DEVELOPING THE MIDWIFERY CARE RELATIONSHIP/PARTNERSHIP

The first step in developing the care relationship is to facilitate open, interactive communication.

Good communication has three parts:

(1) the ability to listen. When you actively listen to another person you are providing the opportunity for them to openly communicate;

(2) how you respond to the person. Responding in easily understood language with information that is timely and useful, and presented clearly and honestly, enables informed decisions. Ensuring that the person has time to consider the information is important; and

(3) create an environment with privacy. Interruption-free discussion and the appropriate physical surroundings enhance open communication.

The next step in the midwifery care relationship is to recognise the woman as a partner in the care experience. A partnership can be initiated at any time, but it will take time to develop and will need to respond to changing circumstances. A partnership implies an informed woman and an informed midwife.

(A 4.1; 4.2; 4.3; 4.4; 4.5; 4.6; 4.8; 4.14.)

In a partnership there are individual and shared responsibilities. The focus is informed, shared decision-making in which the woman and midwife work together for the best possible health outcomes.

Shared decision-making involves:

! identifying the ideas and information that the woman has in relation to her individual care needs;

! responding to the woman’s ideas, concerns, and expectations with the appropriate level of information, advice and support; and

! developing and agreeing on a plan of care and involving others (partner, family, and other health care professionals) as appropriate.

(A: 4.1; 4.2; 4.3; 4.5; 4.6; 4.7.)

CONSENT

Throughout the care relationship consent should be considered as an ongoing exchange of information in which clinical reasoning is shared with the woman. This continual exchange of information not only enhances trust and confidence but also upholds the legal principles underpinning health care interventions. (A: 4.1; 4.2; 4.4; 4.6.)

It is a legal requirement and the right of each woman to give consent prior to any midwifery procedure/intervention.3 Therefore, you must:

! obtain consent of the woman before you perform any procedure/intervention; and

! provide sufficient information for the woman to make an informed decision.

The midwife should confirm and take the necessary action so that the woman has the knowledge to make informed decisions.

In order for consent to be valid, four conditions must be met. These are:

1. Informed disclosure that includes:

3

Procedures/intervention encompasses a range of midwifery care actions including body touch, assessment technique, test, treatment and therapy for the woman and her infant

! the nature and purpose of the intervention in the context of the plan of care;

! intended effects and side effects, risks, harms and anticipated benefits of the intervention;

! reasonable alternative to the intervention including risks, harms and benefits; and

! likely outcomes if the intervention is not given.

2. Comprehension of the information requiring:

! information in language that is understood by the woman: this may involve the services of interpreters and/or leaflets; and

! adequate time for the woman to consider the information.

3. Consent needs to be voluntary, made without coercion, threat, fraud, bribe or misrepresentation of the nature or necessity of the

intervention.

4. The woman has the capacity to give consent if she can:

! communicate her decisions;

! understand relevant information; and

! appreciate the situation and its consequences. (A 4.2; 4.15.)

If the woman has been given a drug that may affect her judgement, valid consent for a procedure/intervention may not be possible. In this situation, if possible:

! wait until the woman is able to make the competent judgement; and

! where possible, discuss the likelihood of a procedure/intervention at a relevant time (eg. end of antenatal period or early labour).

At anytime in the relationship the woman has the right to refuse or withdraw consent, and/or change her mind. Midwives need to respect such decisions.

In a situation where the woman’s decision is in conflict with your professional judgement, as a midwife you should:

! clarify the situation with the woman;

! ensure the woman is fully informed;

! negotiate referral if appropriate;

! with the consent of the woman, consult with colleagues and/or other members of the health team; and

! document the discussion and decisions, and ask the woman to sign and date the entry and include your signature.

(A: 4.1; 4.2; 4.4; 4.5; 4.8; 4.13; 4.15.)

In emergency situations, where a procedure/intervention is necessary to preserve life and the woman cannot make a decision (eg. she is unconscious), the law allows you to provide treatment without the woman’s consent, if you are acting in her best interests. Consult with colleagues and document all decisions.

SCENARIO

A woman attends a midwives’ clinic for a regular antenatal visit at 36 weeks gestation. The midwife’s clinical assessment confirms that the woman is

hypertensive. In discussion, the midwife advises a visit to the consultant, and test. The woman insist she feels well and refuses all treatment. She believes this is an over-reaction and decides to make other arrangements.

How could the midwife respond?

Strategies:

! listen to the woman’s ‘story’, draw her out on her feelings concerning care;

! discuss the care guidelines for women in the midwives’ clinic;

! provide specific information on risks, harms and benefits of the procedure/intervention and negotiate options;

! discuss the woman’s support system and together, identify appropriate options;

! inform other members of the team of the discussions;

! provide appropriate information leaflets or other resources and ensure there is time for the woman to consider the information;

! document all discussion and outcomes; and

! if the woman still chooses to leave the midwives’ clinic and make

alternative arrangements, provide information on how she may contact the clinic or facility should she reconsider her decision or want to discuss the issues later: keep communication lines open for her.

(A: 4.1; 4.2; 4.4; 4.5; 4.6; 4.7; 4.8; 4.12; 4.13)