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Introduction 

Introduction
Chapter:
Introduction
Author(s):

Janet Medforth

, Linda Ball

, Angela Walker

, Sue Battersby

, and Sarah Stables

DOI:
10.1093/med/9780198754787.003.0001
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date: 25 September 2020

Definition of a midwife

The official definition of a midwife comes from the International Confederation of Midwives (ICM):1

‘A midwife is a person who has successfully completed a midwifery education programme that is duly recognized in the country where it is located and that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.

Scope of Practice

The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.

This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practice in any setting including the home, community, hospitals, clinics or health units.’

This definition tells us that midwives have a very diverse role, and it is one that is expanding to meet the needs of modern society.

There are a number of little known facts about what midwives do, and these are just a few examples based on United Kingdom (UK) midwifery practice.

  • The midwife is the senior professional attendant at over 50% of births in the UK.

  • Midwives can give continuous care to mother and baby from early pregnancy onwards, throughout childbirth, and until the baby is 28 days old.

  • Midwives may legally set up in practice and advertise their midwifery services, either alone or in partnerships.

  • It is not necessary to be a nurse in order to become a midwife, although many practising midwives also hold nurse qualifications, in addition to their midwifery registration.

  • Midwives are the only professionals concerned solely with maternity care. The only other people legally allowed to deliver babies in the UK are doctors (who need not have had specialist training in this field).

Reference

1 International Confederation of Midwives (2011). ICM international definition of the midwife. Available at: Introduction www.internationalmidwives.org/assets/uploads/documents/Definition%20of%20the%20Midwife%20-%202011.pdf.

Role of the midwife

The Nursing and Midwifery Council (NMC, 2012)2 sets out standards of practice for midwives, including being able to deliver the following:

  • Safe and effective practice

  • Woman-centred care

  • Meeting ethical and legal requirements

  • Respect for individuals and communities

  • Quality and excellence

  • Lifelong learning

  • Evidence-based practice

  • Reflecting the changing nature of new practice.

In 2014, in England and Wales, there were 777 400 live births.3 This is a decrease of 1.9% from the previous year. In 2012, there were 21 132 full-time equivalent midwives working in the National Health Service (NHS).4 This represents that for each of these working midwives there were 36 births. However, not all working midwives offer the full range of services to women. This is because midwives fulfil many varied roles such as managerial, research, education, or other specialist roles.

According to the National Audit Office,4 midwives should be responsible for 29 births per year using Birthrate Plus, a workforce planning tool. This means that over 2000 additional midwives are needed to provide the commitment to continuity of care for all women.

So the midwife’s role is adapting to meet significant challenges within the childbearing population. Although the birthrate has fallen, the complexity facing women and midwives is on the increase from underlying medical conditions and women who face increased risks in childbirth due to a raised body mass index (BMI).5

Despite this, midwives remain the lead professional for normal birth in the UK and midwife-led care is deemed as safe as other care options.6

References

2 Nursing and Midwifery Council (2012). Midwives rules and standards 2012. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-midwives-rules-and-standards.pdf.

3 Office for National Statistics (2015). Annual mid-year population estimates: 2014. Available at: Introduction www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/2015-06-25.

4 National Audit Office (2013). Maternity services in England. Available at: Introduction www.nao.org.uk/wp-content/uploads/2013/11/10259-001-Maternity-Services-Book-1.pdf.

5 Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (eds.) on behalf of MBRRACE-UK (2014). Saving Lives, Improving Mothers’ Care: Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–2012. Oxford: National Perinatal Epidemiology Unit, University of Oxford.Find this resource:

6 Sandall J, Soltani H, Gates S, Shennan A, Devane D (2013). Midwife-led continuity models versus other models of care for childbearing women Cochrane Database Syst Rev 8: CD004667.Find this resource:

Principles for record-keeping

Record-keeping is an integral part of midwifery practice, designed to assist the care process and enhance good communication between professionals and clients. The NMC (2015)7 as part of the Code of Practice for Nurses and Midwives includes instructions for record-keeping, the main recommendations of which are given below.

  • Keep clear and accurate records relevant to your practice. This includes, but is not limited to, patient records. It includes all records that are relevant to your scope of practice. To achieve this, you must:

    • Complete all records at the time of, or as soon as possible after, an event, recording if the notes are written some time after the event

    • Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need

    • Complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

    • Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated, and timed, and do not include unnecessary abbreviations, jargon, or speculation

    • Take all steps to make sure that all records are kept securely

    • Collect, treat, and store all data and research findings appropriately.

Reference

7 Nursing and Midwifery Council (2015). The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Section 10. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf.

Statutory midwifery supervision

Statutory supervision of midwives has three distinct functions:

  1. 1. To provide a system of support and guidance for every practising midwife in the UK

  2. 2. To protect women and babies by actively promoting a safe standard of midwifery practice

  3. 3. To provide a regulatory aspect; this involves investigating substandard midwifery practice and/or poor outcomes to the mother and/or baby. Following investigations, supervisors make recommendations to resolve the issues found whilst supporting all involved.

The supervision framework has historically been a legal requirement8 which all maternity services have been obliged to provide to midwives and service users. However, more recently, the effectiveness of the existing model of supervision has been challenged with the publications of the Kings Fund report9 and the Kirkup report.10 Within each of the report’s recommendations it is suggested that the current arrangement of supervision is not appropriate for public protection and that the NMC should manage the regulatory aspect of midwives.

The Secretary of State for Health in England announced on 16 July 2015 that the government will change the legislation governing their regulation of midwives. The main effect of the changes will be to take supervision out of the NMC regulatory legislation. Ultimately this change will ensure that, as the regulator, the NMC is responsible for all regulatory decisions regarding midwives. It is likely that the proposed legislative change will take 12–18 months to complete. In the meantime, the current Midwives Rules and Standards11 remain in force. It is important that, during this time of transition, the NMC, along with employers of midwives and the midwifery community, continue to uphold them in the interest of women and babies.

Supervision currently covers a wide range of activity beyond regulatory investigations, including support, development and leadership. The above decision need not affect those activities.

The current purpose of supervision of midwives is to protect women and babies by:

  • Promoting best practice and excellence in care

  • Preventing poor practice

  • Intervening in unacceptable practice.

The practising midwife’s responsibilities are to:

  • Ensure safe and effective care of mothers and babies

  • Maintain fitness to practice

  • Maintain registration with the NMC.

Your responsibility in maintaining current registration with the NMC is to:

  • Identify and meet the NMC requirements for revalidation

  • Meet at least annually with your named supervisor of midwives (SoM)

  • Notify your intention to practice annually to the local supervising authority (LSA) via your named SoM

  • Have a working knowledge of how NMC publications affect your practice.12

References

8 Statutory Instruments 2002 No. 253 (2002). The Nursing and Midwifery Order 2001. Available at: Introduction www.legislation.gov.uk/uksi/2002/253/contents/made.

9 Baird B, Murray R, Seale B, Foot C (2015). Midwifery Regulation in the United Kingdom. London: The Kings Fund.Find this resource:

10 Kirkup B (2015). The Report of the Morecambe Bay Investigation. Available at: Introduction www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf.

11 Nursing and Midwifery Council (2012). Midwives Rules and Standards 2012. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-midwives-rules-and-standards.pdf.

12 Nursing and Midwifery Council (2015). The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf.

Further reading

Nursing and Midwifery Council. Revalidation. Available at: Introduction www.nmc.org.uk/standards/revalidation/.

Role of the supervisor of midwives

As previously mentioned, the role of the SoM is under review. Future models for supervision, along with future names for supervisors, are being reviewed and discussed. Until there is a conclusive agreement from all stakeholders involved the NMC has requested that the existing model set out within the Midwives Rules and Standards13 be upheld until further notice. Below is an overview of what the role of the SoM is currently and what qualities a midwife considering the role of the SoM is required to demonstrate.

The potential SoM is nominated by peers and supervisors in their place of work and must undergo a selection process led by the LSA midwifery officer (LSAMO) and university programme leader and which must include a user representative.

The midwife must:

  • Have credibility with the midwives she/he will potentially supervise and with senior midwifery management

  • Be practising, having at least 3 years’ experience, at least one of which shall have been in the 2-year period immediately preceding the appointment

  • Be academically able—the supervision programme is currently delivered at Masters level

  • Have demonstrated ongoing professional development13, 14

  • Having successfully completed the preparation programme; the midwife must then be appointed by the LSAMO as a supervisor to the LSA and to whom the SoM is responsible in that role14

  • Have good communication skills and an approachable manner as being essential to the role.

The SoMs:

  • Receive and process notification of intention-to-practise forms

  • Provide guidance on the maintenance of registration

  • Work in partnership with mothers, midwives, and student midwives

  • Create an environment that supports the midwife’s role and empowers practice through evidence-based decision-making

  • Monitor standards of midwifery practice through audit of records and assessment of clinical outcomes

  • Are available for midwives to discuss issues relating to their practice and provide appropriate support

  • Are available to mothers to discuss any aspects of their care

  • Arrange regular meetings with individual midwives at least once a year, to help them evaluate their practice and identify areas of development

  • Investigate critical incidents and identify any action required

  • Report to the LSAMO serious cases involving professional conduct and when it is considered that local action has failed to achieve safe practice

  • Contribute to confidential enquiries, risk management strategies, clinical audit, and clinical governance

The ratio of SoMs to midwives should reflect local needs and circumstances and should not compromise the safety of women. This ratio will not normally exceed 1:15.

It is recommended that a named SoM be available to all student midwives and that the student is aware of how and when they can contact an SoM for support.

References

13 Nursing and Midwifery Council (2006). Standards for the Preparation and Practice of Supervisors of Midwives. London: Nursing and Midwifery Council.Find this resource:

14 Nursing and Midwifery Council (2012). Midwives Rules and Standards 2012. Rules 9–16. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-midwives-rules-and-standards.pdf.

Role of the LSA and LSA midwifery officer

The LSA is a body responsible in law for ensuring that statutory supervision of midwives and midwifery practice is employed, within its boundaries, to a satisfactory standard, in order to secure appropriate care for every mother.15 However, as previously discussed on Introduction p. [link] and p. [link], the statutory function of the SoM is currently under review with the aim of its removal from the SoM’s remit. When the law is changed, the role of the LSA and LSAMO will also change dramatically. It is thought that their future role will remain one of leadership to other midwives and one which is key to delivering a national midwifery strategy, but the full extent and remit of the new LSA and LSAMO are yet unknown. Due to this the following information is an overview of the current roles and responsibilities.

Each LSA appoints an LSAMO to undertake the statutory function on its behalf. This must be a suitably experienced SoM,15 who has the skills, experience, and knowledge to provide expert advice on issues such as structures for local maternity services, human resources planning, student midwife numbers, and post-registration education opportunities. The role of the LSAMO is unique as it does not represent the interests of either the commissioners or providers of NHS maternity services.16

The functions of the LSA and the LSAMO are to:

  • Be available to women if they wish to discuss any aspect of their midwifery care that they do not feel had been addressed through other channels

  • Compile an annual report for the NMC, which outlines supervisory activities over the past year, key issues, audit outcomes, and emerging trends affecting maternity services

  • Appoint SoMs and publish a list of current supervisors

  • Ensure that every practising midwife has a named SoM

  • Determine the appropriate number of supervisors to reflect local circumstances

  • Receive annual notification of intention to practice from all midwives within the LSA boundary and forward the completed forms to the NMC

  • Operate a system to ensure that each midwife meets the statutory requirements for practice

  • Provide continuing professional development and updating for all SoMs for a minimum of 15h in each registration period

  • Ensure that systems are in place to investigate alleged suboptimal care or possible misconduct, in an impartial and sensitive manner

  • Determine whether to suspend a midwife from practice

  • Where appropriate, proceed to suspend a midwife from practice whom it has reported to the NMC

  • Investigate and initiate legal action in cases of midwifery practice by unqualified persons.

References

15 Nursing and Midwifery Council (2012). Midwives Rules and Standards 2012. Rules 9–16. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-midwives-rules-and-standards.pdf.

16 Nursing and Midwifery Council (2009). Modern Supervision in Action: A Practical Guide for Midwives. London: Nursing and Midwifery Council.Find this resource:

Drug administration in midwifery

Under the Human Medicines Regulations (2012),17 medicines can only be supplied and administered under the directions of a doctor.

Student midwives can administer any medicine prescribed by a doctor under the direct supervision of a registered midwife.

These regulations permit exemptions which allow other professionals to supply and administer medicines in specific circumstances. Midwives are exempt under Section seventeen, Part three from this requirement in relation to certain specified medicines, provided they have notified their intention to practice and the drugs are for use only within their sphere of practice. This allows midwives to supply and administer these drugs without the direction of a doctor.

This is known as the midwives exemptions list (see below) updated in these regulations. This ensures appropriate and responsive care can be given to women safely as part of a midwife’s normal sphere of practice and especially during emergencies. The regulation exemption allows student midwives to administer medicines from this list under the direct supervision of a registered midwife, with the exception of diamorphine, morphine, or pethidine.

The medicines to which this exemption applies are as follows:

  • Adrenaline

  • Anti-D immunoglobulin

  • Carboprost

  • Cyclizine lactate

  • Diamorphine

  • Ergometrine maleate

  • Hepatitis B vaccine

  • Hepatitis B immunoglobulin

  • Lidocaine hydrochloride

  • Morphine

  • Naloxone hydrochloride

  • Oxytocins, natural and synthetic

  • Pethidine hydrochloride

  • Phytomenadione

  • Prochlorperazine

  • Sodium chloride 0.9%

  • Gelofusine®

  • Haemaccel®

  • Hartmann’s solution.

Midwives can also supply and administer all non-prescription medicines, including all pharmacy and general sales list medicines, without a prescription. These medicines do not have to be in a patient group direction (PGD) for a midwife to be able to supply them.

Patient group directions

PGDs are detailed documents compiled by a multidisciplinary group of a local trust or hospital. They allow certain drugs to be given to particular groups of clients without a prescription to a named individual.

This arrangement is very useful, as it allows the midwife to give a drug listed in the PGD to a woman, without having to wait for a doctor to come and prescribe it individually. The midwife is responsible for following the instructions related to dosage and contraindications provided in the PGD.

Examples of drugs included in a PGD are:

  • Dinoprostone (Prostin E2® gel) for induction of labour; 1mg or 2mg gel can be repeated after 6h. Give a lower dose if the cervix is favourable

  • Ranitidine 150mg tablets.

It is recommended that, if a drug is on the midwives exemption list, it does not need to appear in a PGD. Under medicines legislation, there is no provision for ‘standing orders’; therefore, these have no legal basis.

The NMC (2015)18 has published Standards for Medicines Management which includes dispensing, storage and transportation, administration, delegation, disposal, and management of adverse events and controlled drugs. Registered midwives must only supply and administer medicines for which they have received appropriate training.

There is clear instruction on the role of the midwife in directly supervising student midwives during drug administration and that only a registered midwife may administer a drug which is part of PGD arrangements.

References

17 Statutory Instruments 2012 No. 1916 (2012). The Human Medicines Regulations 2012. Available at: Introduction www.legislation.gov.uk/uksi/2012/1916/made.

18 Nursing and Midwifery Council (2015). Standards for Medicines Management. London: Nursing and Midwifery Council.Find this resource:

Independent midwife prescribing

Current legislation gives independent prescribing rights, including for some controlled drugs, to midwives, nurses, and other health-care professionals within the individual practitioner’s sphere of competence. Whilst the midwife has a wide range of drugs which can be administered within the Midwives Exemptions (UK), there are situations where to be able to independently prescribe has a real advantage for prompt and appropriate action and continuity of care for mothers by experienced, suitably qualified midwives. For example, prescription of antibiotics for mastitis, infected perineum, or urinary tract infection. The drugs to be prescribed will be agreed within the NHS trust, as the employer, for the individual midwife’s sphere of practice, e.g. the labour ward or the community. In this way, the midwife’s personal practice can be enhanced by making effective use of prescribing.

If the midwife is going to prescribe for the newborn baby, the same principles apply, but the midwife must also demonstrate prescribing competency for this special group as overseen and assessed by an experienced paediatrician.

In the UK, the midwife must undertake an NMC-approved programme at a university approved to run the course at degree or normally Masters degree level. For midwives, the lead midwife for education will oversee the mentoring and assessment process to ensure the principles and practice of prescribing are applied to midwifery practice. Once achieved, the qualification is recordable on the NMC professional register. As with other aspects of professional practice, evidence of continuing professional development in prescribing must be kept in the midwife’s professional portfolio.

A designated medical practitioner (DMP) will mentor and assess the required competencies, supported by an experienced midwife prescriber/SoM to support the midwifery perspective.

The programme and assessment are based on:

  • An in-depth knowledge of pharmacology, modes of action, side effects, contraindications, and drug interactions of individual drugs

  • An in-depth knowledge and ability to accurately diagnose the conditions being prescribed for

  • Safe, effective, and cost-effective prescribing

  • Legal and ethical aspects of prescribing

  • Evidence-based practice

  • Record-keeping

  • The seven steps to safe prescribing

  • The single competency framework for all prescribers.

Supplementary prescribing

In some circumstances the midwife may be a supplementary midwife prescriber to an independent medical prescriber, working within the terms of an agreed clinical management plan (CMP). This allows the midwife to make changes to the prescribed dose or drug without the need to see the doctor, providing the criteria of the CMP are met.

Further reading

Beckwith S, Franklin P (2011). What is a non-medical prescriber? In: Beckwith S, Franklin P.Oxford Handbook of Prescribing for Nurses and Allied Health Professionals, 2nd edn. Oxford: Oxford University Press, pp. 3–17.Find this resource:

National Prescribing Centre (1999). Signposts for prescribing nurses—general principles of good prescribing. Nurse Prescribing Bulletin 1: 1–4.Find this resource:

National Prescribing Centre (2012). A Single Competency Framework for All Prescribers. London: National Institute for Health and Care Excellence. Available at: Introduction med.mahidol.ac.th/nursing/sites/default/files/public/knowledge/doc/3.pdf.Find this resource:

Nursing and Midwifery Council (2006). Standards of Proficiency for Nurse and Midwife Prescribers. London: Nursing and Midwifery Council. Available at: Introduction www.nmc.org.uk/standards/additional-standards/standards-of-proficiency-for-nurse-and-midwife-prescribers/.Find this resource:

Nursing and Midwifery Council (2010). Nurse and Midwife Independent Prescribing of Unlicensed Medicines. London: Nursing and Midwifery Council. Available at: Introduction www.nmc.org.uk/globalassets/sitedocuments/circulars/2010circulars/nmccircular04_2010.pdf.Find this resource: