A young primigravid woman presents at 38 weeks gestation with severe abdominal pain and vaginal bleeding. Her antenatal course has been unremarkable and her partner shows you an extensive birth plan requesting minimal intervention. A CTG is placed urgently and reveals a baseline tachycardia of 180bpm, absent variability, followed by a bradycardia of 70bpm. You suspect a placental abruption and a category 1 caesarean section is arranged and promptly performed under a general anaesthetic, with delivery of a floppy male infant who is transferred to the NICU. You are caught up with several other emergencies, and at the end of your shift you are confronted by the partner who is visibly agitated and angry. He yells at you in the corridor accusing you of trying to ‘kill my wife and son’.

Conflict and aggression in the health arena are a growing concern for health professionals. Maternity wards have been identified as a high-risk setting for occupational violence that is defined as ‘any incident where an employee is abused, threatened or assaulted in circumstances arising out of, or in the course of their employment.’¹ The field of obstetrics presents unique predicaments for healthcare providers. Childbirth is an emotionally charged milestone event that is not often regarded as a medical episode. It is filled with high expectations and, often, pre-conceived ideas that are inevitably challenged by the unpredictability of pregnancy and labour.

Is it really a problem?

A survey of obstetricians and gynaecologists in the UK revealed that 50 per cent had experienced violence at work in the past year. ² Similarly, 86 per cent of maternity nurses had been exposed to workplace violence, with patients’ relatives (38 per cent) the predominant source.³ There is increasing evidence that workplace violence contributes to stress and burnout in doctors. In a study of more than 1000 obstetricians, 61 per cent admitted to conflict with patients, and those reporting conflict were significantly more likely to display features consistent with emotional exhaustion (OR 2.8, 95% CI 1.6–4.8).⁴

Causes of conflict

Conflicts may evolve from a number of situations, such as unmet expectations, poor outcomes, discordant goals, inadequate communication, substance abuse and extended wait times. Obstetrics, contrasted with other areas of medicine, often involves detailed assumptions from patients and their families as to the course of their pregnancy and desired outcomes. This may be driven by media, cultural beliefs or the experiences of those close to them. Unexpected situations may arise, such as structural or chromosomal anomalies, miscarriage and other antenatal complications, including preterm birth and fetal demise. The intrapartum period is even more unpredictable. Particularly problematic are obstetric emergencies, where decisions about management are often made and executed swiftly, which may compromise effective communication at the time.

Prevention

Partner inclusion and support

Partners are often neglected during the pregnancy, despite often being the main source of support and counsel for the patient. A longitudinal study of men’s experiences of pregnancy showed that overall levels of stress were elevated during pregnancy, at birth and postpartum. Higher levels were seen intrapartum, and especially high if men felt they were unable to fulfil their expected roles.⁵ Partners must be supported and prepared for risk and uncertainty in pregnancy to effectively support the patient in achieving a successful parenthood experience.⁶ Facilitating partner engagement includes encouraging involvement in antenatal classes and support from clinicians during labour. Barriers to partner involvement have been reported as poor information and lack of support during birth.⁷ Withholding information from partners has been associated with increased rates of anger and frustration.⁸ Other studies have confirmed that partners often feel excluded in labour, with little control over the situation, and that their lack of knowledge may have prevented them from adopting a more active role.⁷

Early identification of issues

Modern medicine has shifted from the paternalistic model of care and women and their partners are usually hungry for information. As clinicians we should be providing our patients the tools to empower them to make informed decisions regarding their care. The American College of Obstetricians and Gynecologists proposes shared decision-making, which is a ‘process where both patients and physicians share information, express treatment preferences and agree on a treatment plan’.^{9 10} Antenatal consultations should be used to discuss potential problems that may arise in the pregnancy or in labour. Women should be encouraged to involve their partners in these discussions. Such issues may include refusal of blood products, needle phobias and high-risk pregnancies. Clear documentation and consideration of referral to other clinicians must not be overlooked. Patients with high-risk pregnancies should be informed of potential complications and recommended interventions. For example, a trial of labour after caesarean section warrants a conversation discussing risks and benefits, as well as the requirement for additional monitoring and intravenous access intrapartum.

Birth plans

Birth plans can be a helpful resource to guide staff as to the woman’s preferences and aid in respecting her wishes. Women usually rely on their birth partners to advocate for their plans during labour. Occasionally, clinicians may encounter a rigid or impractical plan. Antenatal detection of such plans is important and a thorough discussion should take place between the couple, taking into account their personal values and beliefs. Preparation and education for parents is crucial as many will often anticipate that labour will proceed exactly according to their plan.¹¹

Cultural and language barriers

Language barriers often lead to misunderstandings or incorrect information between healthcare professionals and patients and their families. Feelings of helplessness or frustration may be evoked and successful communication compromised. RANZCOG advises that interpreting services should be provided if required and that relatives should not act as interpreters. ¹²

Cultural issues around intimate examinations may arise, including refusal of male clinicians. Occasionally, in an emergency situation, an appropriately trained female staff member may not be available. Patients and their partners should be made aware of this limitation in the antenatal period. Every effort should be made to source a female staff member, and if this is not possible a chaperone should be present if the situation occurs.¹³ Staff should be trained in cultural competency and health services should be flexible and promote the use of appropriate culture-specific services, such as Aboriginal liaison officers.¹²

Disclosure and debriefing

Emergency situations are a reality of obstetrics and unforeseen complications are an unavoidable aspect of medicine. When unexpected events occur, an open and transparent approach is required to facilitate a couples’ acceptance of the loss of their desired outcome. Disclosure of adverse events leads to higher ratings of quality by patients and a reduction in malpractice suits.¹⁴ It is important that, where possible, this is carried out in a timely manner.

Dealing with conflict

Safety is the utmost priority if confronted by an aggressive partner. This includes for yourself, other staff and the patient. If placed in a potentially violent situation, staff should feel comfortable to call for an emergency code (most commonly, a ‘code grey’) to summon extra support and assistance. Recognition of warning signs of a potentially violent situation may allow early action and prevention. These include, raised volume or pace of speech, violent gestures, restlessness or refusal to engage. Non-verbal and verbal communication skills should be employed. Non-verbal skills include an open posture, eye contact and active listening such as nodding. Verbal cues may include open-ended questions and empathy with acknowledgement of the person’s concerns.¹⁵ It is prudent to consider involvement of senior staff and patient advocates, such as patient liaison officers, to aid in resolution. Careful documentation is essential and follow-up reviews should always be offered.

Conclusion

Violence and aggression are not often encountered in day-to-day practice, but the experience can be distressing for staff, with possible long-term detrimental effects. Dealing with an aggressive partner should focus primarily on prevention and engagement in the antenatal period. Healthcare workers need to be equipped with adequate communication skills and support to identify and manage workplace aggression.

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