To reflect upon our practice as midwives and nurses is considered very important. We “reflect” for assessment – carrying out nursing tasks, comparing this with the experience and knowledge of others as expressed in the academic journals, and then putting into words how well we think we did, what we failed to do well or consider, what we did well, and how we can do better.
We are also expected to reflect personally – on paper or screen – in order to understand and appreciate the people, situations and events we encounter. Obviously, there’s not much to reflect on when you are a very inexperienced first year student and rest assured, when there is a whole lot more experience, much of this will contain details of a highly confidential nature that I will not be able to share.
This afternoon, as I sit here at my desk, prettiness in front of me, the fresh popcorn Abby and I made for afternoon tea at my side, and a sweet beeswax candle burning gently with the scents of compassion – all in all, a privileged and fortunate position – I am compelled to share some of that which I have read lately. Last week, we performed our observations of the vital signs on fellow students. These were filmed and we have to reflect upon our performance. I have watched my video several times, collected articles pertinent to the issues I want to discuss – therapeutic communication – lovely, hand washing – forgot before I performed the first task, washed them then opened the bin with my hands so had to wash them again bah! execution of actual tasks – pretty good, bit fumbly with the timpanic thermometer – and I’m almost ready to write. And yet, there is one story that just keeps playing over and over in my head.
The details of this story are on the public record. The coroner’s report – yep, it’s a bad story – is available on line and the case was widely reported in the press at the time. And no, it’s not a terrible homebirth gone wrong (as popular as THAT tale is in the mainstream media). It’s a wonderful hospital birth gone atrociously wrong. A few years ago, a woman named Susannah gave birth to her fourth child in a large public hospital in Perth. She was healthy and strong. The birth was uncomplicated. The baby was perfect. Thirty hours later, Susannah was dead. Why? A hospital acquired infection – strep A – so easily treated but completely ignored.
Five hours after birthing her child, Susannah’s temperature hit 38 celsius and she had a bad headache and stomach pain. Panadol was administered and the midwife on duty advised the attending doctor. He was a very inexperienced doctor who had no suggestions. Two hours later, Susannah’s temperature spiked at 38.7, her pain was unbearable and her pulse racing at 120 beats per minute. As declared by the coroner, this is a crystal clear indicator of a postpartum infection. The doctor conceded to the midwife’s request to consider an infection (took bloods and sent them to the lab) but instead of starting Susannah on a simple antibiotic which would have dealt with the infection then and there, he prescribed morphine, put her on IV fluids and decided her symptoms were simply indicative of uterine involution. Really?
As the day progressed, Susannah was seen by four doctors – one a senior consultant. Her observations were taken erratically by the midwifery staff and very little of the doctors’ observations or suggestions were recorded in her notes. Her pain continued. Her blood pressure plummeted. Despite being pumped full of fluids, she could not pass urine. When it was extracted by catheter, it contained blood. Her bloods came back with all the markers for a strep A infection, but this was dismissed as irrelevant because the bottles used to collect the blood were out of date.
Susannah felt so very sick. By midnight she’d received multiple injections of morphine and the doctors treating her – the most senior of whom admitted in court that he did not once look at her observation chart – pondered the liklihood of kidney stones, renal colic, or a bodgy epidural. At 1.15am she required oxygen to breathe. Her husband was called at 1.30am – the same time they realised she had NO blood pressure. By 2 am, the doctors admitted she required care beyond their capabilities and an ambulance was called to transfer Susannah to the city’s largest intensive care facility. At 2.20am they gave her YET MORE MORPHINE.
By 3.26am Susannah had no pulse. The staff of the intensive care unit gave up their resuscitation attempts at 4.21.
All Susannah needed was a health care practitioner to look at her observation chart, interpret the results correctly and prescribe her a simple antibiotic.
The coroner found that the hospital – a modern, 21st century institution with all the bells and whistles - “clearly failed the deceased”. In fact, he wrote …
“In respect of Doctors Burke and Beckett (two of the junior doctors responsible for Susannah’s care) in particular it is difficult to understand how they were able to pass the necessary exams and to become medically qualified when they had such a poor appreciation of the basics as to be unable to appreciate the severity of the deceased’s condition as her health deteriorated under the watch of each of them, particularly as her pain levels and vital observations reflected that deterioration. “
I have read the report into Susannah’s death 3 times now. Each time, I feel my heartbeat race that bit faster, there’s a big lump in my throat that no amount of hot tea will get rid of, and eventually my eyes fill with ears. I am so very sad for Susannah and her family – but I’m also really, really dismayed and angry. I know that I will encounter many sad instances in my work as a midwife. And I understand how important it is to deal with these empathetically and professionally.
But here and now – as a student who has spent a lot of time this semester reading about the battle that continues to rage between the medical and midwifery professions both here and overseas – I am astounded and horrified. Oh! the pages and soundwaves our media and medical hierarchy fill with their accusations of intemperance, ignorance, unprofessionalism and neglect against those – usually midwives and women – who declare that birth is a natural part of life.
“It is not!” they shriek, scaring our community into uninformed submission and with not a shred of scientific evidence to back them up “It is potentially a medical emergency and the only good place for a birthing woman (only they don’t call her that – they refer to her as “the baby they need to deliver”) is in a hospital, on a bed, with all the technological, expensive, impersonal and invasive wonder we can muster.”
Is that so? Then why did Susannah die.
Because the health care we receive is largely dependent on the skills, knowledge, experience and compassion of the human being delivering it – be they a nurse, a midwife or a doctor. It’s that simple.
And if we cannot take regular, accurate vital signs that are professionally recorded and then appropriately assessed in order to establish a patient’s care plan, we should not be allowed anywhere near that poor patient.
That’s my reflection.
p.s. I should add that I did not give birth at home. Abigail was born at the Mater Mothers – a large public hospital in Brisbane. It was a straightforward birth with two lovely midwives – the Scottish Grahame and his student Mark – and an obstetrician who popped his head in from time to time. At this stage of my study, I see myself as practising within the healthcare system as this is where the vast majority of women in Australia birth their babies and I want to contribute to making the birth experiences of those who choose this form of care as happy, safe, satisfying and normal as possible. This might change … we ‘ll just have to wait and see.