Dear Ellie,
Finding ways
to introduce these concepts in a meaningful and useful way can indeed be a
challenge. The additional difficulties for many of us working in this field is
how to avoid coming across as "anti-intervention" or "anti-doctor", which can be
alienating to many clients.
It is important to remember that a caregiver
having an active management approach is not necessarily the problem. Where the
conflicts arise is when the caregiver has one philosophy and the client has
another. When this mismatch occurs between client and caregiver, communication
can be strained and clients can feel left out of the decision making loop.
One of the techniques that can be very helpful
is to assist your client in determining whether or not she is looking for an
active or expectant management approach and then determining what her caregivers
approach is. The first step is to determine her own perception of the roles of
each person at her birth. We use a grid as set out below and ask the client to
complete this, depending on how she feels about each area of responsibility. If
she is attending classes with a partner we ask them to complete this
together.
|
WHOSE RESPONSIBILITY IS IT TO
MAKE DECISIONS ON EACH OF THE FOLLOWING? |
|
Area of
Responsibility |
Care
giver |
Mother |
Partner |
|
Whether to have
antenatal tests |
|
|
|
|
Whether to have
routine ultrasounds |
|
|
|
|
Whether to have
vaginal examinations in pregnancy |
|
|
|
|
Whether to have
vaginal examinations in labour |
|
|
|
|
Whether to have
an induction |
|
|
|
|
What methods to
use for an induction |
|
|
|
|
Where to give
birth |
|
|
|
|
Whether to have
medication for pain relief |
|
|
|
|
Which position
to be in for labour |
|
|
|
|
Which position
to be in for birth |
|
|
|
|
Whether to have
monitoring and how it should be done |
|
|
|
|
Whether to have
a caesarean |
|
|
|
|
Whether to have
an episiotomy |
|
|
|
|
How to feed the
baby |
|
|
|
|
Whether to have
the baby vaccinated |
|
|
|
|
How long to stay
in hospital |
|
|
|
If the parents tick most areas of
responsibility as being the mother and/or partners alone, they tend to be
looking for an approach where they are the main decision makers. If the doctor
is ticked in most of the same areas as the parents, they are looking for a
shared decision making approach. If the caregiver is ticked as making some of
the decisions alone, there are at least some areas where they are looking for
the caregiver to make decisions on their behalf.
The next step is to give them two more
checklists, completed showing the pattern for an expectant caregiver, and
another for an active caregiver. They can then check their own list again and
see which of these two styles most closely match their own.
|
ACTIVE MANAGEMENT |
EXPECTANT MANAGEMENT |
|
Area of
Responsibility |
Care
giver |
Mother |
Partner |
Area of
Responsibility |
Care
giver |
Mother |
Partner |
|
Whether to have
antenatal tests |
Yes |
Yes |
Yes |
Whether to have
antenatal tests |
|
Yes |
Yes |
|
Whether to have
routine ultrasounds |
Yes |
|
|
Whether to have
routine ultrasounds |
|
Yes |
Yes |
|
Whether to have
vaginal examinations in pregnancy |
Yes |
|
|
Whether to have
vaginal examinations in pregnancy |
|
Yes |
Yes |
|
Whether to have
vaginal examinations in labour |
Yes |
|
|
Whether to have
vaginal examinations in labour |
|
Yes |
Yes |
|
Whether to have
an induction |
Yes |
|
|
Whether to have
an induction |
|
Yes |
Yes |
|
What methods to
use for an induction |
Yes |
|
|
What methods to
use for an induction |
|
Yes |
Yes |
|
Where to give
birth |
Yes |
|
|
Where to give
birth |
|
Yes |
Yes |
|
Whether to have
medication for pain relief |
Yes |
|
|
Whether to have
medication for pain relief |
|
Yes |
|
|
Which position
to be in for labour |
Yes |
|
|
Which position
to be in for labour |
|
Yes |
|
|
Which position
to be in for birth |
Yes |
|
|
Which position
to be in for birth |
|
Yes |
|
|
Whether to have
monitoring and how it should be done |
Yes |
|
|
Whether to have
monitoring and how it should be done |
|
Yes |
Yes |
|
Whether to have
a caesarean |
Yes |
|
|
Whether to have
a caesarean |
Possibly |
Yes |
Yes |
|
Whether to have
an episiotomy |
Yes |
|
|
Whether to have
an episiotomy |
Possibly |
Yes |
|
|
How to feed the
baby |
|
Yes |
Yes |
How to feed the
baby |
|
Yes |
Yes |
|
Whether to have
the baby vaccinated |
|
Yes |
Yes |
Whether to have
the baby vaccinated |
|
Yes |
Yes |
|
How long to stay
in hospital |
Yes |
Yes |
|
How long to stay
in hospital |
|
Yes |
|
What is
valuable with this approach is that you are not dictating one style of care over
another as being advantageous. Rather you are showing that there is a difference
between the two and that it is important that the parents choose a caregiver who
has a similar style to themselves. Once you have completed this exercise you can
work through the B'LIEFS model as outlined in our topic of the month this month.
