Supervision of trainee midwives? anyone got refs to NICE guidelines or similar?

[madwomanintheattic]

i can't find anything and i need to double check a few things...

searches on the NICE website seem to pull up some random stuff...

essentially - what level of supervision should a trainee/ student midwife have at her first live birth? ie what level of secondary checking should the experienced midwife do to ensure safety of mother and child?

there must be official guidance, but i can't find it, help!

Dont know if there are any official guidelines to be honest(?)

As a midwife myself who supervises students and obviously as a previous student myself, it would just be by observation.

Maybe im wrong!

really? ok... so you wouldn't do any double checks - it would just be trusting that she knew what she was doing? and capable/ confident enough to alert you/ anyone if anything was out of the ordinary?

(going to ask you another one now lol - what makes a deceleration 'atypical' and are there guidelines for how to deal with specific instances? or is it again just a matter of experience/ instinct?

(lol - i'm not being cloak and dagger, i'm trying to understand my notes/ trace and work out if my decision to allow a student to carry out her first birth might not have been the wisest of moves...)

(bit small lol at you supervising but not knowing... )

Im sorry, im confused as to what you mean by doing double checks

sorry - as in if the student was doing the whole malarkey (ie checking how far dilated/ physical exam - sonicaid readings etc etc), would there be a point that you would reasonably expect to double-check what s/he was doing? ie if she said '10cms ready to go' would you check? or if she was fannying about with the sonicaid (lol at fannying about) would you check the fhr yourself? or just trust that it was all ok if she hadn't said otherwise?

at the student's first birth, is it the student that retains the ultiamate responsibility for the welfare of the mother and child, or is it the supervisor?

"at the student's first birth, is it the student that retains the ultiamate responsibility for the welfare of the mother and child, or is it the supervisor?"

The NMC makes it very clear that a student midwife is never accountable for her practice in terms of registration, but may be held responsible in law (but would have to be extreme & in full knowledge, IMO).

golly - realise i've potentially made yoy question your entire practise now... not my intention lol

i'm just trying to get my head round the trainee/ supervisor issue - i'm really pro at providing opportunities for trainees lol, i'm not one that dictates x years of experience before you touch me, but i'm curious about the supervision angle.

not meaning to freak you out!

ok it depends where in the training she was. If she was a new student, just starting doing births herself, then i would check. Usually at first students watch births then become more involved.

A vaginal examination i would prob do first myself and if the woman didnt mind, then i would ask if the student could do the same and i would guide her through it. Locating the Fh, well, if she had trouble finding it then i would take over.

A more senior student who did a ve and said someone was fully dilated i would probably trust, unless i jhad never met her before/worked with her.

I would always be in the the room with a student for the birth of course, even a senior student, although i would allow a student to go and listen to the FH without me there and trust her(unless she was a new inexperienced student)

i'm guessing she was fairly experienced lol - obviously i would have no real idea, but there are a few things that concern me. she was obviously having real problems finding fhr - i remember the supervisor putting a little bit of pressure on her because she was struggling, and her just saying '120' and leaving it.

essentially we lost the trace after a few 'atypical' decelerations, but the student continued to do the monitoring. a while later (clearly lol) i had decided to deliver standing/ crouching and the supervisor was briefing her as to what she needed to do in that scenario (as she was going to deliver the baby)

the supervisor kept asking her where the head was/ whether i could start pushing, and the student was quite clearly unsure. eventually the supervisor told her to get out of the way and went to feel for herself, at which point she immediately crashed the SoM and the paeds and heaved me onto the bed for an epidural/ ventouse as the baby's head was cool to the touch... so i don't know whether the student was so experienced or not, really?

anyways, fhr was down to 28bpm when they pulled her out and dd did sustain brain damage.

there just seems to be a long period of time when i am concerned that the student did not have the relevant experience to know/ recognise that something was going wrong.

clearly if nothing had been going wrong, then there wouldn't have been a problem - she would have delievered the baby and all would have been hunky dory - no-one would have been asking questions about supervision lol.

sooooo, i need to know in my head that it was unavoidable, or at least that everything happened as it should have - after all, i gave permission for the student to carry out the birth alongside the midwife i had known and trusted for four months.

outcome may have been the same in any case - i do realise that.

just curious about the trainee/ supervision relationship, and how much confidence students have in their ability to recognise when something is out of the ordinary really (and if it is their responsibility to recogninse that)- obviously i was chosen from a cast of thousands as a nice safe option to practise on lol - and ended up traumatising a student...

Well i would expect and hope a student would speak up and say if she was having difficulty. I would also hope that i would recognise this as a midwife and mentor!

When i was a student myself, or indeed now even, i would have spoken up.

It was ultimately the midwife's responsibilty to do take charge though in a situation like this.if i saw that thestudent midwife was unsure id have taken oven. What is written in your notes during this time?

I am sorry you have such a difficult time.x

it's tricky - the notes are all written up and signed by the supervising mw, but it was the student that was actually doing the checks.

the last 30 -45 minutes have obviously been written in retrospect although it doesn't say that - there are a few 'difficulty finding fh' and the last 30 minutes are written by the SoM whose comment is 'unable to locate fetal heart standing' and then 'returned to bed - episiotomy performed' and then some more notes concerning the actual delivery (managed to squeeze in shoulder dystocia, cord round the neck as well lol)
vx delivered nuchal cord x1 - slipped over head easily, shoulders tight ++

svd live girl - resus apgars 1/1 paeds crashed and paged

later it says 'written in retrospect' -
'shoulders delivered 1st cont within 1 minute of delivery of head, with 2nd push. hr 30, rescue breaths given, cardiac compression, paeds in attendance @ 2 mins'

i'm not concerned about the management of the birth once it had been established that there was a problem - i can't fault them. effectively the supervising mw and the SoM elbowed the student to the back of the room where she sat sobbing for the rest of the delivery/ resus.

hindsight being a wonderful thing - the mw probably saved dd's life by reacting instantly she touched her head - and she was obviously in a pretty poor way at that point, that i am just curious how quickly that could have happened. the sonicaid monitoring was intermittent, but i am wondering in my most paranoid way whether even those two 'recordings' are accurate, given that the student was obviously flustered by this point, and we do know what happened 'next' as it were, and she was recognised to be in a poor way by a more experienced mw without the aid of fhr lol.

i guess what concerns me is that if the supervisor had checked the fh herself, knowing that there had already been atypical decelerations before the ctg lost contact, then it might have resulted in earlier intervention. it might not but it might.

we have had an independent report which states that the student delivered the baby, which was then found to have problems.

it's probably just sloppy admin, but it has the horrible effect of making me wonder if they are trying to cover something up. as they acted without reproach from the point they realised there was a problem, why change the story? should they have known earlier?

this is all far back enough for me to deal with in a reasonably detached manner btw - dd2 is at school and thriving (as much as you can with cp anyway lol) and it is more about getting answers than compensation - she is a clever little bean and at some point will want to know all this stuff.

oh gosh what a story.

Well if the student did the listening to the fh, VE etc, that shoulkd have been documentated as so, with the midife countersigning this.

If decels were heard and there was loss of contact on ctg then the midwife should of either listened in herself or applied a fetal scalp electrode to get a more accurate recording.

Is sounds like the student midwife was out of her depth and the midwife should have acknowldged this. It was her fault not the student.

Why did the student cry at the time? Was it cos the baby came out in a poor condition or becuase she had been pushed aside( bad treatment especially in from of a patient, when it was the midwife not doing her job properly)?

Im glad you dd is ok now.

It is so weird reading through your own labour/birth notes isnt it. Ive done it with both of mine

admittedly the mw did bark at her to get out of the way, and it all went mad at that point, with the mw and SoM trying to get dd2 out as fast as possible by whatever means possible (one was wielding the scissors whilst the other prepped the ventouse) and the poor student was just in the corner sobbing - i imagine it was shock as well tbh, but it must have been quite upsetting to realise it was going wrong, particularly as the experiecned mw realised it immdiately she checked whether i was ready to push, when the student had raised no concerns.

soooooo, where in your opinion do i go from here? do i go back and refute the independent expert's opinion? (in that the problems were detected prior to the birth, which is why the SoM was brought in and delivery hastened, and the delivery was by the SoM) - essentially clarifying the details which are incorrect? or do i just accept their version that the baby was delivered by the student (!) and then they discovered there was a problem and crashed the paeds?

i'm uncomfortable just accepting the version of events that i know to be untrue (whether or not it affected outcome) tbh - particularly when dd2 is going to be living with the consequences for the rest of her life - it just seems right to at least get a true version so that she has a picture of what happened when she asks...

or am i wasting my time?

I am completely unqualified, no medical experience but I absolutely believe that you are entitled to find out the truth about this. Were you offered a debrief afterwards? If it was me I wouldn't rest until I knew exactly what happened, but that's me. It doesn't affect the outcome as you say, but you have a right to know, as will your daughter when she is old enough to understand. I wouldn't accept the version that you know to be untrue, even if it has no bearing on the future, but they are doing you a disservice by incorrectly recording what really happened.

I am so sorry to hear this. Again not qualified medically but from what you have said the birth was spectacularly mismanaged and the trainee midwife was not experienced enough to realise what was happening to your DD.

I would be furious and I have to say this does put me off from allowing trainee doctors/midwives to be in anything but an observational role at my next birth. (I know this is a selfish point of view but I think if you can't be selfish in labour when can you be)

I hope you get some answers that reassure you or at settle what has happened once and for all and I think they face they are changing the official events is very suspicious and is designed to limit their liability.

susie - that's sort of why i'm asking about supervision etc - clearly trainees have to gain experience, and i still feel quite strongly that they need those opportunities. i feel really odd that there doesn't seem to be any guidance for midwives who are supervising trainees... but then i don't really know enough about it to know whether women would find it reassuring or more invasive to have effectively two people doing the same checks... i've been really pro-training.

i had just imagined there would be some sort of guidance - a training syllabus where new mw's would have to work through x births at y level of supervision, then x births at z level of supervision, or whatever... in my head it made sense that, oh, i don't know, for the first 3 births the supervisor checked everything - i know i'm waffling, lol.

i'm just really surprised that it seems to be down to the general 'feel' of the situation from the supervisor's pov...

carmen - thanks for confirming the note-taking aspect - i think i do need to query this.

Sorry for the delay.

We do adopt a system whereby student midwives observe 5 births, then maybe hold their hands over the midwives during the delivery of the next few babies so as to feel the pressure needed etc. Then usually they will actually deliver a baby with the midwife next to them.

It is difficult to comment on how much the midwife actually needed to check the student in your case, as i dont know how far along she was in her training. Im guessing that she was experienced to a degree if she was performing VE'S without them being checked and actually being ready to deliver your baby, but she may not have been at the end of her training either.

Think these issues need clarifying. yOU NEED TO GO BACK AND DEBRIEF AS YOU ARE NOT HAPPY WITH THEIR VERSION OF EVENTS. eXCUSE CAPS!

The staff involved would have almost certainly been asked to make a statemenet at some point regarding the events and especially at what happened with your daughter.

I really do not think there is any official guidance. Certainly not any that i have to follow as such. Apart from the fact that i am completely responsible, not the student, so i would use my judgement to how much i would allow a student to do.

thanks carmen. i know it's all a bit hypothetical as i've no idea where she was in her training.

i've just reread a different bit of the report where it says 'by 1452 the tracing would be categorised as suspicious which means that it should continue to be observed with no need for further intervention...' the CTG trace was then lost, and it says 'with the loss of contact from the CTG they had resorted to intermittent auscultation of fhr.' there is a note to the effect that this deviated from the norm as i had had a previous cs and was therefore not a 'low risk' patient.

would it be normal in those sorts of circumstances to let a student carry on with the monitoring etc, or would it be usual with a 'suspicious' CTG and loss of trace for the more experienced mw to take over?

in my head it seems reasonable that the more experienced mw would take over, but i'm very much aware that these terms can be quite emotive - 'suspicious' and 'loss of contact' can seem quite worrying when they are probably reasonably common lol with baby moving down.

i had a debrief with the cons obstetrician when dd2 had just been discharged from scbu, and he did apologise for the lack of monitoring, as at the time he said 'we just don't know what happened and don't have the traces or anything else to confirm it'... it was slightly surreal - i was elated that dd2 was out of scbu and he was telling me about situations where babies were very much worse off than dd2 (with broken necks from botched forceps etc). he said he hoped she would make a full recovery and time would tell. we had a bit of a discussion about the monitoring, as i said i really didn't want it happening to anyone else, and he agreed.

we didn't really discuss the student aspect - to be honest it was the lack of monitoring that seemed important at that point, not who was carrying it out.

so would there be statements on file somewhere from both midwives and also from the trainee?

i was quite worried about her, you know - both of the other midwives visited dd2 in scbu for some time, and i did ask them if the student was ok. it must have been an awful way for her to start her career...

The issue here i think is that you were not continously monitored which you should have been as A prev CS and suspicious trace.

If there was difficulty picking up Fh with ctg then a fetal scalp electrode should have been attached to baby;'s head to get an accurate recording, or the very least someone holding the transducer onto your abdomen.

I think its difficult to say who should have been doing the monitoring as you should have been hooked up to the monitor with the midwife interpreting it, or the student interpreting which the midwife checked and countersigned.

As for statements. At our trust if the is a poor outcome at birth or a number of other triggers then we would be asked to write a statement in case there was a complaint or it went to court at some point.
I dont know about your trust but if you were to take this further then the midwives/ dr's involved would be asked the same.

thanks for your help, carmen.
i think i've got my list of questions sorted. i'm sure the ultimate answer will be 'we don't know', but at least i will have tried.

Youre welcome. GOOD LUCK.