Making Connections

I`ve been making connections with my previous post, which describes some of the theories by Neighbour, with my practice when looking after women in labour. There are some things I have been thinking about which include, the setting up of a trolley for birthing, challenging the thought process of student midwives I`m working with and how my reactions to the progress of labour are so different on each occasion. I find that I always feel I`m at my best with the woman in labour and I can gain a deep sense of connection. My responder self is at its best, sensing and intuitively working in partnership with her until the moment of birth.

The setting of the trolley.

I have often thought and wondered why I set a trolley with the required equipment and why everyones trolley is set slightly differently. In the past the moving of the birthing process to within the hospital setting to create the aseptic technique of `delivery` was aimed at reducing the maternal death rate from puerperal sepsis and the setting up of a sterile trolley was part of the process. Assessing one day how I felt one day when I was setting my trolley, I realised it was as much about me preparing myself for the imminent birth as it was about maintaining a clean environment. I was in effect getting ready and it was a task that the 'organiser' part of my head felt comfortable doing, staying one step ahead of the process and being prepared. There have of course been those times when I`ve not been prepared at all because I`ve been so tuned in with my `responder` head, emotionally connecting that it is with some annoyance to others they`ve had to set the trolley for me and get some warm towels prepared.

Monitoring of labour

When it comes to challenging student midwives, I`ve often found that some senior student midwives I have worked with have developed some 'routine' task orientated habits when it comes to their assessment of women in labour. This demonstrates to me that the 'organiser', task orientated part of their heads is working well but I am often looking for them to be developing their 'responder', intuitive part. One of the task orientated assessments is the routine use of vaginal examination on admission to the labour ward. When challenged as to why they just want to 'jump' straight in there with the assessment they often explain, "Well how am I to know where she is up to, or if she is even in labour". It is always important to continue to challenge this as not just 'routine' as Sheila Kitzinger says,
"Hospital staff tend to perform vaginal examination far more frequently than is necessary in order for them to assess the mother's adherence to their definition of 'normal' labour, and also because their lack of close surveillance means they are unable to understand what is happening within the mother by more intuitive, non-invasive means. This further increases the risk of infection being introduced into the mother. "
There is plenty of research on the subject of vaginal examinations none more so than a recent article in the NZCOM journal http://www.midwife.org.nz/index.cfm/3,114,279/nzcom-journal-oct05.pdf, in this article Lesley Dixon examines the reasons for vaginal examinations and why it is important to keep them to a minimum.
I often wonder though how much influence cases such as this that are recorded with the Health and Disability Commissioner http://www.hdc.org.nz/complaints/opinions?98HDC13531 cause a midwife to lose a little confidence in herself and do one quick internal check.
I found it easier to challenge the student to just take a thought and observe the woman`s behaviour for a while, when she has been seeing the woman antenatally for a while and is confident with the results of palpating. I always see a look of shock when I suggest that if someone who has been niggly for 3 nights, is having her second baby and has had to drive one and a half hours to come in and arrange a babysitter to do so, she is only gonna come when she knows she is in labour. These are the cases that can be used, I feel, to increase the skill of the 'responder' head, sit back, observe, feel and watch the woman's behaviour. I had a mentor once at the start of my training who used to leave me in the room, make me sit in the corner and she used to say, 'call me when her toes start to curl.'

Different reactions to labour.

In the past I`ve been know to question myself. Where I worked in the UK, in Shrewsbury, there were 4,000-5,000 births a year, there was a consultant led unit and five outlying midwife led units which each took care of 500 of these births each. The midwife led units ranged from 40-90mins out from the consultant led unit. I was mainly based on the consultant led labour ward with the usual story of lack of staff and looking after up to 3 women at different stages of birthing, going from room to room sometimes forgetting that I needed to drink and most of us had learnt to just pee once during a night shift. I started it seemed to develop a sense of what was happening to a woman during labour but then I began to wonder if I was just aiming to get that woman to fulfil my prophecy or was I correctly identifying and anticipating a problem? I therefore requested a move to one of the midwife led units to regain my midwifery roots.
It is that experience I draw on now when I adapt to the individual women in labour. I find that now I am able to follow labour intuitively with my 'responder' head trusting the process of what is happening and then I am able to recognise the need to be more the 'organiser' head, anticipating that there is an impending, developing problem leading to being one step ahead of the game and ready for anything that may present itself.