I think the point is that the information gathered on VE is not itself the be all and end all - it is a *means* to an end, and that end may be achieved by other methods, including tuning into the woman.

So, woman comes in to hospital, contractions are 1:10 (had been 1:5 at home), lasting 30-45 seconds, mild on palpation, she is in some pain with contractions describing as like period pain, breathing and talking through contractions and easily distracted from the pain by being talked to during them. Are you really going to VE her to tell her that she is not in established labour? That's what is meant by "tuning in" (not having second sight that allows you to diagnose her as 1 cm dilated by your X-ray vision).

It's an extreme case, but you get the picture. The more you have to rely on other signs than VE, the more skilled you might get at interpreting the subtleties of women's behaviour.

For position - it may be more difficult to define position on VE than from abdominal palpation. VE may confirm position that you've already defined on abdominal palpation, if you are certain of position and that's the reason you are considering doing VE, the maybe you don't need to do one if you happy. Besides, the only time when knowing position will change your management of the labour is when considering forceps - in which case the reg having a really good feel and being certain is important. Otherwise, doesn't the advice remain the same (upright position, mobilise, etc...)

Descent can also be felt abdominally, and confirmed with VE if necessary.

What dilatation tells you is minimal - in a multip it may well not define the difference between latent and established labour (she might have a multips os of 3cm) and if you find she is 7cm that doesn't give you a clue as to how soon she is likely to be fully (since she could take 30 minutes or 3 hours to get to fully).

There are likely to be external signs in the woman of slow labour progress, and then you have an indication for VE. But that doesn't mean that VE has to be done routinely to exclude slow labour progress if every external sign suggests that labour is progressing normally.

So, it's not so much that tuning-in helps you do an accurate VE, but that tuning-in might obviate the need for a VE.

That is just my point, whilst I want to promote normality, I cannot whilst training, I have discussed why a woman would receive an aspect of care. But i am not a midwife and am not knowledgable nor competent enough to influence that care, possibly this will be practicable in year 3, maybe not.

As far as when women become high-risk, this is not my opinion, this is based on trust policy, many women are defined as high-risk and individual circumstances influence those decisions. And I was speaking of the women in the CLU in which I have my clinical practice placements, not nationally, of that I have little knowledge and it is of little concern at the moment.

I own that book, it was one of the first I bought and it is influencing my thoughts with regards to normality in labour care. And I don't know what type of midwife I will be, my hope is I want to promote normality and advocate, but that may have to be a gradual process after qualification, so I won't conform to hospital protocol, but I also want to gain knowledge and experience when it is my pin and not someone else's in order to know when to and when not to.

__________________

Please don't be defensive.

When you say "I am not knowledgable nor competent enough to influence that care [promote normality]", I would suggest that you are both knowledgeable and compentent enough to do so - but that institutional structures inhibit or obstruct you from doing so. That is a horrible place to be in, and often the response to being in the position is to become an apologist for the insititution.

As for high risk, I was interested in what is actually high risk, not what the institution defined as high risk.

I think every student has to deal with situations in which they practice according to how their mentor wants them to (and then resolve never to practice that way on your own PIN!) ...but....let me try an analogy...

If a woman antenatally says "I'm going to breastfeed, I want to know how to make it work" you know that she has an excellent chance of success. If a woman antenatally says "I'm going to try my breastfeed, but if it doesn't work out I'll bottlefeed" you know the likelihood is that she will be quickly discouraged when it doesn't just "happen".

I think if you don't learn how to swim against the current as a student, the chances of you being able to swim against it in your career are reduced. Of course, there are midwives who have had a Damascene moment sometime after qualifying which has fundamentally shifted something in their approach - but I would suggest that is not typical.

I like that analogy. That is pretty much what I was trying to say, that 'other ways of knowing' can only be enhanced when you decide that you will not just rely on one method of assessing a woman's labour.

I've always thought that student midwives ought to be ask to place themselves where they think they are on the philosophy of midwifery spectrum, because it is good to know where your bias is and acknowledge it.

I am quite happy to be challenged, after all these are merely my opinion and I would welcome any well-thought out counter-statements.

By the way, I only view unwarranted inductions of labour (which most of them are) as high risk for the fact that they are being carried out.

Well said, and apologies for perhaps being defensive, at times those who know and understand better and are stronger in character, can at times be viewed are persecutory. It is likely that is how I felt.

Whilst training, very early on I began to realise the disparity between theory and practice, this concept is nothing new asit was particularly evident in my previous career also.

There are many influences on a student, and these differ with their personality and previous experiences, also with the mentors that become involved in the development and the ethos of staff working in that environment. Whilst your analogy was a good one, and I appreciate that. Possibly though with this analogy as with the situation I am currently in (as with I am sure many other students) this situation can change with experience and the attainment of knowledge.

I am not sure I am getting my point across and I don't think we're at odds here at all. I'd like to be the next Mary Cronk, but yes, I am conforming. This course is like playing a game with your moves being led by a mentor it does not mean I cannot see where better moves can be made.

__________________

Hmmm, what is an unwarranted induction in your book, LE? I would say that there are inductions done without medical indications (perhaps social inductions, may be unwarranted - but depends a bit on situation), inductions with weaker medical indications (prophylactic inductions), inductions with stronger medical indications (therapeutic inductions), inductions with 'traditional' indication not supported by research evidence (unwarranted inductions). To give examples in each of these categories:

Social

Time birth (after 40 weeks) because partner in military is going to be posted overseas. IMO, woman's choice if she has had risks of induction explained.

Prophylactic

Induction after 41 weeks to prevent prolonged pregnancy

Therapeutic

Confirmed Pre-eclampsia (with PET bloods), but judged to have time to avoid CS.

Unwarranted

Confirmed IUGR with evidence of fetal compromise (should not be inducing with compromised baby, if delivery needed, go straight to CS)
SGA, but simply statistical outlier - no reason to expedite delivery
Macrosomia/prevent big baby (in absence of diabetes) - no reason to induce.

Ahh, I agree with your unwarranted list, in my books, unwarranted (maybe that is the wrong choice of word, maybe I should have said 'barbaric' instead :P) are those inductions that got booked at 39+5, oooh, you're 39+1, we might as well book your induction date so you don't miss the boat cos it'll be the weekend when you bla bla bla so let's do it earlier, that sort of induction. The sort of induction that doesn't get done if they are too busy on the wards. In my mind, they're the ones who produce corkers of obstetric emergencies.
Biased, me? Definitely!!!

Edited millions of time because I am semantically challenged today.

But LE, are those sorts of "no reason whatsoever" inductions at 39+5 really done in the UK? Often? In the US, yes - but here? Maybe I'm just blinkered....

I've had experience of it, some in the past, one quite recent. The recent one was induced at 39+5 so consultant said she might as well have an induction because the baby was 'big' enough. And that if she went in on the Monday, she could be induced and if things failed, it would be fine cos the consultant is doing surgery on Tuesday. I know this cos I had to come home from my holiday to be with this woman. It was not explained to her that NOTHING would be done to her for another 24hrs once the propess in put in on monday morning, this woman thought she was going to have her baby by the end of Monday.

During my training, I've sat with midwives who booked women in for IoL earlier because it is going to be the bank holiday, long weekend, consultant on holiday next week.

The only social induction I have had experience of is this woman who insisted on being induced and she had 3 lots of prostin and it did nothing. So they sent her home. I think she was 39 weeks pregnant.

I think in time you will come across 'gems' like that, Wannabe and I have to say, when I experienced it, my head was spinning so fast trying to get to grips with it, it was most disorientating.

I agree with the philosophy behind what you are saying but the reality is very different. Id like to hear your views on this after you have started the course. I understand what smwife is saying completley. As a student who is learning, gaining confidence and then getting it knocked out of you the next day is very common, one day you'll feel like you can change the world the next you feel like nothing will ever change. You may make a suggestion to a mentor who supports your school of thought, or place on the spectrum and feel a million dollars but equally you can be heavily patronised or belittled for advocating something that is not usual practice. The environment can be very tough and there are days when you dont want to go in as much as you love what you do, you feel you are getting nowhere fast ....

I think the way to navigate the choppy storms in practice when you are developing your style and clinging on to your place on the midwifery spectrum is to be supported by like minded people, those more experienced can soothe and calm you while others can share how they got through x while keeping strong to their beliefs.

__________________
J
StudentMidwife.NET Founder & Director

"You're braver than you believe. Stronger than you seem. And smarter than you think."
Christopher Robin in Pooh's Grand Adventure

Please help us raise funds for a bereavement room in Honey's memory by taking part in the SMNET Auction & Raffle here thanks x