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Q u a l i t y W o r k
						
				
		
		
				I recently caught up with Cecile at the Robson Workshop at 
				National Women's Hospital. We chatted about what we were both up to 
				and before I knew it I was saying, "Yes, of course I'll write you an article 
				for." (Nice move Cecile!)
		
		
				I am no longer an active member of SAMCL. Following a period of feeling 
				burnt out, I decided I had to have a life style change. I now have an 
				interesting job at WDHB, my title is 'Midwife Co‐ordinator, Quality, 
				NSH' and am also one of the Local Coordinators for the PMMRC, which is 
				a recent service wide appointment. I also work one shift a fortnight 
				wherever I am needed to retain my practicing certificate, and I do a few 
				homebirths through the hospital to keep me happy!
		
		
				Let me enlighten you as to what my job actually entails! 
				I have 4 areas of focus in my work. The first area is ‘
				
						Best 
						practice’
				
				
						. 
						This means that I liaise closely with the Midwife Educator, 
				
				Clinical Midwife Coach, Clinical Charge Midwives and Emma Farmer, our 
				Associate Director of Midwifery on many issues about best practice. 
				Best practice has to become integrated within into our everyday 
				midwifery practice through our education programmes and within our 
				policies, protocols, RBPs and guidelines. This involves me doing a fair bit 
				of research into the latest and greatest and generally keeping up to date 
				with new midwifery issues as they arise. I also get landed with writing a 
				few policies..........but, with the dawning of the dreaded re‐certification 
				points, many midwives are now trying their hand at policy writing! It can 
				be a long process, but I believe we use a robust process, with 
				consultation at every stage with LMCs and hospital based staff. I often 
				‘help alongside’a midwife as she writes a policy. 
				
						It can be exciting to 
						discover that guidelines can help to change practice and raise 
						standards.
				
		
		
				I am also a resource person for midwives to come to. I joke about having an open door policy ‐ this maybe due to the fact that I don't have an office, I’ in a quieter part of the postnatal ward open to all..... I welcome midwives queries and listen to concerns, as this really keeps my feet on the ground as a midwife
		
		
				 
				
						The next area is ‘ 
				
						Consumer focus’
				
				. 
				
						I look at the Consumer 
						Feedback Forms that women are encouraged to complete at discharge. I try 
						to sort out any minor complaints amicably on the telephone, and I 
						photocopy forms which mention midwives by name and give the midwife a 
						copy ‐ knowing that you did make a difference is very encouraging for core 
						staff!
				
		
		
				I hold focus discussion groups every few months where women who have recently had a baby at NSH are invited to come back and tell us what it was like for them. We encourage them to spill all ‐ warts and all. I am very impressed to say we get relatively few complaints, but lots of great suggestions as to how we can help women during their transition into motherhood. Sometimes mums talk about stuff we didn't even think about. 
		
		
				I co‐opt (or maybe even coerce?) enthusiastic mums onto the second consumer group I’ involved with, the Consumer Forum. I have worked hard over the past 15 months to get a greater number of new mums involved with the Consumer Forum and am pleased to say that my various strategies have been fruitful. 
		
		
				We now have the Forum chaired by a consumer with several extremely articulate and generous mums supporting the group. Not allof the consumers are members of Parentcentre, La Leche League or Plunket, which I think is healthy, as they speak their own mind, not 'toe the party line'! 
		
		
				Midwives need to remember that consumers  are powerful. They can write letters to the hospital board asking why certain things happen (private obstetricians have been told that elective sections by maternal request are no longer allowed at NSH due to this intervention), they can request statistics on all sorts of things (bless them!), they can ask their friends to 
				support them in certain issues and generally raise awareness for the local 
				
						consumers. We must always remember our partnership 
				
				with the women we care for is what makes midwifery 
				strong.
		
		
				The third area is 
		
		
				
						Safety & Risk . 
				This covers health & safety, infection 
		
		control, emergency readiness, incident reporting, significant incident 
		reviews, risk registers…
		
				As my manager isn't a midwife, she often runs things by me "as an expert 
				midwife, for my opinion". Flattering, but I'm not sure how she copes with 
				some of the things I point out. An example ‐ in her Pandemic plan was a 
				suggestion that 90% of women would need to be birthed at home. 
		
		
				Now there's an idea…. What, NorthShore women birth at home?!!! We 
				appear to lack midwifery confidence that women can birth normally at 
				times, let alone be able to supply enough equipment suitable for 90% of 
				homebirths on the shore.....
				
				
		
		
				
						'Industry and Professional Standards’ 
				
				is the final area. There are 
		
		many regulatory standards that hospitals strive to meet covering a wide 
		range of issues, these include; Health & Disability Sector Standards, 
		infection control, restraint minimisation & safe practice, BFHI (voluntary of 
		course), meeting individual professional requirements and internal & 
		external audit.
		
				Some of these subjects I must confess, still zoom over my head, but my 
				manager does a lot of the nitty gritty reports as ‘he has a tidy legal mind’ 
				Thank goodness someone has, who likes this sort of thing!
		
		
				Strangely enough it is one aspect of this area of the job that I have 
				developed an enormous passion for. I keep the data on stillbirths, 
				coordinate and present our Perinatal Mortality Reviews. This can be a neglected area as most midwives find IUDs so distressing. However, I believe there is enormous value in becoming interested in this area. The stillbirth rate hasn’t dropped that much in the last 20 years, despite increased knowledge on healthy diet, healthy pregnancy, screening processes and antenatal detection of problems. We sometimes appear to fail to integrate our knowledge with our practices.
		
		
				As a Local Coordinator for the PMMRC I help to complete the PMMRC coding and classification forms ‐ these follow the PMMRC rapid reporting forms that LMCs complete online following a stillbirth. The PMMRC will be publishing a report including recommendations, from the first 6 months of data gathered last year.
		
		
				They are also about to produce a booklet about Post Mortem examination and placental examination, in an effort to increase the number of PMs performed. Despite what you may hear, in PM results we regularly find 
				there was a disease process resulting in an IUD, where medical input early 
				in subsequent pregnancies produces a consequent live birth. 
				
						Please  
				
				encourage families to consider a PM or pathologist’ examination 
				of placenta. The emotional distress women may have regarding PM 
				examinations is often counterbalanced by the knowledge gained for her 
				future pregnancies.
		
		
				
						A few tips for midwives. 
				
		
		It would appear that raised 
		
				
						BMI and IUD are linked 
				
				. Recording 
		
		BMI at the beginning of a pregnancy is 
		
				
						really 
				
				important, so please do it 
		
		without fail! Even when you may think it is hopeless, still give healthy 
		eating advice and offer a referral to a dietician. You may be the one who 
		makes a difference. 
		Refer women to see an obstetrician before 
		28/40 for a management plan.Where you have an obese client, consider doing a HbA1c test at booking. This is a more accurate test than a fructosamine or random blood sugar.• Fructosamine ‐ glycated albumin. Mean blood glucose over preceding 1 –3 weeks. The result can be altered by obesity and proteinuria
		.
		
				•
		
		HbA1c 
		< 6.0% ‐ glycosylated haemoglobin, 
		
				reflects the average blood glucose over the life of the red blood cell 
		
		( 90 –120 days)
o HbA1c of 5‐6% = BG of 4‐6 mmol/L o HbA1c of 9‐10% = BG of 11‐13 mmol/L
		
				•
		
		You can see HbA1c really tells you what her diet has been like for the past few months. 
		
				It should be below 6%. 
		
		
				•
		
		A raised HbA1c indicates possible GDM, so appropriate management can be given earlier than usual.
		
				The most accurate results from placental swabs 
		
		are obtained by swabbing between the 2 membranes.
		
				•
		
		This reduces maternal contamination and gives a truer indication of chorioamnionitis being present or not.
§An American study revealed that 
		
				90% 
		
		of women 
		
				preferred 
		
		to self swab vaginally and did it 
		
				more thoroughly 
		
		than health professionals.
Where 2 swabs were taken on the same woman, one by self one by health professional, the women’ results picked up more bugs –it was thought that we are too gentle!§
		
				
						Best pick up of GBS is done by a 
				
				
						
								perianal
								swab
						
				
		
		. 
		Instruct the woman to waggle the swab around in her lower vagina and to ‘treak it’up to her anus as she takes it out. This reduces the cost of doing 2 swabs (time in labelling etc too!) and is the standard way of detecting GBS in many countries.
		
				
						Author 
						Eleanor Gates