To Ve or not to Ve? THAT is the question?!

Me too, smwife! My unit is an obstetric unit but I cant see how that affects my VEs... curiouser and curiouser... explain yourself madam!

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Surely being in an obstetric unit means you are more likely to VE "to protocol" - depending on what your protocol is. For example, in an obstetric unit IME, it is quite usual for midwives to do admission VE, because labour ward coordinator wants to know who is doing what (likely to delivery, NIEL and needs sending home, etc...). Whereas in the birth centre, there is no requirement for admission VE, they make a judgment, allow woman to potter see what happens, and "reassess" (which does not necessarily include VE) four hours labour. I've heard women say "Aren't you going to VE me?" to which the midwife has replied "Well, I can see your in established labour just by looking at you". I don't think that would happen in an obstetric unit...

Sorry, who's supposed to explain what? I am confused.

The training is supposed to enhance critical thinking and decision making. Just because the unit is supposedly high risk, whatever that means - perhaps the very fact that these women chose to have their babies in hospital makes them high risk. The majority of women are physically able to have their babies physiologically, whether or not they can psychologically is another thing. So if we accept that women in general should be able to birth normally, then why are there more high risk obstetric led units than they are small stand alone birth centres? Surely that has little to do with clinical picture but more to do with where we are as a society.

So you either accept your responsibility as a student to be an agent of change (after all, that must be the reason why it is now an academic course) as you have access to research that should back a more holistic approach to childbirth and midwifery, OR basically consider that perhaps you are not going to affect any change and just carry on perpetuating the subculture and be part of the status quo. Which is it going to be?

I do agree that we are being taught as students to be agents of change as you put it Lotus eater, but in practice, once in placement, we tend to revert (certainly in yr 1) to what our mentors do. I do believe we have the power of change but not the confidence whilst still a student. I think that the confidence of change comes much later.

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STMW 2nd year - no, really!

I was asking smwife to explain what she means but I think I get what she means after a re-read - that we wont get much direction with other signs of knowing in an obstetric unit.. as the culture is 4 hourly VE's...etc

Confidence as a student is a tricky thing, the balance between fitting in or being the 'bolshy student' the balance between being in the 'gang' and developing your own style and practice... all this while still learning your craft...

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StudentMidwife.NET Founder & Director

What do we live for, if it is not to make life less difficult for each other?
(George Eliot, 1860)

Not a very nice tone developing here.

I am a STUDENT and am learning, so bear with me, I am certain you learned once so try your best to remember.

What I meant was an obstetric unit, but the majority of women are high-risk, this could be because they have a fetus that is large for dates, an epidural in situ, cardiac problems, choleastasis, polyhydramnious, induction for postdates, premature etc. Due to these factors, watching the purple line or any other signs is a difficult one, the section rate is 25% there too.

I was merely making a point that that although we obv do get normal deliveries and spend time with normal labouring women, protocols are adhered to quite rigidly, partograms are used and when women do not follow the supposed progress line they may have began as low-risk, but then become high as syntocinon is used to augment, ARM, then continuous CTG monitoring is used the woman can no longer mobilise etc etc.

These aspects make it really hard IMO for students to see real normality in labour and birth and to be truly with woman.

The four-hourly VE's go some way to start this cascade of intervention and is my point.

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I think you are right. As a student, it is difficult to change your mentor's rationale. However, there are midwives out there that promote normaility within obstetric units and these have the knowledge and the skills to use other external and non intervential signs to assess progress, but you have to be very sure of your skill base before doing this and going against local guidelines as you have to have the justification for doing so. Not all students have that rationale in the 1st, 2nd or even start of 3rd year. It might not happen during your training if you have never seen it done in practice, so you might develop this skill after your training.

Students who train in obstetric units have little or no experience of the wonders of small midwifery led units or birth centres - and perhaps this should be addressed during training to recieve a wide range of experiences.

KS x

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Just adding my two penneth worth, when a midwife the does an examination, and really struggles to define, position, effacement, dilatation etc... Is it then she she has not tuned/honed in to that woman, or is it that she simply cannot tell???
Perhaps then, my confidence/luck/skill has nothing to do with if I have in fact got the VE right (I'm talking about when checked by a mentor), its all about if I'm tuned in to the woman... This is a bit difficult on an admission VE for example, I mean just how quickly can you tune in to a woman??? (say 10-15 mins??)
So what about when you simply cannot tell??? Is it time to give up? As your communication skills are out of the window/you didn't bring your tuning/homing in device with you that shift???
Just wondered, after all we can all have an opinion can't we?
Nobody has to be chastised in a derogatory manner for saying/suggesting something now do they? that would just be silly!!!

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Absolutely, this is my point.

I read Di Blake's article in the recent Practising Midwife with interest as it discusses students training more in low-risk units. And as a student I am learning there is another side to midwifery that we rarely see. I agree there are some midwives who have the knowledge and passion to promote normality in the CLU's, but they are in the minority and there are also few who genuinely advocate for their women. Though I am a mere second year I have a keen interest in normal labour and birth and am quite despondent that we see so little of it during our course thus far.

I do see when things are going wrong and have discussed these points with my mentor at the time, however as a student there is only so much that can be said without coming over as bolshy and a know it all (which I am neither)

I have had so far only two weeks experience of a birthing centre, and sadly only one labouring woman to help care for during this period. In my community placements, despite putting myself on call with every member of the team I never got to see a home birth. I do believe there is more emphasis on intervention rather than normality and students do not get to lean these while training so this does not enable me to develop a rationale to deviate from any guideline (at least not the knowledge and therefore confidence to do so)

Does that make sense?

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If you don't develop the ability to swim against the current as a student (in relation to VEs, or anything else) how likely is it that you will suddenly change direction and start swimming against the current once qualified?

I think this is the biggest issue: university education teaches to think outside the box and introduces a theory-practice gap which makes everyone feel very uncomfortable. The question is how to resolve that discomfort. Some will simply float with the current (whichever direction it happens to be going in), but for others the awareness that current practice they are accommodating to is far from perfect and even harmful is very challenging, and that this is what people are reacting to. It is perhaps easier to be defensive about how something is said than actually address the substance of what is said.

It comes down to first principles: what is it really want to know and why? Is a VE the only or best way of finding out? I would recommend Denis Walsh "Evidence-based Care for Normal Labour and Birth", especially the chapter on the rhythms of first stage.

On "high risk", it is plain that the majority of women labouring in obstetric/consultant-led units are not high risk - these units take a mix of risk (except perhaps in parts of Wales and other areas where low density of popultion means some areas are served by MLU/GPU only).

Also, what are you defining as large for gestational age? How predictive are your antenatal tests for this? And at what point does it become high risk? just curious about how these risk parameters are drawn.