Exploring the Exceptions

I have previously written about a principle that I was taught and have subsequently shared with many other midwives.

It involves asking oneself whether offering a screening test would change one’s management, or what one would offer to a woman.

I suggested that such principles can give people who are learning midwifery (and other arts) a solid starting point.

And I also noted my belief that this solid ground can also serve as a point from which to explore the exceptions to the rule.

Perhaps also the times when general rules should be ignored or broken.

Exploring an exception

The example I shared in my previous article involved asking whether performing a vaginal examination (VE) in labour is likely to change what we do, say or offer the woman.

Because if it isn’t, then we might ask why are we doing it.

Such questioning can help even experienced practitioners to reflect on their actions and make course changes that can help improve their practice.

But the best rules also have exceptions, which can sometimes enable us to think even more deeply about what we are doing.

The following examples are based on actual experiences shared at a home birth emergencies workshop that I facilitated a few years ago, but the details have been changed to preserve confidentiality.

Why listen in?

In the story, two community midwives were awaiting an ambulance with a woman who needed to be transferred from her home to the hospital for a cord prolapse. (I’ll save you the suspense by telling you now that she and the baby were both fine.) The woman was in a knee-chest position and one midwife was holding the baby’s head up and off the cord. The second midwife leant in to listen to the fetal heartbeat with a hand-held Doppler.

When we discussed and reflected on this situation, the first midwife said that her thinking at this point was, “Why listen in? It’s not going to change what we do. We can’t do any more than we’re already doing. If the fetal heart is really slow, it will increase everybody’s anxiety, and we probably have enough of that for now.”

When she said that, I nodded, as did most of the experienced midwives in the room. Most of us were aware of Cochrane’s aphorism. That is, the idea that, if a test wouldn’t change your management, then there might not be any point doing it. But practice is often more complex than that. And the whole point of the workshops that we were facilitating was to focus on deep thinking about emergency situations rather than simply follow the set rules. When you’re in a community setting with fewer resources and personnel than you might have in the hospital, you often need to adapt, and creative, critical thinking is a key skill to have and to practise.

Sharing experiences

In sharing my own experience of a similar situation, I want to stress that I’m not proposing this as the right answer. There isn’t necessarily a right answer here. That’s what makes midwifery practice so interesting. It’s also, if I may say so, why having to work within rigid guidelines can be so soul-destroying to some midwives. But my contribution to the conversation was to share my experience of a similar situation in a hospital setting.

In that situation, I was the midwife holding the baby’s head up off the pelvis. (Everyone in this story was fine too, by the way.) I had heard the fetal heart decelerate in the delivery room (where the woman was having her labour induced, which is why she was being continuously monitored and quite possibly why the cord prolapsed). I quickly gained consent to do a VE, felt cord, got help, talked to the parents and moved the woman onto all fours while holding the baby’s head off the cord. The woman and I were taken on a rapid ride on the bed down the corridor. We got to theatre and the obstetrician decided to do the caesarean section on the delivery bed to save time. That made sense. But this meant that the bed needed to be pumped up, which meant I needed to slide off it temporarily, while keeping my hand in situ.

Because I was about two feet shorter than the obstetrician, the bed was being pumped up to a height where I couldn’t keep enough pressure on the baby’s head to prevent cord compression. Because the obstetrician had asked someone to hold a sonicaid on the woman’s abdomen while he was scrubbing, we all heard this change in the baby’s heartbeat. We were able to adjust my position. The fetal heartbeat went back up and all was as well as these things can be. But what this story demonstrated was that, even though listening to the baby’s heartbeat wouldn’t have changed the fact that we were going to do an immediate caesarean section, it still gave us valuable information. Which allowed me to adjust my posture in order to reduce compression on the baby’s cord.

Do we want to know?

Does that mean we should always listen to the fetal heart in a similar situation? Or that it’s justifiable to do VEs just so we can know what is happening? Of course not. No two situations are the same, and there are always multiple things to take into account. That’s one of the key reasons that we need to get away from the idea that the answers are all held in guidelines, rules or principles of any kind. Sure, as I discussed last month, the principles can be really helpful when we’re learning a new area and trying to make sense of how it all fits together. But there’s a time for us to rely on them, a time for us to question and explore them in order to see where the cracks and the gaps and the exceptions are, and then there’s a time to move on and develop one’s understanding of how things fit together. In my humble experience, some of the most interesting people in any field are those who understand the rulebook really well but who have gone beyond it in order to develop their own unique understanding of their field.

In order for that to happen, we have to slip between the cracks in the guidelines and create and seek spaces in which we can still think for ourselves. I know that’s not always easy. This sort of thinking isn’t encouraged, it isn’t valued, and it isn’t counted as evidence. But none of those things make it any less important to the wellbeing of women and babies, who rely on midwives’ continued ability to think.