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I answered each statement as I progressed through the form. My answers are in bold

Competency One:

“The midwife works in partnership with the woman/wahine throughout the maternity experience.”

Explanation

The word midwife has an inherent meaning of being “with woman”. The midwife acts as a professional companion to promote each woman’s right to empowerment to make informed choices about her pregnancy, birth experience, and early parenthood. The midwifery relationship enhances the health and well-being of the woman/wahine, the baby/tamaiti, and their family/whanau. The onus is on the midwife to create a functional partnership. The balance of ‘power’ within the partnership fluctuates but it is always understood that the woman/wahine has control over her own experience.

Describe briefly how your current practice meets this competency referring in particular to how you:

promote and provide continuity of woman-centred midwifery care;

I believe continuity of caregiver offers the best care for childbearing women; this is based on my caseloading experience of eight women over 6 weeks as a student, and due to the literature base which supports the model with high quality evidence (Benjamin, Y.; Walsh,D; Taub, N. (2001)).

A recent example of my professional practice facilitating this would be following a woman from birth centre low risk care to delivery suite, as auscultation of the fetal heart with a sonicaid indicated CTG monitoring. I was able to help her achieve a normal birth without an epidural her, provide breastfeeding help and give her care for the next two days on the ward.

 This woman centred approach I believe encourages feelings of confidence in women's ability to birth and parent, reduces rates of episiotomy and instrumental birth, and has numerous other positive outcomes backed up by evidence (Hatem et al 2008). I often request to work with women I have cared for previously, as I believe it offers better care, and is a very positive experience for parents and for myself.

acknowledge the woman’s culture;

I trained in in an area in which the main city is due to become one of the world's first plural cities (Leicestershire, UK) – this means no ethnic minority will be present. I have therefore worked with a range of clients; from privileged to poor socio-economic backgrounds, with a range of nationalities and language barriers, and women from Muslim, Hindu, Christian, Pagan, and other religions.

An example from my care would be facilitating the Islamic 'adhaan ' (call to prayer), a very important practice in Islamic culture involving a senior member of family saying a prayer as one of the first sounds a new baby hears. This can be difficult to facilitate on a busy delivery suite, but often supports the women culturally within her community, and makes for a good relationship between maternity staff and the woman and her family.

encourage the involvement of family;

My current hospital has started a 'Daddynatal' service to support men in their transition to parenthood. The attitude from these classes has perfused into the hospital and care is given still obviously primarily for the women and her neonate/s, but also for the partner and family, and her relationships which will support her in motherhood.

 A further example of encouraging involvement of the family is my facilitation of siblings to visit new babies early, and if possible family as well. It is important to allow time for rest, and also carefully consider if having family present soon after birth is the best woman-centred approach, but there is strong evidence to suggest a good social network makes for good outcomes(Tarkka and Paunonen 1996), and therefore I emphasise family involvement .

promote understanding that childbirth is a physiological process;

Currently my hospital offers waterbirth as an alternative to pharmacological pain relief in labour; I mention this in reference to this point as I believe the encouragement of alternate birth positions, the endorphins provided by the water, and the gentle hands off approach greatly encourages women to have faith in their ability to birth. 

Another example of my promotion of childbirth as a physiological process is on of my favourite aspects of care: parentcraft. If women come to look round the birth centre or delivery suite, I always try and make the time to recommend the birth aids like balls and slings to encourage upright positions, and talk through any questions or fears they might have.

facilitate informed decision-making;

I support informed decision making in my work in all aspects of pregnancy and birth, from; screening bloods; scans; dietary advice; to selecting the birth environment for example: home, birth centre, delivery suite; through use of non-pharmacological pain relief or epidural, pethidine, entonox; screening tests for neonates; infant feeding, and many more areas.

 It is very important to give balanced information without personal preferences, and to encourage the women to make a personal decision as she knows her needs best. To give an example, use of pethidine would be offered as part of access to pain relief; we would discuss the effects on the neonatal respiratory system, the effects opiate based pain relief can give, the alternatives, the possible side effects for the woman, and how she felt about it. I would give written information if appropriate to allow for time to think about her decision, especially if we were talking before she was in labour.

 As the UK Nursing and Midwifery council recommend (2008), I would decline answering 'what would you do' and keep encouraging her to make her own decision.

 negotiate the midwifery partnership;

I aim in my current practice to be as described by Walsh (1999); a 'professional friend'. This means knowing the woman, her preferences and birth plan, expectations and wants. It also means if an emergency arises, acting in the woman's best interests with her consent, but knowing already how she is likely to react.

For example, I recently looked after a woman who was frightened of intervention from delivery suite. Her Hb was too low for birth centre guidelines, but only just. We talked this through, and discussed the possible outcomes with her and discussed the matter with a consultant who was happy for her to birth in a low risk centre as she had been taking iron tablets since that result. We made a plan to have an active third stage and to have her in a low risk room closer to delivery suite.

 I was professional and respectful of her wishes, and talked to the consultant on my own in private as she did not want to see a doctor in labour. This facilitated a good trusting relationship between us; however, she was aware if an emergency such as post-partum haemorrhage had occurred, I would be quickly asking for her consent to intervene, for instance, cannulating and calling the medical team. I would also support her through any events like this.

 Overall, I negotiate the midwifery partnership by being personal, yet professional, with the women I look after.

maintain confidentiality and privacy;

I am always careful not to leave notes out and current practice at my hospital is to lock notes into a cabinet when not in immediate use. I also always log out of computers which have any care details; I understand this will become more of an issue as notes are entered electronically onto computer systems and have a great deal of respect for maintaining password systems and other insurances for confidentiality.

 I maintain privacy by knocking on client's doors before entering hospital rooms, and ensuring they know they can ask for time alone. I also make sure they have clothes/sheets/anything else they need to protect their privacy and dignity, and ensure other members of staff understand they need to maintain this privacy as well.

I also only share client information with staff who needed to know for care reasons.

Formulate and document the care plan.

I understand the important of documentation; it is to ensure safe and effective care so the next practitioner looking after the client doesn't miss vital information, for audit purposes to improve care, and for legal reasons.

 I am clear and to the point with my handwritten documentation, and follow guidelines from the hospital. I try to use graphs (partograms, growth charts) as I believe they can pick up patterns and problems easily.

 I understand the legal need to have notes, and although I try hard not to practice defensively to avoid documentation being the centre of care, I utilise documentation to fully support care.

Competency Two:

“The midwife applies comprehensive theoretical and scientific knowledge with the affective and technical skills needed to provide effective and safe midwifery care.”

Explanation

The competent midwife integrates knowledge and understanding, personal, professional and clinical skills within a legal and ethical framework. The actions of the midwife are directed towards a safe and satisfying outcome. The midwife utilises midwifery skills that facilitate the physiological processes of childbirth and balances these with the judicious use of intervention when appropriate.

Describe briefly how your current practice meets this competency referring in particular to how you:

work across the midwifery scope of practice which includes the provision of antenatal, intrapartum and postnatal care;

Antenatal care is often given my myself to women attending hospital for medical reasons, such as pre-eclampsia or diabetes; these women require collaboration with the medical team and monitoring using CTG and other scans, blood tests etcetera to meet their pregnancy needs. I care for low risk antenatal women by explaining the birth centre facilities, and making birth plans with them which are specific to their needs. During my training I looked after antenatal women in all stages of pregnancy and in many capacities, from 'booking in' appointments to cervical sweeps to try and induce labour.

 Intrapartum care forms a big part of my current work, and although my assigned area is low risk intrapartum care, I frequently look after women with higher risk needs such as medical conditions, syntocinon augmentation, and epidurals. I feel I have the best of both worlds, as I can look after low risk women and have a woman-centred attitude to care, while still maintaining and developing my high risk intrapartum skills.

 Postnatal care includes observations and suturing in the immediate postnatal period, but also working with women with a range of medical, social and psychological needs up to 28 days postnatally. I perform neonatal checks, care for women with sutures and caesarean scars, teach and support breastfeeding, and offer help for parenthood skills to name a few activities.

 interpret relevant investigative, diagnostic and screening tests;

As part of my midwifery role I interpret scan reports for growth issues/fetal abnormalities, check blood and other sample results to check for infections or issues in terms of medical conditions like pre-eclampsia, offer routine blood tests to identify low Hb and screening for blood borne infections, measure fundal height, palpate to ascertain growth and fetal position, and offer timely and sensitive vaginal examinations to name but a few tests.

 I am sensitive in giving results and would only do so if it was within my sphere of practice as a midwife, for instance, identifying rheus negative blood type. If results were more abnormal I would refer to the appropriate practitioner and work with them to achieve complex care needs.

 support and promote normal physiological birth;

An example of my doing this is low risk labour care which suggests non pharmacological pain relief including use of upright positions and mobilisation, water labour and birth, massage, music, and emotional support to support normal labour and good outcomes. Parentcraft and birth plans are also discussed above.

 make timely midwifery interventions throughout labour and birth;

In my capacity as a birth centre midwife I often have to make midwifery based clinical decisions; for instance amniotomy may be indicated if there is a lack of progress. In these decisions the whole clinical picture is taken into account, guidelines known and considered, and my midwifery colleagues would be aware of my plan and the woman's condition.

 A recent example from practice would be my recommendation that a woman take some time mobilising out of the birthing pool. This was due to her contractions slowing to 2 in 10 minutes; after hydration and some light food, and some mobilisation on dry land the contractions increased to 4 in 10 minutes. Full discussion with the woman and her partner was undertaken, and documentation included a plan in case cervical dilatation was not within normal limits at the next examination.

 Identify factors in the woman or her baby which indicate the necessity for consultation and/or referral;

This would be anything that fell out of normal midwifery care, and was out of my sphere of practice. This includes abnormal routine blood results indicating for instance pre-eclampsia or cholestasis; suspicious or pathological fetal heart auscultation; per vaginum blood loss; social concerns for instance parenthood support needed; mental illness like depression, schizophrenia, or borderline personality disorder; any obstetric emergencies; fetal or neonatal abnormality, and many more.

recognise and respond to any indication of difficulty and any emergency situation;

I am always vigilant to pick up indications of obstetric emergencies, and would always call for help early at for instance, excessive blood loss, pathological CTG, shoulder dystocia etcetera. My clinical area has numerous skills drills and my time on delivery suite both as a student and qualified midwife has given me good experience and training. I participate in obstetric emergencies as a member of the team, for instance rubbing up contractions/checking drugs with medical team in the case of postpartum haemorrhage, initiating HELPER manoeuvres and calling for help in case of shoulder dystocia.

 assess the health and well-being of the newborn;

I undertake the midwife's initial checks on neonates to assess for abnormalities that need referral such as cleft palate, hypospadias or talipes; also for anything that should be noted and discussed with parents like a Mongolian blue spot.

I undertake daily checks, assess feeding and overall well-being, do observations, can take and interpret bloods for jaundice and the day five heel prick test.

 promote and support breastfeeding;

Breastfeeding support in my care involves teaching positioning and attachment, confidence building, use of biological nurturing techniques, cup feeding, syringe feeding, and use of nasogastric tubes for unwell neonates as indicated.

 assess the health and well-being of the woman and baby throughout the postnatal period;

Checks are indicated normally over the first ten days for mother and neonate during which I can pick up any issues like difficulties adjusting to parenthood, infection, breastfeeding issues like sore breasts or mastitis, sutures or caesarean scar not healing well, and many more. Observations like blood pressure and pulse are useful; in depth conversation and having a positive relationship with the woman and her family are also key in identifying problems.

 do the end-point assessment of the woman and her baby before referral into well woman and well child services;

Discharge of women and babies is something I often complete on the ward; it is necessary to do a complete check and talk through normal maintenance of health through good diet, basic exercise, pelvic floor exercises, good social and family support, and ensuring women have a contact number so they can always get help and advice. Referral pathways should be in place if additional care is needed. I also give Information on neonatal and maternal illness and well-being, for instance, poor feeding or high temperature for neonates, and signs of deep vein thrombosis, or increase in lochia/offensive smell indicating infection for mothers. Basic cares such as bathing and nappy changing are also included in a final check before discharge.

share decision making with the woman;

I believe midwifery care should support women in making decisions about their care; for instance, if a woman decides she would like to forgo routine blood tests, as long as she understands the reasons for them and the possible outcomes from not having them, and understands she can still request them at any time, it is her choice.

 There are situations in which decisions have to be made quickly, for instance when emergency caesarean is indicated for fetal heart abnormalities, and in these situations a to the point explanation would be given by myself and informed consent obtained; having a good working relationship with women in key in these situations as I already have an idea of their likely reaction

provide accurate and timely documentation.

As discussed above, my documentation is to the point, clear, accurate and written as soon as is practicable in order to get the best account of events.

 Competency Three:

“The midwife promotes practices that enhance the health of the woman/wahine and her family/whanau and which encourage their participation in her health care.”

Explanation

Midwifery is a primary health service in that it recognises childbirth as significant and normal life event. The midwife is therefore responsible for supporting this process through health promotion, education, and information sharing, across all settings.

Describe briefly how your current practice meets this competency referring in particular to how you:

offer formal and informal learning opportunities to women and their families;

I have discussed how I offer informal learning opportunities as I show women around the birth centre, discussing mobilisation, light diet, use of music and massage, water therapy and birth partners to help achieve good outcomes.

Informal learning also is a part of my everyday care; for instance when taking a routine 28 week blood sample, I discuss diet in terms of iron rich food, and talk about the symptoms of anaemia with the woman and her family.

Formal learning includes parentcraft: as a student I often took sections of classes on active birth, breastfeeding and baby cares, and used videos, discussion, props such as pelvis and doll, and drawings to teach effectively. Leaflets to take home are a part of this.

Formal learning is also scheduled at discharge from hospital, when key topics are talked about, for instance Sudden Infant Death Syndrome. When discussing this I break information into a few key ideas, for instance, rooming in but not bed sharing, baby always on the back to sleep, and temperature. I then share other pieces of information such as dressing appropriately/effects of smoking as part of these categories. I provide a leaflet and a contact number for any questions, and I then discuss and get feedback on the topic with the woman and her family to ensure she has all the information clearly. I would also check there was no language barrier, and use a translator if necessary. It is important to actively involve women, and I would always discuss with them rather than just stating information.

 Learning in terms of parenting is also best when it's client specific; some women respond well to a large amount of medical information, and some want a basic overview. Taking into account the woman's prior knowledge also helps ensure critical information is present while maintaining a good working relationship.

 apply your understanding of infertility, complicated pregnancy, unexpected outcomes, abortion, adoption, loss, and grief to the care of women and their families.

I have cared for women involved in surrogacy, IVF, and adoption. These events are often emotionally charged, and require knowledge of legal aspects and other agencies such social workers. Being a good open listener, non-judgemental, and acknowledging and caring for the grief and other emotions women may experience is key to this type of care. Documentation is also very important to records events accurately.

 

I care for complicated pregnancies during shifts on delivery suite, and understand the need to collaborate with the medical team. A recent example would be a woman with threatened premature labour at 28 weeks; along side the medical team I gave physical care in terms of monitoring and observations, and made sure they had time to discuss outcomes with a consultant obstetrician. Overall, giving empathic care, keeping parents informed of events, saying when you don't know answers but finding out from relevant professionals, and being a good open listener are the key skills.

 

Pregnancy loss is something I had to quickly adapt to; I did not come across it so often as a student, but my first birth as a registered midwife was a term intrauterine death.

Using staff members to guide me through the complex paperwork and legal requirements was fairly challenging but rewarding. Supporting the woman and her family by giving physical support like pain relief; good care in terms of monitoring mum's well-being; respecting wishes in terms of clothing and treatment of the baby; offering continuity of care over two days; making sure more specialist members of staff who were trained to deal with grief were available and making sure the woman knew support systems such as SANDS were available was a humbling and appreciated experience.

I had a good relationship with the woman in question and was able to give her lots of my time to ensure she could ask for the emotional support she needed; I had positive feedback from her and her family and found the experience furthered my ability as a midwife.

As a student I had a two day placement at an abortion clinic and found it very interesting; I understand the physical process of medical/surgical abortion, and feel I can offer non-judgemental, empathetic, and supportive care to women undergoing abortion for a range of social and medical reasons. As a qualified midwife I have primarily looked after women undergoing abortion for fetal abnormalities. Legal documentation is of paramount importance, and acknowledging grief may be felt by women to same degree as any other kind of pregnancy or neonatal loss is key. In my current hospital, the care model involves women feeling in control of their care, and having choice about pain relief options and support partners being in hospital with them.

Competency Four:

“The midwife upholds professional midwifery standards and uses professional judgment as a reflective and critical practitioner when providing midwifery care.”

Explanation

As a member of the midwifery profession the midwife has responsibilities to the profession. The midwife must have the skills to recognise when midwifery practice is safe and satisfactory to the woman/wahine and her family/whanau.

Describe briefly how your current practice meets this competency referring in particular to how you:

demonstrate you accept personal accountability for your midwifery practice;

The Nursing and Midwifery Code (2008) in the UK plainly states that midwives are personally accountable for the work they do. I believe this is a good policy, and one that I would follow in any case, as clients rely on midwives at a vulnerable time in their lives. My professional pride means I always strive to give the best care I can, which includes clinical skills being kept up to date (see my curriculum vitae); attention to detail in terms of observation, history of clients and documentation; recognising quickly if an omission has occurred, apologising and making sure the task is corrected; and keeping professional and confidential about events that occur under my care.

A recent example of my taking personal accountability would be consulting my core midwife about a plan of care. A client requested amniotomy at 7 cm dilation as she believed it would speed her labour up and I talked through all the possible outcomes such as meconium and need for CTG, unlikely event of cord prolapse, and infection, in the knowledge that she trusted my judgement and skill as a midwife to make a good clinical decision. I also let her know I would not have recommended amniotomy normally in this situation as labour was progressing normally, but respected the woman's request and choice.

I consulted a more senior midwife for further information, and the hospital guidelines before undertaking the amniotomy. I then documented the informed choice of the client and the events. I acted in this way because if I can undertaken amniotomy without discussion, and cord prolapse or another problem had occurred, I would have been professionally accountable for the client’s decision as she would not have had informed choice. Discussing the action with the leader of my shift was also part of my own accountability to make sure the best knowledge available was applied to the clinical decision.

recognise and address your strengths and limitations in skill, knowledge and experience;

As qualified midwife for a year now, I constantly assess my strength and weaknesses and learning needs. This includes in clinical practice in terms of practising skills like attaching fetal scalp electrodes and suturing, to maintaining my thirst for knowledge and passion for my job which I have carried over from being a student. I also attend regular preceptorship meetings and do written work to improve my skills and make sure my knowledge is up to date (see my portfolio: 'Flying Start Workbook') 

An example of my strength in practice is my low risk labour support; I feel able to monitor intermittently whilst encouraging upright positions, massage, use of the pool etcetera (as described previously).

A recent example of my limitation in experience is suspecting breech presentation but not being able to confirm it. In this instance I called for medical review, and assisted in preparation for emergency caesarean. I emphasise calling for advice when I am not sure about a situation, and always try to improve my knowledge in these situations.

recognise the impact of policy on women, midwives and the maternity services provided in your own country;

Policies in the UK come from organisations such as the Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institute of Health and Clinical Excellence (NICE), and hospitals' own guidelines.

 They aim to use best evidence to support policies; for instance, meta-analysis of systematic reviews by NICE concluded that oxytocin should be recommended in the third stage of labour as routine.

This is an example of policy having an impact on a large number of women. It means midwives must be sure to give a balanced approach - while still stating research suggests that an active third stage will reduce risk of primary postpartum haemorrhage (NICE 2007).

I also make sure I discuss the option of physiological third stage as a safe option for low risk women. I talk about the lack of side effects like nausea and vomiting, and that it has no known long term effects on women's health, for example exhaustion at 6 weeks (NICE 2007).

Others policies I see impacting in my current practice include offering screening tests for fetus and mother, encouraging birth to be seen as a physiological process for low risk women, aiming for continuity of care, and encouraging breastfeeding.

I understand the New Zealand integrated model of care policy for women, and find it interesting in contrast to the model in the UK; the Changing Childbirth policy (1993) aimed for a similar model of care, though due to budget it was not feasible in the same way, though some aspects such aiming for continuity of midwife in community settings have been made and had some positive impact.

review your midwifery practice and reflect on and integrate feedback into your midwifery practice;

Currently I ask clients for feedback on discharge in an informal way, and had had some very positive feedback, and some interesting points to improve.

These included appreciation for empathetic care, and giving time to make decisions so clients don't feel rushed; these are areas I have maintained.

Constructive criticism has included a partner wanting a little more information during an obstetric emergency; I tend to now use health care assistants to explain what is happening if I can't. Feedback from colleagues and team leaders has mainly been positive, but I have appreciated tips on making transition time to theatres quicker by having paperwork completed early, and timekeeping in terms of making sure I get breaks as well as completing work!

 I am always interested in my work area's statistics in terms of normal birth and keep up to date with change of policy.

avoid imposing your own values and beliefs on others;

As expressed above, I always try to give balanced information and would decline answering 'what would you do'. Although I believe pregnancy and birth are normal and physiological processes, I also support women if they decide to labour with more high risk care, for instance an epidural, and never let my belief in this matter affect the care I give. I respect clients' choice about their care and their bodies.

I am not religious, but as indicated before, have worked with a range of women with different religious beliefs; I have never found it difficult to respect their views and aim to facilitate needs.

organise your time to allow participation in ongoing professional development; 

I attend regular meetings for my work area which feature skills drills, and attend monthly preceptorship meetings to ensure I am up to date and continue learning. I recently completed a Knowledge in Medical Systems fetal monitoring module (see my portfolio), a cannulation course, and group B streptococcus policy briefing.

assist and support student midwives;

I have worked with many student midwives as a qualified midwife. I enjoy teaching skills I have learned and feel it is one of the best ways to consolidate my own learning; I also enjoy working with students because they often have information about up to date research.

 I feel I am good at teaching and facilitate students learning styles, for instance using diagrams or written text, and breaking down physical clinical skills into stages. For instance, in teaching venepuncture I have used a diagram of the vein, assisted them with the tourniquete, and clearly instructed them in using the needle and bottle. Positive feedback is a large part of teaching as well to improve confidence in new skills.

Although I am a newly qualified midwife, students have worked with me and this has been positive for both parties. This is because I often ask for help/confirmation from other midwives that my plan is appropriate, and I feel this is a good message to pass on.

work collegiality and communicate effectively with other midwives and health professionals.

 As referred to above, I work with midwives in a team well and benefit from knowledge of other practitioners; a recent example from practice of my working with others is looking after a client who was 7 weeks pregnant, on a methadone program, had hyperemesis, and severe abdominal pain.

I worked with senior members of the midwifery team and a consultant obstetrician to work out the correct dose and type of pain relief to give her; worked with a specialist midwife, pharmacist and social worker to ensure her methadone programme and support was continued in the community; and the scan department to get diagnostic tests organised on behalf on the consultant. As the client was very demanding, I also had to organise my workload accordingly; my colleagues working with me on the ward took some of my other clients to assist me.

I felt supported by them and our good working relationship meant we approached the jobs on the ward as a team.

I feel particularly lucky to have worked with a few midwives I trained with at my current hospital. These and other band 5 midwives have bonded to form a good support network within the bigger maternity staff community, and there is camaraderie in what is often at the moment a stressful working environment.

I feel this makes care of a high standard, and has increased my skill, knowledge and enjoyment in terms of being a midwife in my first year of qualification.

References:

Benjamin, Y.; Walsh,D; Taub, N. (2001) A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomesMidwifery, Volume 17, Issue 3, Pages 234-240

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2

Nursing and Midwifery Council (NMC) (2008) The code: Standards of conduct, performance and ethics for nurses and midwives NMC, UK

National Institute of Clinical Excellence (NICE) (2007) Intrapartum care of

healthy women and their babies dur ing childbirth 2nd edition, National Collaborating Centre for Women’s and Children’s Health

Tarkka, M.; Paunonen, M. (1996), Social support and its impact on mothers’experiences of childbirth. Journal of Advanced Nursing, 23: 70–75.

Walsh, D. (1999) An ethnographic study of women's experience of partnership caseload midwifery practice: the professional as a Midwifery Volume 15, Issue 3 pp 165-176