Friday, December 19, 2008
Strategies To Support Students Learning Presentation For Interview 2
This is the presentation I recently gave for my interview to become a tutor with CPIT. Unfortunately I didn`t get the job but hey there`s always another day!
Sunday, December 14, 2008
Men in the labour room. Do they want to be there?
How it all began.
At the start of my LMC career here in New Zealand, I also began teaching antenatal classes for Parents Centre during this I was also studying for a Diploma in Childbirth Education. I began educating the antenatal classes with definate ideas in mind, one of which was the session with men and women divided. A male educator would visit the session and take the men away and they would cover some aspects of the birth from a male perspective. This bothered me, as an educator I had no idea of the content of the session and I also had the firm belief that the couples should be encouraged to share their communication and be open and honest in the sessions. I held true to this for the first few courses, abolishing the separation of men and women keeping them together and then I began to question myself and I wondered if I was doing the right thing, therefore when it came to my special topic section of my Diploma I decided I should look into the subject and ask a few of the male membership of Parents Centre how they felt about being a part of the labour and birth.
What to look at.
I wanted to look at whether as an educator I did enough to prepare the men in class? Do they want to be present during the labour and birth? Are they the most appropriate person to be adequately supporting women through the birthing process?
I also wanted to know if the men felt under pressure to be present during labour and birth and where did that pressure come from their partners or their peers. I also wanted to know if their intention was to be supportive or was it more about witnessing the birth of their offspring? But whatever the questions I wanted to know if there was more I needed to be doing as an educator and midwife to prepare the men to be more effective as a support person.
In the beginning
Traditionally birth was generally thought of as being 'women's' work, labour and birth took place in the home. In this environment life carried on as normal, women got on with the household tasks during the early phase of labour preparing the household for the imminent arrival of the newborn baby. At the appropriate time the birth attendant was called. During this time the men may have been still at work or busy within the home chopping wood, shooting or fishing or dare I say it maybe even down the local inn having a pint or two. once in attendance the birth attendant would give the man of the house tasks to do as the time of birth drew near, maybe lighting the fire to prepare a warm room, finding warm dry towels to wrap the newborn in and boiling water. The point of this observation is to demonstrate that the men had their role; it was one of practical assistance and one which appeals to their way of thinking. Men are thought of as warriors, hunter providers and enjoyed the practical role during this phase, they were constantly occupied and were just left to pace around the living room at the point of birth itself, to give a sigh of relief once the cry of the newborn was heard and brought out to them wrapped in the warm towels he had provided. He then stayed out of the room until his wife was cleaned up, washed, hair combed and invited to join her in the room once she was presentable.
During this time he was never called upon to give emotionally to the process of labour, he never saw any of the 'gory' bits of childbirth, it remained a magical mystery to him and his wife remained a demure woman in his eyes to once again be able to produce off spring. He had no idea what she had just gone through and had no interest in finding out.
Change begins
In the early 1900's, the process of birth was promoted to be a potentially dangerous one. There was a review of the statistics for maternal death, neonatal death, and morbidity with many women dying of puerperal sepsis. Instead of addressing some of the underlying issues around poverty (many were giving birth in areas of poor sanitation) and poor health, the government looked to providing state hospitals for women to give birth in. It was obviously the cheaper option. 4hrly aseptic washing techniques were employed and the birthing process became sterile and aseptic. The recommendation was made that all women should come into hospital to give birth. The trend continued and by the 1950`s almost all births were taking place in the medical environment. The midwife became a part of the medical establishment and the role of support person came up for grabs as she disappeared to look after more than one woman in labour. In this medical environment women now found themselves in the hands of strangfers, being told what to do and how to behave and became disempowered, lossing belief in their ability to give birth.
Bucking the system
Helen Brew was a person who believe that if they wanted to, 'husbands should be allowed to give comfort and support to their wives in labour'. She began the movement of Parents Centre which fought to allow the husbands into the labour room. The emphasis of this statement should be, 'if they want to'. The problem can now be that it is expected and accepted as part of the 'norm' that the husbands/partners will be present. More than 3/4 of men now attend their childrens birth in the Uk it is 90%. Is this an acceptable pressure to put on men? Is it possible that men can truly be a support to their partners during labour if they have never felt the process of labour and birth and the feeling of empowerment this process gives a woman?
Men in the hospital environment
In the hospital environment the men are now a part of an alien environment, shouted at if they disturb the aseptic area, they are excluded from certain parts of the environment, equipment room, staff tea room, there is nothing provided for them no refreshments, no food nothing to welcome them. Yet they are expected to provide full emotional support, men are hunter gathers, rational and calculating. This seems to be a complete role reversal for them to take on without any preparation or guidance. Where can they turn for advice? Their own fathers may never have been a part of the process and so cannot provide advice or insight, there are very few books and the countless magazines appear to be targeted towards pregnant women. I doubt that any of the men would want to be seen picking up one of these magazines unless he could hide it in his Pig Hunters weekly! Men are not renowned for talking to each other about labour and birth, instead concentrating on what the baby may be up to after he/she is born, quickly it seems turning to the recent rugby team`s performance rather than discussing how the labour was. One article I read which describes a fathr`s experience of birth interestingly pointed out that his wife actually felt less 'connected' to him during labour and she thought it created a distance between them. He felt his role was one of a companion but she wanted him to support her. she saw him as distant, combative and unaware of her needs. Bradley and Lamaze created the role of 'coach' for the father asking him to guide and direct the birthing woman. This can make the fathers role difficult; his tasks can be conflictive with the medical establishment who are trying to 'manage' the labour. Sometimes the early part of labour appeals to the task orientated male, timing the contractions can give him a job to do and commands his attention. As labour progresses some women can then find this distracting and annoying. The men seem to lack the intuitive instinct that other females can have to change to the adapting needs of the labouring woman.
The effects of men in the labour room
Many of the Lead Maternity Carers I interviewed for this special topic, felt that the men seemed uncomfortable and on edge when along side their partners in labour. The men often found it a struggle to see their partners in pain and often influenced the woman`s decision to have medical forms of pain relief. The men appear anxious and afraid and the LMC`s feel that this transmits to the women. They claim to see visible signs of relaxation from the men when the women decided to have epidurals and they often turned back to their magazines and settled into their lazy boy chairs with their feet up to catch up on sleep once she shows no signs of discomfort. Some men have been known to comment, "Well I wouldn`t have a tooth pulled at the dentist without an anaesthetic". Women are also distracted by the obvious discomfort that their partners are feeling and not wanting him to suffer any longer she will opt for strong methods of pain relief. Dr Michel Odent believes that expectant fathers can often cause more problems than they solve and can be partly responsible for the upsurge in caesarean section because they cannot stand to see their partners in pain,
"The baby`s father - a man - is not always the best possible person to help his wife to feel secure."
They can become aggressive in their stance to see what they perceive to be a problem, 'sorted out' and are prepared to push the midwife to call in an obstetrician who then believes they may face litigation if they don`t carry out their wishes. He can often then convince his partner that she should not have to continue with this 'suffering' as he sees it and should opt for surgical assistance.
The National Childbirth Trust believes we should change the culture which means that partners will be there. This statement seems to be in direct contrast with earlier beliefs when they wanted to get partners into the birthing room.
Headlines from the BBC News state that men suffer baby blues as a direct result of witnessing the birth. 4% of UK men nationwide and 10% of Londoners suffer 'postnatal depression'. Most of those men suffering who had witnessed the birth had found it off putting.
Michel odent dares to suggest that in France where men were involved in the process of birth a % were followed a year later by divorce. I think there are many reasons for this and possibly not just due to the birthing process.
Sam Janus, a psychologist in New York, found a high proportion of men were impotent following participation in the birth of their babies. He found the men`s masculinity had been challanged because he could not fulfill his role of protector and he had witnessed the pain of labour something which he felt responsible for.
According to Jon Smith in his book, "The blokes Guide to Pregnancy," there is no information geared towards men and men often feel overwhelmed by the power of contractions and the intensity of birth. Men in unfamiliar surroundings, witnessing medical procedures, feel irrelevant and useless. They can also feel embarrassed and powerless. There can be a sense of failing, failing to make the birth easier. Labour can be a boring process for them, there is a need to hurry the process along. They cannot cope with their partners becoming instinctive in their response to labour and try and keep them from slipping out of a rational, controlled state.
Considering why they should be there
It is considered that men should be a part of the birthing process because he has the benefit of early bonding with the baby. It is an experience which can provide a postitive affirmation of the relationship.
Dr Gita, a gynaecologist in India is now experiencing an increasing number of 'new age' dads who wish to be present during the birth of their children. She believes that their presence at the birth makes the process complete.
" The father also forges a stronger bond with the child if he is present during the birth, and holds the baby as soon as it is born."
Other doctors from the same area believe that it gives the husbands a greater sense of belonging.
Grantly Dick-Read author of, "Childbirth without Fear", values that the couple have to be united in the experience of birth and that it can enrich their relationship.
Andrea Robertson, a leading expert in childbirth education, believes that the man`s needs are often ignored with everyone focusing on the woman and her needs. She believes that they have the benefit of a unique perspective which deserves to be considered, especially if the family unit is to remain strong.
Questionnaire
I decided to take a group of new fathers who had all attended the antenatal classes with Parents Centre and send them a questionnaire. I sent questionnaires to 69 new fathers and received 34 responses.
Only 7 men wanted to write about their experiences of birth.
10 of the men questioned felt under pressure to be present at the birth, 24 felt under no pressure.
All 34 respondents wanted to be present
16 had secret fears about birth, 18 had no fears
When questioned the men felt their main role during labour and birth included, being there, support, reassurance, encouragement, to act as advocate, keep hair out of face, test blood sugars, to assist with crowd control, make her feel strong, understand her needs, provide comfort, keep her calm, to get her there on time, keeping postive and smiling.
only 16 of the respondents were involoved in writing the birthplan, 18 were not involved.
27 men knew there was a birthplan, 7 didn`t know there was one.
5 men didn`t expect their partners to cope with labour, 21 expected her to cope well, 1 respondent had no idea.
13 respondents were surprised at the pain of labour, 17 weren`t surprised.
29 respondents said that the chosen method of pain relief made the job of supporting her easier, 2 said it didn`t and 2 women had no pain relief at all.
When asked what would they teach other men to help them to be a support to their partners during labour they listed,
gain as much information as possible about unexpected outcomes, just be there, don`t get a new job in Australia and be away for the due date, be sure to ask for clarification if you are unsure as to whats happening, stand up to the staff after the birth if you don`t feel they are being helpful or understanding, just do as you`re told, know what your options are, don`t take it personally when you get called bad names, communicate well, be involved, relax, stay calm, be patient, trust the midwife, make sure they have drugs, read as much as your wife does, seem really interested, use the words, "yes dear", "great job", always end by saying, "I love you", ask for epidural early, make your wife wear a hairnet, take responsibility, grow up and bacome the fathers we had or the ones we wished we had. Always maintain a sense of humour, massage, cuddles and verbal support. Only give 2 fingers for your partner to hold.
Conclusion
I can reflect now that men need guidance and support to fulfill the role expected of them during labour and birth. We cannot exclude them from the labour room but we can make certain recommendations. We need to not put men under any pressure to attend the birth. It appears that there is a proportion of men who feel under pressure and that his presence can influence the labour outcome, the woman`s perception of labour and it can aslo influence their relationship following the birth. Interestingly Grantly Dick-Read recommends that there is an assessment of every male prior to the day of baby`s birth. He would then like to place the man into one of 3 categories,
At the start of my LMC career here in New Zealand, I also began teaching antenatal classes for Parents Centre during this I was also studying for a Diploma in Childbirth Education. I began educating the antenatal classes with definate ideas in mind, one of which was the session with men and women divided. A male educator would visit the session and take the men away and they would cover some aspects of the birth from a male perspective. This bothered me, as an educator I had no idea of the content of the session and I also had the firm belief that the couples should be encouraged to share their communication and be open and honest in the sessions. I held true to this for the first few courses, abolishing the separation of men and women keeping them together and then I began to question myself and I wondered if I was doing the right thing, therefore when it came to my special topic section of my Diploma I decided I should look into the subject and ask a few of the male membership of Parents Centre how they felt about being a part of the labour and birth.
What to look at.
I wanted to look at whether as an educator I did enough to prepare the men in class? Do they want to be present during the labour and birth? Are they the most appropriate person to be adequately supporting women through the birthing process?
I also wanted to know if the men felt under pressure to be present during labour and birth and where did that pressure come from their partners or their peers. I also wanted to know if their intention was to be supportive or was it more about witnessing the birth of their offspring? But whatever the questions I wanted to know if there was more I needed to be doing as an educator and midwife to prepare the men to be more effective as a support person.
In the beginning
Traditionally birth was generally thought of as being 'women's' work, labour and birth took place in the home. In this environment life carried on as normal, women got on with the household tasks during the early phase of labour preparing the household for the imminent arrival of the newborn baby. At the appropriate time the birth attendant was called. During this time the men may have been still at work or busy within the home chopping wood, shooting or fishing or dare I say it maybe even down the local inn having a pint or two. once in attendance the birth attendant would give the man of the house tasks to do as the time of birth drew near, maybe lighting the fire to prepare a warm room, finding warm dry towels to wrap the newborn in and boiling water. The point of this observation is to demonstrate that the men had their role; it was one of practical assistance and one which appeals to their way of thinking. Men are thought of as warriors, hunter providers and enjoyed the practical role during this phase, they were constantly occupied and were just left to pace around the living room at the point of birth itself, to give a sigh of relief once the cry of the newborn was heard and brought out to them wrapped in the warm towels he had provided. He then stayed out of the room until his wife was cleaned up, washed, hair combed and invited to join her in the room once she was presentable.
During this time he was never called upon to give emotionally to the process of labour, he never saw any of the 'gory' bits of childbirth, it remained a magical mystery to him and his wife remained a demure woman in his eyes to once again be able to produce off spring. He had no idea what she had just gone through and had no interest in finding out.
Change begins
In the early 1900's, the process of birth was promoted to be a potentially dangerous one. There was a review of the statistics for maternal death, neonatal death, and morbidity with many women dying of puerperal sepsis. Instead of addressing some of the underlying issues around poverty (many were giving birth in areas of poor sanitation) and poor health, the government looked to providing state hospitals for women to give birth in. It was obviously the cheaper option. 4hrly aseptic washing techniques were employed and the birthing process became sterile and aseptic. The recommendation was made that all women should come into hospital to give birth. The trend continued and by the 1950`s almost all births were taking place in the medical environment. The midwife became a part of the medical establishment and the role of support person came up for grabs as she disappeared to look after more than one woman in labour. In this medical environment women now found themselves in the hands of strangfers, being told what to do and how to behave and became disempowered, lossing belief in their ability to give birth.
Bucking the system
Helen Brew was a person who believe that if they wanted to, 'husbands should be allowed to give comfort and support to their wives in labour'. She began the movement of Parents Centre which fought to allow the husbands into the labour room. The emphasis of this statement should be, 'if they want to'. The problem can now be that it is expected and accepted as part of the 'norm' that the husbands/partners will be present. More than 3/4 of men now attend their childrens birth in the Uk it is 90%. Is this an acceptable pressure to put on men? Is it possible that men can truly be a support to their partners during labour if they have never felt the process of labour and birth and the feeling of empowerment this process gives a woman?
Men in the hospital environment
In the hospital environment the men are now a part of an alien environment, shouted at if they disturb the aseptic area, they are excluded from certain parts of the environment, equipment room, staff tea room, there is nothing provided for them no refreshments, no food nothing to welcome them. Yet they are expected to provide full emotional support, men are hunter gathers, rational and calculating. This seems to be a complete role reversal for them to take on without any preparation or guidance. Where can they turn for advice? Their own fathers may never have been a part of the process and so cannot provide advice or insight, there are very few books and the countless magazines appear to be targeted towards pregnant women. I doubt that any of the men would want to be seen picking up one of these magazines unless he could hide it in his Pig Hunters weekly! Men are not renowned for talking to each other about labour and birth, instead concentrating on what the baby may be up to after he/she is born, quickly it seems turning to the recent rugby team`s performance rather than discussing how the labour was. One article I read which describes a fathr`s experience of birth interestingly pointed out that his wife actually felt less 'connected' to him during labour and she thought it created a distance between them. He felt his role was one of a companion but she wanted him to support her. she saw him as distant, combative and unaware of her needs. Bradley and Lamaze created the role of 'coach' for the father asking him to guide and direct the birthing woman. This can make the fathers role difficult; his tasks can be conflictive with the medical establishment who are trying to 'manage' the labour. Sometimes the early part of labour appeals to the task orientated male, timing the contractions can give him a job to do and commands his attention. As labour progresses some women can then find this distracting and annoying. The men seem to lack the intuitive instinct that other females can have to change to the adapting needs of the labouring woman.
The effects of men in the labour room
Many of the Lead Maternity Carers I interviewed for this special topic, felt that the men seemed uncomfortable and on edge when along side their partners in labour. The men often found it a struggle to see their partners in pain and often influenced the woman`s decision to have medical forms of pain relief. The men appear anxious and afraid and the LMC`s feel that this transmits to the women. They claim to see visible signs of relaxation from the men when the women decided to have epidurals and they often turned back to their magazines and settled into their lazy boy chairs with their feet up to catch up on sleep once she shows no signs of discomfort. Some men have been known to comment, "Well I wouldn`t have a tooth pulled at the dentist without an anaesthetic". Women are also distracted by the obvious discomfort that their partners are feeling and not wanting him to suffer any longer she will opt for strong methods of pain relief. Dr Michel Odent believes that expectant fathers can often cause more problems than they solve and can be partly responsible for the upsurge in caesarean section because they cannot stand to see their partners in pain,
"The baby`s father - a man - is not always the best possible person to help his wife to feel secure."
They can become aggressive in their stance to see what they perceive to be a problem, 'sorted out' and are prepared to push the midwife to call in an obstetrician who then believes they may face litigation if they don`t carry out their wishes. He can often then convince his partner that she should not have to continue with this 'suffering' as he sees it and should opt for surgical assistance.
The National Childbirth Trust believes we should change the culture which means that partners will be there. This statement seems to be in direct contrast with earlier beliefs when they wanted to get partners into the birthing room.
Headlines from the BBC News state that men suffer baby blues as a direct result of witnessing the birth. 4% of UK men nationwide and 10% of Londoners suffer 'postnatal depression'. Most of those men suffering who had witnessed the birth had found it off putting.
Michel odent dares to suggest that in France where men were involved in the process of birth a % were followed a year later by divorce. I think there are many reasons for this and possibly not just due to the birthing process.
Sam Janus, a psychologist in New York, found a high proportion of men were impotent following participation in the birth of their babies. He found the men`s masculinity had been challanged because he could not fulfill his role of protector and he had witnessed the pain of labour something which he felt responsible for.
According to Jon Smith in his book, "The blokes Guide to Pregnancy," there is no information geared towards men and men often feel overwhelmed by the power of contractions and the intensity of birth. Men in unfamiliar surroundings, witnessing medical procedures, feel irrelevant and useless. They can also feel embarrassed and powerless. There can be a sense of failing, failing to make the birth easier. Labour can be a boring process for them, there is a need to hurry the process along. They cannot cope with their partners becoming instinctive in their response to labour and try and keep them from slipping out of a rational, controlled state.
Considering why they should be there
It is considered that men should be a part of the birthing process because he has the benefit of early bonding with the baby. It is an experience which can provide a postitive affirmation of the relationship.
Dr Gita, a gynaecologist in India is now experiencing an increasing number of 'new age' dads who wish to be present during the birth of their children. She believes that their presence at the birth makes the process complete.
" The father also forges a stronger bond with the child if he is present during the birth, and holds the baby as soon as it is born."
Other doctors from the same area believe that it gives the husbands a greater sense of belonging.
Grantly Dick-Read author of, "Childbirth without Fear", values that the couple have to be united in the experience of birth and that it can enrich their relationship.
Andrea Robertson, a leading expert in childbirth education, believes that the man`s needs are often ignored with everyone focusing on the woman and her needs. She believes that they have the benefit of a unique perspective which deserves to be considered, especially if the family unit is to remain strong.
Questionnaire
I decided to take a group of new fathers who had all attended the antenatal classes with Parents Centre and send them a questionnaire. I sent questionnaires to 69 new fathers and received 34 responses.
Only 7 men wanted to write about their experiences of birth.
10 of the men questioned felt under pressure to be present at the birth, 24 felt under no pressure.
All 34 respondents wanted to be present
16 had secret fears about birth, 18 had no fears
When questioned the men felt their main role during labour and birth included, being there, support, reassurance, encouragement, to act as advocate, keep hair out of face, test blood sugars, to assist with crowd control, make her feel strong, understand her needs, provide comfort, keep her calm, to get her there on time, keeping postive and smiling.
only 16 of the respondents were involoved in writing the birthplan, 18 were not involved.
27 men knew there was a birthplan, 7 didn`t know there was one.
5 men didn`t expect their partners to cope with labour, 21 expected her to cope well, 1 respondent had no idea.
13 respondents were surprised at the pain of labour, 17 weren`t surprised.
29 respondents said that the chosen method of pain relief made the job of supporting her easier, 2 said it didn`t and 2 women had no pain relief at all.
When asked what would they teach other men to help them to be a support to their partners during labour they listed,
gain as much information as possible about unexpected outcomes, just be there, don`t get a new job in Australia and be away for the due date, be sure to ask for clarification if you are unsure as to whats happening, stand up to the staff after the birth if you don`t feel they are being helpful or understanding, just do as you`re told, know what your options are, don`t take it personally when you get called bad names, communicate well, be involved, relax, stay calm, be patient, trust the midwife, make sure they have drugs, read as much as your wife does, seem really interested, use the words, "yes dear", "great job", always end by saying, "I love you", ask for epidural early, make your wife wear a hairnet, take responsibility, grow up and bacome the fathers we had or the ones we wished we had. Always maintain a sense of humour, massage, cuddles and verbal support. Only give 2 fingers for your partner to hold.
Conclusion
I can reflect now that men need guidance and support to fulfill the role expected of them during labour and birth. We cannot exclude them from the labour room but we can make certain recommendations. We need to not put men under any pressure to attend the birth. It appears that there is a proportion of men who feel under pressure and that his presence can influence the labour outcome, the woman`s perception of labour and it can aslo influence their relationship following the birth. Interestingly Grantly Dick-Read recommends that there is an assessment of every male prior to the day of baby`s birth. He would then like to place the man into one of 3 categories,
- Men, who are prepared, interested and have confidence in the process of birth can stay.
- If man cannot overcome their own fears they should be kept out of the delivery room
- Those who have done no preparation should definately NOT be allowed in.
Special consideration for Midwives and Childbirth Educators
- Antenatal classes should include discussion and information directed primarily at men and provide them with opportunities in the group to share and work together on issues of specific importance meeting their needs.
- There needs to be a separate session for men alone with a male group leader.
- Men need clear factual information.
- Give the men a tick sheet on the hospital visit to make a note of where to get ice, where the toilet is, bean bags, extra pillows, sheets and towels.
- They need to know how to dim lights and move furniture.
- They need to know where to park and how to access the unit and which door to use.
- The man needs to know the midwife and should attend some of the antenatal check ups.
- The midwife should acknowledge his feelings during the process of labour and birth.
- he should be provided with a sleep area if the labour is taking a long time
- He should be able to join his partner in the shower and have the privacy to do so.
- He needs clear explainations about what is happening at all times
- There should be an opportunity for fathers to debrief following the birth
So yes, reflectively I have changed my practice as a midwife to accomodate the special needs of the partner and I have reverted back to having a session at antenatal class which is divided into men/women only session.
Saturday, December 6, 2008
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.
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.
Monday, December 1, 2008
What have I learnt about how to interact with women and their families.
The Inner Consultation, Roger Neighbour
Chris, my husband gave me this book to read. It is aimed at GP`s in practice and looking at how they interact and consult with their patients, so you may wonder why he should suggest a midiwfe should read it and I must admit to being skeptical. I did wonder what on earth I could get from a book which is set in a medical context? Chris did reason with me, that as a practitioner in a primary care setting that I may be able to adapt some of the philosophies of which the author describes.
I have to admit that after reading the first section, he is right. So often as midwives we are taught in our training about the practicalities of the job and we are left to our own devices to develop our own intuative style of connecting with women. I`m left to reflect, is there more that could have been done during my training which would have helped?
In the begining
It is important for us to look at and examine how we are taught our consultation style. Often we have learnt our style from our mentors with whom we have worked during our training. These were women who at times could seem infalible, with the huge amount of what seemed infinate knowledge they had and some of us held them in high regard.
Models of consultation can also be looked at to make the skills of connecting seem easier. I like the description he uses for `keeping it simple` and `the consultation as a journey` because I often see the midwife/woman relationship as a `journey` through pregnancy, birth and with her new baby. It is often when considering this `journey` we can look at the models that are used.
The `role model`
In his book, Neighbour describes this model of the patient entering the `sick role` and they hand over partial or complete responsibility for their well-being to the doctor. I liked this role model to the one of the pregnant woman going to see the obstetrician for a consultation regarding her pregnancy. She may assume the role of `sickness` because she has only ever associated the doctor with being sick and during that consultation she begins to partially or completely handover control to the obstetrician and although she had every intention of having a normal labour and birth she ends up before she knows it booked for an elective c/s. I enjoyed reading about the `role signals` which may lead a woman to assume this role. How often have we seen the obstetrician in his clinic, enthroned behind a desk in a white coat with what Neighbour describes as `access rituals`, such as receptionists, appointment systems and the women having to present their urine specimens as gifts to secure the obstetricians attention.
The doctor-centred or patient centred consultations
I was left to reflect how often I have over heard the `midwife-led` consultation, the woman is bombarded by information which must be covered so that a box can be ticked in the box of the careplan with a total disregard for anything that the woman may have wished to discuss and a disregard for whether she has heard it all before or if she has found it out herself. The midwife is happy at the end of the visit having accomplished her agenda. Or on the other hand the `woman centred` consultation whereby none of the essential information is covered at all and the woman is in charge of the visit.
The Task orientated model
This is very much similar to the above model whereby the visit is dominated by tasks that have to be completed and the success of the visit is set with the accomplishment of these tasks.
The Health Belief Model
This is the model that most interested me, especially in the climate which I have worked. In this model he discusses that the beliefs and motivations which the patient (woman in midwifery world) brings into the visit influence the understandings and intentions she takes away with her and passes on to her family. With this model it is useful to consider the ideas, concerns and expectations the woman has with regard to her pregnancy, birth and with her new baby. These aspects I believe, will influence her choices and the information she looks to the midwife to provide during the pregnancy. Then depending on what she has heard and absorbed her health beliefs will influence how she transmits that information to her family and friends.
Talking with two heads
After reading this chapter I was left reflecting how often I use two heads during an antenatal assessment. In his book, Neighbour names these heads as the Organiser and the Responder and he takes us through a couple of examples and I have been left trying to construct a midwifery example in my head. The organiser head is the intellectual part of the brain, is very logical, task orientated, is calculating, likes to anticipate and stay one jump ahead of the game. It sets your goals and `wants` certain things to happen. It deals with the checking of urine, Bp`s, palpation and the documentation of the visit and the checking of the careplan. The responder is the spontaneous head, naive and intuitive and picks up on not only verbal communication but non verbal communication. Have you ever wondered why you connect with some women better than others? Thats because your responder head has been busy reading all the non verbal cues which may be suggesting that the woman isn`t connecting with you, such as lack of eye contact, fidgeting, hesitancy of speech.
The responder head and the organiser head may alternate during a visit with one or the other whispering in your ear as you talk.
One exercise which I found useful is to recall some visits which you have done recently and see if you can remember some of your internal dialogue and then jotting your thoughts down.
Continuing with the two heads theme I was left to reflect on the midwife/obstetrician relationship in the book he says, "Two heads are better than one just as long as they are each working towards the same goal, and each respects the strengths and weaknesses of the other." I was left thinking of the recent signing of a memo by the College of Obstetricians and the College of Midwives to each share the aspiration to work towards the health of the mother and baby and wondered if that would ever be possible if we don`t respect each others strengths and weaknesses.
I look forward to reading the second part of the book and picking out the information which may improve how I connect with women or having the reasons for the times that I don`t.
Chris, my husband gave me this book to read. It is aimed at GP`s in practice and looking at how they interact and consult with their patients, so you may wonder why he should suggest a midiwfe should read it and I must admit to being skeptical. I did wonder what on earth I could get from a book which is set in a medical context? Chris did reason with me, that as a practitioner in a primary care setting that I may be able to adapt some of the philosophies of which the author describes.
I have to admit that after reading the first section, he is right. So often as midwives we are taught in our training about the practicalities of the job and we are left to our own devices to develop our own intuative style of connecting with women. I`m left to reflect, is there more that could have been done during my training which would have helped?
In the begining
It is important for us to look at and examine how we are taught our consultation style. Often we have learnt our style from our mentors with whom we have worked during our training. These were women who at times could seem infalible, with the huge amount of what seemed infinate knowledge they had and some of us held them in high regard.
Models of consultation can also be looked at to make the skills of connecting seem easier. I like the description he uses for `keeping it simple` and `the consultation as a journey` because I often see the midwife/woman relationship as a `journey` through pregnancy, birth and with her new baby. It is often when considering this `journey` we can look at the models that are used.
The `role model`
In his book, Neighbour describes this model of the patient entering the `sick role` and they hand over partial or complete responsibility for their well-being to the doctor. I liked this role model to the one of the pregnant woman going to see the obstetrician for a consultation regarding her pregnancy. She may assume the role of `sickness` because she has only ever associated the doctor with being sick and during that consultation she begins to partially or completely handover control to the obstetrician and although she had every intention of having a normal labour and birth she ends up before she knows it booked for an elective c/s. I enjoyed reading about the `role signals` which may lead a woman to assume this role. How often have we seen the obstetrician in his clinic, enthroned behind a desk in a white coat with what Neighbour describes as `access rituals`, such as receptionists, appointment systems and the women having to present their urine specimens as gifts to secure the obstetricians attention.
The doctor-centred or patient centred consultations
I was left to reflect how often I have over heard the `midwife-led` consultation, the woman is bombarded by information which must be covered so that a box can be ticked in the box of the careplan with a total disregard for anything that the woman may have wished to discuss and a disregard for whether she has heard it all before or if she has found it out herself. The midwife is happy at the end of the visit having accomplished her agenda. Or on the other hand the `woman centred` consultation whereby none of the essential information is covered at all and the woman is in charge of the visit.
The Task orientated model
This is very much similar to the above model whereby the visit is dominated by tasks that have to be completed and the success of the visit is set with the accomplishment of these tasks.
The Health Belief Model
This is the model that most interested me, especially in the climate which I have worked. In this model he discusses that the beliefs and motivations which the patient (woman in midwifery world) brings into the visit influence the understandings and intentions she takes away with her and passes on to her family. With this model it is useful to consider the ideas, concerns and expectations the woman has with regard to her pregnancy, birth and with her new baby. These aspects I believe, will influence her choices and the information she looks to the midwife to provide during the pregnancy. Then depending on what she has heard and absorbed her health beliefs will influence how she transmits that information to her family and friends.
Talking with two heads
After reading this chapter I was left reflecting how often I use two heads during an antenatal assessment. In his book, Neighbour names these heads as the Organiser and the Responder and he takes us through a couple of examples and I have been left trying to construct a midwifery example in my head. The organiser head is the intellectual part of the brain, is very logical, task orientated, is calculating, likes to anticipate and stay one jump ahead of the game. It sets your goals and `wants` certain things to happen. It deals with the checking of urine, Bp`s, palpation and the documentation of the visit and the checking of the careplan. The responder is the spontaneous head, naive and intuitive and picks up on not only verbal communication but non verbal communication. Have you ever wondered why you connect with some women better than others? Thats because your responder head has been busy reading all the non verbal cues which may be suggesting that the woman isn`t connecting with you, such as lack of eye contact, fidgeting, hesitancy of speech.
The responder head and the organiser head may alternate during a visit with one or the other whispering in your ear as you talk.
One exercise which I found useful is to recall some visits which you have done recently and see if you can remember some of your internal dialogue and then jotting your thoughts down.
Continuing with the two heads theme I was left to reflect on the midwife/obstetrician relationship in the book he says, "Two heads are better than one just as long as they are each working towards the same goal, and each respects the strengths and weaknesses of the other." I was left thinking of the recent signing of a memo by the College of Obstetricians and the College of Midwives to each share the aspiration to work towards the health of the mother and baby and wondered if that would ever be possible if we don`t respect each others strengths and weaknesses.
I look forward to reading the second part of the book and picking out the information which may improve how I connect with women or having the reasons for the times that I don`t.
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