Friday, July 05, 2013

documenting a 'Record of Understanding'

The National Midwifery Guidelines for Consultation and Referral (ACM Guidelines) are an essential tool for midwifery practice.  They set out, in a systematic way, the situations in which a midwife will initiate a conversation, or a consultation, or a referral of a woman receiving primary maternity care into a specialist level of care.

The third edition (2013) has recently been published (pictured here).  To order a copy, click here.

A new appendix to the new edition is called a 'Record of Understanding', to be used when a woman chooses to act outside the Guidelines or against the advice of her midwife. As I read through the Record of Understanding for the first time, my thoughts went to situations in which I might consider using this tool.  Recent situations in which I have prepared a written record of discussions between myself and a client, when the woman has chosen a pathway that may be at odds with usual professional advice include women who are planning homebirth after a previous caesarean, or women who have had a large number of children.

When using the new Guidelines' Appendix B: Record of Understanding, I will be required to ask the woman to answer, in writing, a series of questions:
1. What information, evidence, or concerns have you considered in your decision to decline the hospital's advice to have an elective caesarean?
2. What questions/ concerns do you have?
3. What is your understanding of the answers you received to your questions or concerns?
4. Did you discuss your maternity care option(s) with your midwife and/or other care providers? Why/why not?
5. What is your understanding of those decisions?
6. What questions do you have about your midwife's recommendations to you?
Decision-making in maternity care is always complex, and ongoing until the completion of the episode of care.  For example, a woman who finds that her baby is presenting as breech near Term is confronted with a whole series of big and small decisions: each one either opening or closing potential pathways.  The one basic choice that a woman has any degree of control over concerns the way the baby will be born: either spontaneously, or with medical management.  My role, as the woman's midwife, is to go with her and provide accurate information as she considers her options.
It seems to me that this 'Record of Understanding' has taken professional documentation to a new level, and this disturbs me.  The matter that I take issue with is the expectation, in the Guidelines, that a woman will provide written answers to these questions.  The unmentioned assumption seems to be that this documentation will be produced in the event of a coronial inquest or other professional inquiry.   I have a duty of care to the woman, and this includes supporting informed decision making.  The woman has no reciprocal duty to provide me with reasons for her choices.  The Australian Medical Association acknowledges this fact in its statement on maternal decision making.  A woman may have her own reasons for declining a recommended course of action in her maternity care, and should not be coerced or placed under pressure to explain that reason. 
The potential value of a written 'Record of Understanding' as it is described in the new Guidelines is that midwives and women will be forced to confront difficult decisions in a way that clearly has not happened in some of the well-known recent cases that have been reported publicly. 

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