I have found, over quite a few years of teaching midwifery, that people who are learning midwifery and similar arts often like to have building blocks in the form of rules, lists and principles that they can learn and explore in theory and then follow in practice. I’m not saying that everyone wants this, or that it’s the only way to learn. But I have noticed that such frameworks can help some people feel more confident, while also – if taught and discussed well – helping people to see that nothing works every time and that flexibility of thought and action is also important.
Coat hangers and principles
I suspect that one reason principles work well for some people is that it is reassuring to learn something that feels solid, when you’re in a practice setting that may feel alien or unpredictable. For others it might simply feel useful to have a kind of metaphorical coat hanger or framework upon which to hang new ideas and knowledge. Further down the line, when you know what you’re doing, you can adapt. You might alter the shape of the metaphorical coat hanger, completely change the clothes that you’re hanging on it or even throw it out of the wardrobe and replace it with something entirely different, but that’s OK. It has served its purpose in helping you to gather and make sense of the first bits of knowledge that you needed in order to function in a new field.
I do realise, by the way, that I’ve just circumvented citing about 50 pieces of interesting educational theory by using that analogy, but I’ve only got a couple of pages here and I want to move on to the principle that is the subject of this article and which I have shared with many of my students over the years. It can be found in the title of this article, it is known in some circles as Cochrane’s aphorism, and it is a question that I was taught and that I now encourage other practitioners to consider when they are trying to decide whether to offer a screening or other test.
So, IS this going to change your management?
I’d like to add a quick note here, though, because the word management doesn’t gel with my ideology of midwifery practice which, for me, is about accompanying a woman on a journey. But I’ve never found a better way of summing up this principle. Which is that, given that much of what we do in midwifery is about applying screening tests, one of the most important questions we should ask ourselves when we are deciding whether we really need to offer a screening test, is whether the result has the potential to change the course of action that we might recommend or that a woman might decide to take. If not, then is there any need to offer the test?
One of the best examples of this in everyday midwifery practice is vaginal examination (VE) in labour. Let’s just pretend for a moment that we are autonomous practitioners who aren’t working in a system that demands that we offer regular VEs. Let’s pretend that we can decide ourselves when to offer a woman a VE, and that her decision to accept or decline will be fully respected.
In most contexts, an intrapartum VE serves as a screening test. Its main purpose is to determine whether a woman’s labour is progressing within normal limits or not. So, you’re an experienced midwife looking after a woman who is doing really well, and you can see many other signs that her labour is progressing and you know that she and her baby are well and happy. Your midwifery student asks you if you are going to do a VE and you gently ask, “Well what would be the reasons for doing a VE at this stage? Would the results of a VE change our management?”
Other reasons for wanting to know
Now, that’s not the only purpose for doing a VE, of course. Like many other midwives and obstetricians, I have cared for women who have been desperate for a VE so that they can know that they are making numerical progress. Even when I’m happy with the other signs of labour progression. I might secretly wish that I lived in a world which hadn’t so successfully sold women the idea that the progress of their labour was best measured quantitatively and via the space left behind when their fundus moves their cervix. But numerical knowledge is what the woman wants in that moment. The same is sometimes true when women and families are considering whether they want their unborn baby to have screening tests for anomalies. They might already know that the answer wouldn’t change what they would do, but they might still want to know. I maintain, however, that thinking about the possible outcomes of performing a screening test is a good general principle and a potentially useful framework for discussions around decision-making.
A practice challenge
If this is a new idea to you, and you think it might be useful to reflect upon, then I have a challenge for you over the next month. When you’re working in practice and you go to ‘do’ something to a woman, whether it is to take her blood pressure, perform urinalysis, do an abdominal or vaginal examination or carry out a postnatal or baby check, ask yourself whether you’re carrying out a screening test. (All of the above can be considered as screening tests, along with many more things that we do every day.) Then, ask yourself whether the results of the test that you’re about to carry out are going to change your management. I almost always end up realising or thinking interesting things when I do this. (Yes, I realise that many midwives feel compelled to do things because they are required of them by their employers, but even if you’re doing things by the book, you can still think about how you might do them differently if you weren’t constrained in that way.)
As I said in my coat hanger analogy at the beginning of this article, though, the thing about those general principles is that, while they can be very useful as a starting point, they are also really useful in another way: once you’ve gathered the building blocks of an art such as midwifery, the principles are there to be developed, broken and replaced as we learn more.
So next month I shall return to this from another angle, and share a story about a situation which made me reflect on this principle again, and from an entirely different perspective.
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