health and parent education and supports the mother and her family throughout the childbearing process to help them adjust to their parental role.
  

  The midwife also works in partnership with other health and social care serv- ices to meet individual mothers’ needs, for example, teenage mothers, mothers who are socially excluded, disabled mothers, and mothers from diverse ethnic backgrounds.
  

  Midwives work in all health care settings; they work in the maternity unit of a large general hospital, in smaller stand-alone maternity units, in private maternity hospitals, in group practices, at birth centres, with general practi- tioners, and in the community.
  

  The majority of midwives practice within the NHS, working with other midwives in a team and other health care professional and support staff. Midwives can also practice independently and there is a small group of midwives who do so.
  

  In any one week, a midwife could find herself teaching antenatal classes, vis- iting women at home, attending a birth, providing parenting education to new mothers or speaking at a conference on her specialist area. So there is more to the role than delivering babies, even though this is a very important aspect of the work of the midwife.’
  

  In 2008 in England there were 672 807 livebirths. This is an increase of 2.7% from the previous year. In the same year there were 19 639 full- time equivalent midwives working in the National Health Service (NHS). This represents that for each of these working midwives there were 34 births, however not all working midwives offer the full range of services to women. This is because midwives fulfil many varied roles such as manage- rial or other specialist roles.
  

  CHAPTER 1
  Introduction
  

  6‌‌
  

  Principles for record keeping
  

  Record keeping is an integral part of midwifery practice, designed to assist the care process and enhance good communication between profes- sionals and clients. The Nursing and Midwifery Council (NMC)
  ¹
  has pub- lished guidelines for record keeping, the main recommendations of which are given below.
  

  The principles of good record keeping apply to all types of record, regardless of how they are held. These can include:
  

• Handwritten clinical notes
  
• Emails
  
• Letters to and from other health professionals
  
• Laboratory reports
  

  •
  X-rays
  

• Printouts from monitoring equipment
  
• Incident reports and statements
  
• Photographs
  
• Videos
  
• Tape-recordings of telephone conversations
  
• Text messages.
  

  Patient and client records should:
  

• Be factual, consistent, and accurate
  
• Be written as soon as possible after an event has occurred
  
• Be written clearly and so that the text cannot be erased
  
• Be dated accurately, timed, and signed, with the signature printed alongside the first entry
  
• Not include jargon, abbreviations, meaningless phrases, or offensive subjective statements
  
• Identify problems that have arisen and the steps taken to rectify them
  
• Be written with the involvement of the mother
  
• Provide clear evidence of the care planned, decisions made, care delivered, and information shared with the mother.
  

  Alterations or additions should be dated, timed, and signed so that the original entry is still clear.
  

  Record keeping is part of the midwife’s legal duty of care and should demonstrate:
  

• A full account of the assessment, and any care planned and provided for mother and baby
  
• Relevant information about the condition of the mother/baby and any measures taken in response to needs
  
• Evidence that all reasonable steps have been taken to care for the mother/baby and that their safety has not been compromised
  
• Any arrangements made for continuing care of the mother/baby.
  

You need to assume that any entries you make will be scrutinized at some point. It is normal practice for mothers to carry their own records in the antenatal period and have access to their postnatal notes while under the care of the midwife.

Other members of the team involved in the care of the mother and baby will also make entries into the care record, and information about the

PRINCIPLES FOR RECORD KEEPING

7

mother and baby is shared on a need-to-know basis. The ability to obtain information while respecting the mother’s confidentiality is essential.

Midwives should at all times give due regard to the way in which information systems are used, issues of access to records, and keeping their personal and professional knowledge and skills for record keeping responsibilities up to date.

It is a requirement of the NMC Midwives Rules and Standards (2004) that records are kept for at least 25 years.
²

1. Nursing and Midwifery Council (2009).
   Record Keeping: Guidance for Nurses and Midwives
   . London: Nursing and Midwifery Council.
   
2. Nursing and Midwifery Council (2004).
   Midwives Rules and Standards.
   London: Nursing and Midwifery Council.
   

   CHAPTER 1
   Introduction
   

   8‌‌
   

   Statutory midwifery supervision
   

   Statutory supervision of midwives provides a system of support and guid- ance for every midwife practising in the UK and is a legal requirement.
   ¹
   The purpose of supervision of midwives is to protect women and babies by:
   

   • Promoting best practice and excellence in care
     
   • Preventing poor practice
     
   • Intervening in unacceptable practice.
     

     The practising midwife’s responsibilities are to:
     

   • Ensure the safe and effective care of mothers and babies
     
   • Maintain fitness to practise
     
   • Maintain registration with the NMC.
     

     Your responsibility in maintaining current registration with the NMC
     is to:
     

   • Identify and meet the NMC requirements for PREP
     
   • Meet at least annually with your named supervisor of midwives
     
   • Notify your intention to practise annually to the local supervising authority (LSA) via your named supervisor of midwives (SOM)
     
   • Have a working knowledge of how NMC publications affect your practice.
     ²