Reflection is a fundamental component of learning that we all practice unknowingly. Through reflective learning, we self-evaluate our decision with the aim of learning and self-improvement from past experiences. How and why we learn from our past actions and reaction are reflected in our future behaviour (Schon 1995).
In this essay, I will reflect on a communication episode in a booking appointment that took place in an antenatal clinic during my first placement. I cared for a woman that was eleven weeks pregnant accompanied by her partner under the supervision of my practice supervisor. The structure of this essay is based on the model of reflection named Gibbs (1998). Through this model, the reflection will be based on an impartial observation of both the positive and negative elements that impact the woman-centered care during the booking, communication skills and how to enhance my aptitude for learning from this experience. According to the Nursing and Midwifery Council’s code: standards of conduct, Performance, and Ethics for Nurses and Midwives, to be in line with the regulations and standards of confidentiality, and data protection (Gov.uk, 2015), I will be using pseudonyms to refer to the parties involved(NMC,2014). I will refer to the woman as Monica, the woman’s partner as Rajesh and my practice supervisor as Annabel.
During my first days in placement, I observed and acquired practical knowledge from my practice supervisor Annabel. I was able to practice and develop basic clinical skills. Annabel decided that it was time for me to develop some medical and communication skills by leading some booking sessions at the antenatal clinic.
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One of the women I cared for was Monica, a woman in her late twenties accompanied by her partner Rajesh. Once they entered the room, I introduced myself and Annabel. I stated that I was a student midwife and asked if it was okay for me to carry out the assessment, and she gave her consent (NMC 2015). Due to being her first appointment with a midwife, Monica fell under the Nice (2008, antenatal care for uncomplicated pregnancy guidelines) which says that a midwife should measure blood pressure, take blood and urine samples, undergo a questionnaire to assess the best care and discuss any concerns the client may have. At first, Monica seemed fine and slightly impatient but as the booking progressed, I notice she was getting increasingly anxious.
Talking to Monica, she revealed that she had an abortion at the age of 19 followed by multiple miscarriages in her twenties. She kept whispering that it was all her fault, she regrets what she did and that she has herself to blame. I dispelled her fears by telling her that she shouldn't blame herself, I reminded her that support and alternative care are available. I noticed a sudden change in her behaviour: she was very shaky, her legs trembled. Suddenly, Monica began to cry. At that moment, I stopped typing at the computer, gave Monica my full attention and consoled her. As I was listening, I maintained eye contact with her and nodded sympathetically. She was worried about brown discharges and light bleeding that she had recently: she thought it could be another miscarriage. The thought of losing another baby triggered stress, anxiety, and discomfort that lead to her having a tearful breakdown. I impulsively told her that I could attempt to hear the baby's heartbeat to confirm its presence. Once she laid on the backrest, I used the sonicaid, also known as Doppler ultrasound device, to look for the baby's heartbeat, which I was able to find after a couple of attempts. Once she heard the heartbeat Monica started to smile and cried tears of joy. Monica's mood was completely changed for the best. Monica left the appointment smiling and grateful for the help she received.
Feelings and thoughts
Through the experience, I felt sorry seeing Monica being emotionally in pain. Filling the questionnaire on the computer with a lack of eye contact could be considered desensitized care but I’m glad I chose to tune into what she was going through and prioritize her feelings. Part of me felt that what she needed at that moment was for me to prioritize listening and understanding, what she was going through, instead of worrying about completing the questionnaire.
According to Wold (2005), empathetic listening is essential concerning the willingness to know the other individual not just judging the person’s statement. I was surprised to discover I had an aptitude in taking the lead of the situation and show compassion while being competent at the same time. It is still a bit confusing to understand where my boundaries are when it comes to dealing with other people's emotions and space. Understanding my limitation being a healthcare provider but at the same time showing that you are a human being that genuinely cares is crucial.
Communication is a complex process of interaction between individuals (Northouse and Northouse, 1998). It was during my placement in community that I realised the importance of effective communication skills. In this situation, I was able to communicate with care and compassion by following the guidelines giving by “the Code” on prioritizing people and respecting their choice (NMC, 2018).
Monica showed signs of stress and anxiety, which I was able to act on compassionately and politely (NMC,2018). In this situation, what made the difference to Monica, was the reassurance and confidence in answering any doubt she had in simple words, without using big jargons.
I used Body language, eye contact, tone of voice, reassuring words and touch, which had an impact on this situation and made me think about how vital these are when we need to show empathy and compassion in this role.
Apart from the Code, also the Mehrabian model of communications talks about the importance of factors other than words alone in a conversation. According to this model "care needs to be taken in considering the context of the communication: style, expression, tone, facial expression and body language” (Mehrabian, A.1981). I was improving my communication skills; I was able to manage the situation and provide the best care for Monica within my capabilities as a student midwife.
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From my perception of the events instead of following the typical ‘ticking the box’ (Boyle et al. 2016)approach to care during bookings appointments, I might not have completely followed the Nice guideline on the antenatal procedure of uncomplicated pregnancy when it comes to the use of the doppler device. Despite the fact the Nice guideline does not recommend listening to the baby’s heart at routine antenatal visits until 16 weeks of gestation, it also states that it could be used earlier for reassuring purposes for parents to hear their baby (NICE, 2008).
The use of both verbal and non-verbal communication was very important in providing care for Monica. According to research, even though we mainly use our voice to communicate, up to seventy percent of communication shared is non-verbal (Mehrabian, 1972). As a student midwife, I followed the Code (2015) guidelines in recognising when people are anxious or in distress and respond compassionately and politely. I understood how important it was to respond to Monica’s emotional breakdown professionally by making sure that I express myself with the right words, the right tone of voice and body language in a reassuring manner (NMC 2015). These are elements of ‘channels of communication’ (Pavord & Donnelly 2015) that I used in this situation.
Generally, student midwives are predisposed to help mothers and their families to deal with their emotions, but as we continue to learn, it is important to identify where the boundaries of confidentiality are set when supporting the people we care for. It is important to understand the emotional aspects of midwifery, as the way we cope with someone’s feeling they could potentially affect not only us but also the women for whom they are caring (Hunter, 2004).
Carnwell and Buchana (2005) shed light on the fact that in recognising the needs of the people we care for, will also lead to recognise the role of the people around them that care for them. Even though the care was mainly focused on Monica, Rajesh contributed by encouraging her. He was a good support system for Monica. The loss of a pregnancy at any stage can be a devastating experience and particular sensitivity is required in assessing and counselling couples with recurrent miscarriages ("Recurrent Miscarriage, Investigation, and Treatment of Couples,2011). Being able to ‘pick up signs’ in a covert way is perceived to be a key skill of midwifery (Hunter,2014), and in this situation, it seemed Monica mainly needed support and adequate care. No signs of Mental illness or depression were detected and for this reason, she wasn’t referred to a mental health midwife, but she was made aware of the different types of support available for her.
Although Monica was eleven weeks pregnant, according to the NHS, a midwife may offer to listen to your baby’s’ heartbeat using a handheld doppler from 16 weeks gestation (NICE,2014). Following NICE guidelines (2008) it confirms that “it is not recommended to listen to the fetal heart rate as it is unlikely to have any predictive value but can be done to provide reassurance to the mother”. For this reason, with my practice supervisor's permission, I proceeded to look for the fetal heart rate. After my research on auscultation, I understand why the use of a handheld doppler is not recommended in routine visits due to the potential production of pulsive radiation of heat from the device (Ultrasound Obstet Gynecol, 2002). A study showed that using this device routinely is now becoming a trend when purchased for personal use. The usage of Doppler ultrasound devices at early stages of pregnancy when the developing embryo could be sensitive to damage by physical agents (Barnett SB, 2001). When performing a Doppler examination at 11 weeks' gestation, the exposure time should be kept as short as possible, usually no longer than 5–10 min (Salvesen et al., 2011). If kept on for one minute, and done occasionally, it shouldn’t have any harmful side effects.
Nice (2018) states that pregnant women should be offered an early ultrasound scan between 10-13 weeks to determine gestational age and to detect multiple pregnancies. This appointment will also help Monica to monitor the wellbeing of the baby. Research has shown that women with unexplained recurrent miscarriage are more likely to have a healthy pregnancy next time if they have supportive care at a specialist unit (Australian Journal of Obstetrics & Gynaecology, 1991). Knowing that she will undergo a series of screenings and appointments to monitor the baby’s wellbeing, will also be beneficial in promoting her emotional wellbeing.
Conclusion and Action Plan
Writing this reflection has made me aware of how much I still have to learn when it comes to dealing with other people's emotions. Active listening is important, but I need to understand the balance between caring for women while getting the work done. All women are different, with different needs, different experiences and different ways to reacts to a situation. As a student, I noticed that women might react differently depending on the type of approach you use. In order to improve my skills as a student, I will need to run more antenatal appointments to build a variety of skills. The beauty of midwifery is that you get to face different circumstances and meet people from different backgrounds and culture so there’s always something new to learn. My plan for my future role as a midwife is to make sure to always provide the best adequate care when possible. Be able to learn from past experiences is the motivation needed to give the best care and to become the best advocate for women.
- Australian Journal of Obstetrics & Gynaecology (1991) written by Liddle, Pattinson & Zanderigo. Recurrent miscarriage – outcome after supportive care in early pregnancy; 31: 4: 320-322.
- Barnett SB, e. (2001). Guidelines and recommendations for safe use of Doppler ultrasound in perinatal applications. - PubMed - NCBI. Retrieved 11 January 2020, from https://www.ncbi.nlm.nih.gov/pubmed/11392597
- Boyle S., Thomas H. & Brooks F. (2016) Women׳s views on partnership working with midwives during pregnancy and childbirth. Midwifery 32(Supplement C), 21-29
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- Recurrent Miscarriage, Investigation and Treatment of Couples (Green-top Guideline No. 17). (2011). Retrieved 10 January 2020 from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg17/
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