Soraya and Thandi are midwives who work together on a team, sharing care of about 100 clients a year. They alternate clinic duties weekly.
New patient Veronica's first visit is with Soraya at 10 weeks into her pregnancy. Her two prior births were C- sections and she is excited to experience a different model of care. During their initial birthplace discussion, Veronica tells Soraya, “I definitely want a home birth." Soraya explains the risks of a home birth after two C-sections and that an obstetrics consult is needed due to her two C-sections. Soraya's recommendation is a hospital birth but to help Veronica make an informed choice about birthplace, she provides some articles and Internet links about trial of labour after C-section. Soraya documents the visit, including the place of birth informed choice discussion.
At handover, Soraya and Thandi discuss Veronica's request. They consider the following two options:
- Option 1 - Provide care
The midwives discuss Veronica's request, factoring in their ability to safely and reasonably offer the care requested and whether providing the care puts them or their client at an unacceptable level of risk. They decide that if Veronica understands the risks and still wants a home birth, they will support her. Soraya and Thandi plan an
informed choice discussion with Veronica about her request at the next visit.
At the next appointment Thandi revisits the birthplace discussion. She explains that even though the request is outside of home birth and community standards and goes against their recommendation, they will support Veronica's decision. They come to an agreement prior to labour on when to transfer to hospital. The midwives also inform Veronica that they might be required to consult or transfer her care during labour as set out in the
Indications for Discussion, Consultation and Transfer of Care guideline. Thandi documents the discussion and their decisions in the client record.
Over the next months the midwives ensure that no other clinical indications have arisen that may create additional risk for home birth. As Veronica's due date approaches the midwives communicate with the hospital's health professionals involved in Veronica's care. They clarify when and who to call once labour begins and finalize the hospital's plan in case of a transfer. These discussion and meetings are documented in Veronica's record.
Soraya and Thandi also call BCCNM
regulatory practice support to ensure they are interpreting relevant standards and policies correctly and connect with their liability insurance provider to review legal implications of their decision.
- Option 2 - Terminate care
Soraya and Thandi know that they have the option to terminate care if a request is outside home birth and community standards. They call BCCNM
regulatory practice support to ensure they are interpreting relevant standards and policies correctly and connect with their liability insurance provider to review legal implications of their decision. After discussing, Soraya and Thandi determine they are unable to safely provide the care Veronica is requesting as they believe it creates an unacceptable level of risk for the client and their practice.
At the next visit, Soraya and Thandi have an
informed choice discussion with Veronica about her request, explaining that the request is outside home birth and community standards, and they are unable to safely provide the requested care. They explain the type of care they can safety provide given her history of two caesarean births. They also offer her a consultation with another midwife (or physician/ nurse practitioner) for a second opinion.
Veronica declines the consultation and asks for some time to think about what the midwives have told her. They agree to revisit the issue at a follow up visit. At the next visit, Veronika confirms that she would like to proceed with a trial of labour at home. Soraya and Thandi respectfully inform Veronica that they cannot safety provide the care she is requesting. The midwives and Veronica agree to mutually terminate care.
The midwives follow up the discussion and send a letter to Veronica confirming termination of care at a date that gives her enough time to find another care provider. A copy of the letter is filed in the health record. Once the alternative care provider is found the midwives provide them with a copy of the client's health record. The midwives complete the other updates to Veronica's records with the associated hospital. All discussions and decisions are documented in Veronica's medical record.
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