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The response to a crisis experienced in the maternity unit at Waitakere Hospital, New Zealand resulted in profound improvements in care
Waitakere Hospital in urban West Auckland has a busy maternity unit. Most of our mothers receive care from independent midwives working within the hospital’s birthing facilities. Complications during labour are referred to the duty obstetrician. Natural anxiety about coping with emergencies during labour and childbirth is exacerbated by the unit’s isolation from other acute services. In 2001 multiprofessional dissatisfaction provoked a breakdown in relationships between obstetricians and midwives.
In some aspects of obstetric care we were not alone. Caesarian section rates in New Zealand between 2001 and 2002 increased from 20.8% to 22.1%,1 but when our caesarian section rate hit 27% the sense of crisis was ours. Pofessional relationships fractured in a series of “tipping point” events (box 1). The symptoms of a breakdown rapidly multiplied: nine major patient complaints in 3 months; enquiry into neonatal deaths; an obstetrician suspended for competency review; and independent midwives refusing to attend hospital policy review meetings at which clinicians questioned midwifery practice. The viability of on call rosters was threatened as morale plummeted and staff resigned.
Box 1 A “tipping point” crisis
The mother had written an eight page birth plan: no drugs, no machines, no medical interventions; childbirth was to be a mystical and rewarding experience. Progress was slow. The midwife encouraged, supported, and coached the mother through a day and night of painful labour. After an hour of pushing, the exhausted mother began to despair. The midwife was concerned about fetal wellbeing and began continuous monitoring of fetal heart rate. The trace was not reassuring. Experience had taught her that calling the obstetrician would lead to immediate caesarean section. After another half hour of pushing, there was a sudden …
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