From surprise to shock, anger, sadness, acceptance and determination. A reflection on when things go bad with your clients

  • 03, 05, 2012
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As private midwives we are in a unique position of taking on truly the role of a ‘professional friend’ (Mavis Kirkham 2000). Our clients become fast friends, sharing their most intimate and personal feelings with us and we invest in them emotionally as well as professionally. But sometimes these relationships, because of their very nature, can turn sour and leave the client and the midwife feeling very hurt, misunderstood and alone.
Up until now I have not really had this experience and had been floating along on my own cloud of love for women and my part in being totally with my women. But this all changed very suddenly when a hospital transfer did not go to plan and I was faced with how angry and hurtful our clients can become when they feel they have not been given the service they expected.
I had felt very close to his particular client and dearly wanted to support her and her husband in their home birth experience. They were having their first child and had just arrived in the city. They were very positive about normality in birth and absolutely convinced that home birth and more to the point, home birth with me as their midwife was what they wanted. Their enthusiasm was contagious and although there were some warning signs that things could not go to plan, I believed in them totally as they did me.
Although this was their first child they felt so confident that they opted out of antenatal sessions and chose hypno birthing instead. I knew this was their choice and made one of my first mistakes, but not insisting that they take some kind of ante natal education. I have very high regard for hypno birthing but I am also aware that some times it leaves women with the idea that there will be no pain during their labour and when they experience pain, they panic. This is what happened to my client. Who was a physiologist by profession. Of course it is never a good idea to generalize any one but I have found it true to say that women who work in very mental based professions or those who work in professions where they are in control on a mental level, do tend to struggle in labour. This is because they find it difficult to let their heads go and their bodies take over and give birth. This was the crux of the situation with this client and I had not taken it on myself to prepare her fully for what she was to embark on in labour. This was my second mistake.
Another factor in the relationship of ‘midwife and mother’ is the trust aspect. They trust you to keep them not only physically safe but emotionally safe as well. In retrospect I now feel that this is not actually possible. Although the midwife can give assurances of her professionalism she is not in control of every aspect of the mothers birth which is also the fact for the mother. The midwife can prepare for every possible eventuality in which she could have power over but must also make it very clear to the mother that in reality there are no guarantees as life never comes with these. My in ability to make this clear to my client in this case was my third and biggest mistake.
Another factor to take into consideration which is paramount to the relationship and mother is the fact that both the midwife and the mother are simply just people and at times people falter. This was the hard lesson learned from thei experience. Although I feel I acted safely and wisely as their midwife and birth support their came a time when, exhausted and confronted with the unexpected unprofessional and down right aggressive nature of a hospital employe. I faltered and failed in my job as an advocate trough not giving a proper hand over at point of transfer.
My client, who had been contracting in coordinately and gently through the night, rang me at 7 am to say she was concerned because her contractions were getting painful and wanted me to come and support her. This I did and arrived at her home 1 hour later. After ascertaining that fetal heart was normal I calmly assured her that things were fine. She went on to be supported with massage and positive verbal encouragement for 6 hours by myself and our Doula, who had also done hypno birthing and was a brilliant coach. After this time my client wanted to use the birthing pool so I did a vaginal exam before she entered. Her cervix was posterior and 1 cm dilated and babies head was high about -3 to spines. I told her it was early days but that she was doing well and she entered the pool to aid her in dealing with the contractions. She he was desperate for continued verbal reassurance and encouragement and found it nearly impossible to stop asking questions and disconnect from her head and let her body open. I tried to encourage her to do this and at times removed my self from her presence to remove the temptation for her to question me about her every contraction.
Time went on and her contractions became stronger but with this came exhaustion and and a desire on her part to slow things down so she could rest. Hours of massage and encouragement passed. Food was prepared and teas for energy, but on the second exam very little progress was made, but there was progress. I was advised by my colleagues not at the birth, to leave until she got herself into ‘real’ labour. But when I attempted this, she seemed her labour seemed to step up in intensity, so the Doula and I stayed to give support. I could tell my client was afraid and ironically, I did not want her to feel abandoned.
More time passed and by 22:00 I had rang for the 2nd midwife to come and give me support. I knew it would be a long night and baby would not come until the following day, so I needed to rest as did the Doula and husband. I finally went to sleep at midnight and slept for 4 hours. When I awoke I found our client contracting ‘strongly’ and was exhausted. She had wanted to get in the pool to slow things down and rest but my 2nd would not allow it. This upset my client some what. I gave my 2nd a break for her to rest and then allowed my client to enter the pool again, but I made her understand she was not to ask any more questions about her dilatation or if she was progressing. I told her she needed to be with her contractions and not try to escape them. I also made her take a more upright position in the pool. After 2 hours she said she felt pressure and I did a quick check in the pool. Babies head had come down a bit to -1 and her cervix was now soft and moving into an anterior position. This encouraged her quite a bit and she continued in the pool like this for awhile. I tiil a break after andother 30 to 45 min and went to explain to her husband why I had asked her not to speak and question everything. He said he understood. He was later called to the pool to sit with her, but 10 min after he was there she had got him to take her out of the pool for a rest from her contractions. She told me she needed verbal assurance and that she needed to change position as the contractions where too strong. I tried to explain that se needed to stay with her body and not talk through things as this slowed her labour, but she became uoset and said we were angry with her.
After this she went into her front room with her husband and I felt that feeling of acceptance come over me, I knew this was the end and we were going for a transfer. Five min later her husband came to get me as her waters had gone and there was fresh green meconium. I listened to baby and then preformed a sterile exam. Her cervix was now anterior, very soft but not effaced and only 2cm dilated. Babies head was not flexed and not applying real pressure to the cervix. I explained this to her and told her we needed to go to hospital as I was not happy to continue with these factors. Everyone agreed and off we went.
I feel that it is important to note that my 2nd midwife was new to our team and not a Catalan or Spanish midwife. She was like me a foreigner and I feel this had a strong influence on the reception we received at transfer point. I had made transfers before with my Catalan colleagues and things always went smoothly and professionally but unfortunately for us all this was not the case this time. Thinking of my clients safety I did all of the things I had seen my colleagues do in a transfer but on arrival to the hospital and being stopped by the security guards I lost my train of thought and had to ask for directions to the labour ward. This was a point of issue for my clients husband. He felt it was un professional of me to have done this. He felt this showed how I was unfamiliar with how things were done in hospital settings. I also did not request a wheel chair for my client, because I felt she was not ill and could walk with npo problem. I also felt that her being upright would aid flexion and held to get babies head down. I also knew that many women do not enjoy sitting down on their bottom in labour or being wheeled at great speed down corridors by over zealous porters. Unfortunately, my clients husband felt that this was another failing on my part.
Once at the desk I and my 2nd checked our client in and a staff member took our client into the labour room. This staff member never identified themselves to me or my 2nd and after we checked our client in we were left alone in the waiting room, not knowing exactly what had happened. After 10 min I buzzed the door which opened automaticly. No one was in sight so I stepped in side with the hope of finding a midwife to hand over my client to. Instead I was confronted by a member of staff whom I still do not know who they were. I was shouted at and told to get out. I was told my information was not needed and I was not allowed to be where I was. After two attempts to speak to this person I could see they were only becoming more aggravated and I was beginning to feel tears well up in my eyes. I could not understand what I had done wrong. I felt ashamed of my inability to speak Spanish well enough to make my self understood. I felt as if I was a trespasser and was ashamed of these feelings. I stepped out and not wanting to let my 2nd know how upset I was made a joke about what had happened. Very soon after that I suggested we leave, as I was becoming less able to keep my self from crying. Feeling very out of place and worthless I walked my 2ndout of the hospital ans pointed her in the right direction for the metro. I stayed behind contemplating going back and tried to call one of m Catalan colleagues. But after a few rings and no answer, I gave up and went home.
My mobiles had been on silent since I entered my clients home and I had faild to turn on the sound so I did not hear the call from my clients husband who was sent out to find me by her doctor. I had been given no information as to what was happening with her and had no idea when or if they would come to tell me anything. I was given the idea by the angry member of staff that all was well and I was not needed. Yet again unfortunately my clients husband saw my absence and the fact that I did not answer my phone, as a great betrayal. Questions were asked by the doctor he could not answer and I was not there to assist them. This is my deepest regret. I had because of my own emotions caused them unnecessary grief and worry. I had failed them at their last point of contact with me and although I was tired and upset, this was no excuse.
My client went on to labour over 7 hours more with oxitocin and an epidural. She had an assisted vaginal delivery with ventouse but has been left with fecal incontinence. Because of their anger and disillusionment with me, they did not contact me after the birth and I was not able to assist them with breastfeeding. This particular hospital is not good for breastfeeding support and subsequently their baby spent 4 days on special care because of a massive drop in weight. There were other problems with the hospital but my client and her husband were happy with the care they received from them. I on the other hand will go down in their memory as someone who was not up to the job, which in some respects is true.
This experience has taught me that many things but what I feel is most important is the understanding that our feelings are very powerful and can be used to help create a wonderful birth experience, when we are able to use them well, but if we are not in control of them they can cause real harm to our clients and ourselves. My understanding of the importance of antenatal education has been greatly increased and with a very sore ego, I hope to never put myself in the position of taking on the emotional responsibility of my clients again. The births I attend are not mine and it is the mother who must find the strength in her self to bring her child into the light. My job is simply to be by her side. To be aware of what occurs in normal birth and act when deviations occur. I have also learned that the most important part of the professional friendship between mother and midwife is the professional part.   

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