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Deskilled

Deskilled

How has it gotten to October and I have published nothing for all of September on this site?!?  The time is flying, and to be perfectly honest, I am slightly overwhelmed. Being a student is HARD. Being a mom is HARD. Being both of those together is VERY hard. And let’s not forget trying to be a good spouse, friend, sister and all the rest…there’s too much to get done every day, and not enough hours in a day. We’re currently on placement again now, working in the clinical setting, but in two weeks I have an in-class debate to research and prep for, plus a research activity due which involves critiquing a research study and then sharing it with the class. The first week in November our second 15-page(-ish) assessment is due, which I have started researching but have not yet written a single word for. We also have our Year 1 exams in December, focusing on anatomy, physiology and the role of the midwife, which I have started studying for, but again…this is not something you can do in a single cram session the night before. So, yeah, that’s the homework front. Add to that 12 hour work-days, not seeing my kids for entire days at time (because if I’m doing a day shift, I leave in the morning before they’re awake and come home once they’re asleep) and using my days off to try to desperately make it up to them with quality time…and also using my days off to try to get on top of the mound of homework. This student midwife business is definitely not for the faint of heart!

Clinical placements have been challenging for lots of reasons. The work is fabulous, and it has been such a joy to be attending births again, and particularly births in the lovely midwifery-led unit/ birth center that is part of the hospital where I’m at. But it’s been painful to realise how many of my skills I have lost during the long break I took over the last 4 years where I wasn’t working as a midwife. Things that used to come very easily to me are now things that I am grappling with again. Is that really the right position of the baby I’m feeling on abdominal palpation? Is the baby vertex or breech? Is that the baby’s back? Are those the feet and hands? Is that cervix 7 cm dilated, or 8? What is the estimated fetal weight? I used to be really good at this stuff…now I find myself in the dark with it a lot more, much like I was during my first student experience. Muscle memories that have been forgotten and need to be retrained into hands again. How to press just so on the doppler to be able to angle it upwards into just the right position to find the fetal heart. How to get the monitor straps to be able to hold the tocometer/CTG in the right place. (Annoyingly, the straps are very new to me; in the US the women wore an elastic band over their bellies and you just had to slip the monitors underneath the band and they were magically held in place, without too much fiddling involved. We did have straps, too, for occasional use, but again, they were a different design and not at all like the straps in my new trust, which I think require some fancy angling and folding and tying tricks to get them to be angled/ placed correctly, of which I have by no means mastered yet!)  And don’t even get me started on the hospital policies, the documentation, the pro formas that have to be filled out. The new computer system.  There are even things that I murmur and say during deliveries: “Good job”, “you’re doing great”, “you’ve got this” which sound so American to my ears now. My mentor more often says “well done” instead of “good job”. Tiny things like this which I wonder about, and I wonder if my American-ness is helpful in labour, or if I was speaking better British-English, would that be more reassuring? It’s all new. So in SO MANY ways I feel like a complete novice at this again.

But that’s the part that sits uncomfortably with me. I had gotten used to feeling competent after years as a midwife in the US. I knew the system, I knew how my hospital’s policies worked. I knew exactly what documents needed to be filled out, and how to document correctly.  Feeling competent had become part of my identity. Feeling incompetent again is painful. I have to keep reminding myself that I am a first year student, because I AM. There is so much I don’t know. And in fact, there is a term for what’s been happening to me. It’s called being deskilled, or deskilling: losing skills which I had had in the States and had taken for granted, and needing to re-learn these skills again from scratch. Not fun in any way whatsoever! And in some regards, there are even bad habits I had picked up which I need to un-learn as well. And completely new skills which I never had in the first place, like using a Pinard’s stethoscope or estimating how many fifth’s palpable the baby’s head is in abdominal exam. In the States we would say the baby was engaged or floating, but never had to document exactly how engaged (3/5ths engaged, 1/5th engaged etc.) the baby was.

I was painfully reminded of this awhile ago when I experienced my first true emergency as a student on labour ward. A woman had been brought in by ambulance in booming labour, and was barely into a side-room before the baby had been delivered. And then she began to seize afterwards. The emergency bell was pushed in her room, everyone ran in to help (including my mentor), and I was out on the fringes trying to be helpful but not actually able to do very much. Whatever was called for from inside the room, I was one of the task-rabbits running to get it. I put out the overhead hospital-wide emergency call to bring the larger team to the room, which I had never done before, and didn’t even know what room the patient was in without asking another midwife about it. I got a screen to cover the door for privacy. I brought a table and emergency trolley to the room.  Which is helpful, a bit, but that was about as much as I could do, and I was conscious that if this had happened in my old hospital in the States, I would have been in the room, in the thick of it, being a lot more helpful.  And it was scary. In my 6 year career in the US, I had never seen a full-blown seizure like that. I hope I never do again, any time soon.

Midwifery is a highly-skilled job. It takes years to master the skills necessary to do it well. And years of training and experience in a particular setting to know all of the ins and outs of the job. And I am just at the very start of this journey again, deskilling and re-skilling again.

Differences so far…

Differences so far…

Wow, I’m not even sure where to start here. There have been A LOT of differences so far between American midwifery and British midwifery. Here’s just a small sampling.

First, abbreviations. Some of them are the same, most of them are completely different. In the US, an IUD is an intrauterine device (i.e. contraception). In the UK, it’s an intrauterine demise (stillborn baby). BIG difference there. In the US, taking a medication twice a day is BID (“bis in die”, Latin for twice daily); in the UK, it’s just BD. QID = QD, TID = TD. In the US when I see PE on a chart, I would think Physical Exam. Here it means Pulmonary Embolism. In the US, contractions are measured on a tocometer, or abbreviated as “toco”. Here it’s abbreviated as CTG (meaning cardiotocograph). FHHR is fetal heart rate heard regular, rather than just FHR (Fetal heart rate). Small things like that, but it adds up.

The antenatal visit schedule is very different as well. In the US, pregnant women can get anywhere from 12-14 prenatal visits through the course of their pregnancy. Here, a nulliparous woman (first-time mom) will only have 10 visits total with her midwife, and a multiparous woman (second-time mom) will only have 7 visits total with her midwife. In the US, generally the longest time between visits would be 4 weeks, but here there can be up to 6 weeks between midwifery visits. I can see how this might be a much more efficient schedule and use of resources (and the NHS is all about using resources wisely), but I wonder if there is flexibility in this schedule for the mums that may have a lot of issues going on and might actually needs more frequent follow-up. I wonder how that works with the overall schedule, and I wonder how midwives get around that (extra sonograms in place of visits, maybe?). This will be a very interesting area to learn more about. According to NICE guidelines for antenatal care, the schedule looks like this: Initial booking appointment with the midwife by 10 wks if possible, 10-14 wks: ultrasound for gestational age (but no midwife visit), 16 wks: midwife, 18-20 wks (ultrasound for fetal anomalies/ anatomy scan, but no midwife visit), 25 wks: midwife (nullips only), 28 wks: midwife (nullips AND multips), 31 wks: midwife (nullips only), 34 wks: midwife (nullips & multips), 36, 38 wks: midwife (nullips & multips), 40 wks: midwife (nullips only), 41 wks: midwife (nullips and multips, to discuss postdates options). And that’s it, folks.

The screening schedule is slightly different. For instance, in the US an initial visit usually involves a pap smear and a test for gonorrhea and chlamydia. Here in the UK, these are not routinely offered. Pap smears are done routinely by a GP (rather than OB/Gyn or midwife or women’s health NP) on a different screening schedule (every 3 years), so  there’s no need to try to catch up on smears at an initial pregnancy booking. In the US, since many women don’t have access to routine care, it’s sometimes been years and years since they had a pap smear (and sometimes they’ve *never* had a pap smear before), and because pregnancy is actually a time in a woman’s life when she accesses care, the US system is designed to try to take advantage of this and do a lot of catch-up primary care/ health promoting tests at the same time as the routine prenatal care. But thanks to the beauty of UNIVERSAL health care, routine health promotion practices are already in place, so pregnancy care is exactly that: *pregnancy* care. Also interestingly enough, there is no vaginal/ pelvic exam at an initial pregnancy visit here, and many of the British midwives I have spoken to are very puzzled by the need for one. “Why would you routinely do an invasive, uncomfortable exam at an initial pregnancy booking on all women?” Well….because….well….I don’t really have a good answer to that. Because in the States this is something we’re taught to do: pap/ gonorrhea+chlamydia test/ vaginal exam/ bimanual exam/ pelvimetry, at every initial antenatal visit. But in a healthy, low-risk woman who’s already had access to regular check-ups and care, is all of that really necessary? Paps are routinely screened for in the general public by GPs here, and there is a national screening program for all women under 25 years of age for chlamydia, so again chlamydia is already being routinely screened for in the most at-risk population. There is no mention of gonorrhea testing as a routine part of antenatal *screening*. I guess this means that GC/CT are screened for only if there is an indication through the woman’s personal history? Again, this is something I’m going to have to learn more about. Also very interesting is the fact that Group Beta Strep is NOT routinely screened for in all pregnant women at 36 wks here. Which is rather mind-blowing to me. But in a less litigious, more resource-efficient society, perhaps this makes sense too. And it would drastically cut down on the overuse of antibiotics and antibiotic resistance (not to mention the damage routine antibiotic use is doing to our collective human microbiome on a population level). Again, this is something I’m going to have to learn a lot more about.

And finally, ANATOMY is different here. I kid you not! I thought surely the Latin names for muscles and bones and organs and structures would be the same. But no, lots of new names I’ve never heard of before. For example, I would call it the rectouterine pouch. Here it’s call the Pouch of Douglas. What I would label the pubococcygeus muscle (in the levator ani), the Brits call the pubovisceral muscle. What I would call the puborectalis (again in the levator ani), the Brits call the puboanalis. Lots and lots of little things like that. Very similar, but not quite 100% the same. Which means that even though a lot of this material is familiar, I can’t assume that I know it. I don’t know it (and I had forgotten most of the names of all of these muscles anyway). So I am having to study it all again as if I’m learning it for the first time. Time to hit the books!

 

Day One and Two: Full on!

Day One and Two: Full on!

Hello lovely readers: guess what? I’m in midwifery school again! And trust me, I never thought re-qualifying was going to be a walk in the park, but these last two days have been a pretty brusque reminder to just how intense this is going to be. And I know I’m capable (and thankfully, a lot of it will be familiar, at least), but man–here we go!

Yesterday was a general orientation to the program: the course requirements, the timetable, our first assignments. Thursday is a day-long orientation to the library, where I suspect we’ll be spending *a lot* of our time. We’ve received an independent study guide, a workbook on medications and abbreviations and prescribing in labour, and an inch-thick workbook on reproductive physiology, plus some fervent warnings to keep up with the work and not let it pile up. Right! We also spent yesterday and today working in small groups, getting to know each other, and discussing the role of the midwife and the principles of midwifery care, which is always nourishing and enriching work.

The class itself is fabulous–there are 28 of us in total, ranging in ages from 18 and fresh out of sixth form (sort of the UK high school equivalent) through late 40s with teenager children, all from very diverse cultural and social backgrounds, and with a myriad of reasons for wanting to be midwives. I was very relieved to discover that I’m not the only mature student, by a long shot, and not the only mother going back to university with children at home. In fact, most of the other mothers in my class have three children rather than just two, and a few of them even have four children (and one with a set of twins), so if they can do it (superwomen!), I can too. I made a comment along the lines of “wow, how do you do it?” to a mum of four in my class, and her response was “You just have to get super organised.” Right! Wise words; that is definitely the plan! We’re still just getting to know each other, but everyone seems very friendly and welcoming so far, and I suspect that the wonderfully stressful bonding experience we’re all about to go through will ensure some lifelong friendships. I still think of my midwifery school friends from my US qualification with such love and warmth, and even though most of us don’t talk or hang out much any more, I still feel like many of them are my sisters as much as friends and colleagues, and the feeling hasn’t faded through the years, despite the distance and limited contact (mostly through facebook these days). So there is definitely something to be said for midwifery school friends!

Tomorrow is our orientation to our clinical site. My first rotation will be community midwifery, which is an area I’m very excited to learn more about, as it doesn’t exist in the United States. At all. In fact, the UK’s commitment to community midwifery is a bit of a rarity even among European countries, and is very exciting. My limited understanding of it so far (I’m sure I’ll have a much better grasp of it in the weeks and months to come) is that community midwives are responsible for delivering midwifery care in womens’ homes. This includes providing home births, of course (which is my particular love, and where I want to be practicing when I finally graduate again), but the more remarkable feat of community midwifery is that here in the UK, ALL women (even those who delivered in hospitals) are given follow-up postnatal care by a midwife in the comfort of their home, usually 1-2 days after returning from the hospital, then again around Day 5-6 postnatally, and finally one more time around Day 10 when the woman and baby will finally be discharged from midwifery care. Let me say that again, because it still sounds so incredible to me: a midwife will come to your *house* in the first few days and weeks after you give birth, check your bleeding, help with breastfeeding, weigh the baby, perform the newborn screen etc. etc., and this is not some extra, luxury service for wealthy clients with private insurance, but ROUTINE POSTNATAL CARE.  In the US, postnatal care generally looks like this: you give birth, you’re seen in the hospital by a midwife or OB on postnatal Day 1- Day 2 (which is usually when you’re discharged if you’ve had a vaginal delivery; usually Day 3-4 if you’ve given birth by cesarean), and then…that’s it. Your next postnatal visit is booked for 6 weeks later. And to a new mom with a newborn baby, the chasm between Day 2 and 6 weeks might as well be the Grand Canyon. SO much happens during those first 6 weeks–so many questions, such a steep learning curve–and you’re basically on your own for most of it (unless there’s a rare complication that would necessitate an earlier visit). Add to this the fact that many women in the US are also expected to return to work around 6 weeks, and maybe it begins to sink in just a little bit how cruel and inadequate the US maternity leave/ postnatal care system is.

Which isn’t to say that UK postnatal care is perfect.  In fact, most of the complaints I’ve heard since I’ve been working as a lactation consultant here for the past 3 years is that postnatal care isn’t nearly supportive enough, and that the advice about breastfeeding in particular can be very inconsistent. Also, one of the reasons community midwifery follow-up happens so quickly here is because many women are being released from the hospital within 6-24 hours after giving birth, which can also be very disorientating and stressful, for first-time moms in particular, I think.

In any case, I am very excited about working in the community initially–and I’m even hopeful that I might be able to attend a home birth, if I’m lucky. Fingers crossed! But our clinical rotation is still 8 weeks from now, and first…there’s a whole lot of reproductive physiology to review.

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s all starting to get very, very real! I went to my new university on Friday to attend a midwifery seminar, which they hold every 6 months or so. It was a fantastic morning listening to some very interesting speakers and topics (I’ll give you a run-down below). I also received my student timetable for the first year of the course (let’s just say….lots and lots of work ahead, and very few holidays), and yesterday I also got a notice from the NHS that my fees-only bursary has been approved. What a huge relief that is! And for the record, I am an incredibly lucky student, as I am part of THE VERY LAST COHORT of incoming midwifery students who will be eligible to receive an NHS bursary. Starting in Aug. 2017, all incoming midwifery and nursing students will have to pay for their education (to the tune of 9,000 GBP per term), whereas if you are lucky enough to begin your education under the old scheme (as I am), your fees will be covered for your entire course (i.e. 3 years worth of education). As you can imagine, there are a lot of organizations (most notably, the RCM and RCN) which were quite distressed about this change, as it may limit the numbers of incoming student nurses and midwives and destabilize the future of maternity care in the UK. I am not entirely convinced about this, as midwifery and nursing education has ALWAYS been paid for by students in the US, without detrimental effects on the number of students choosing to enter these professions (but obviously coming out with lots and lots of student debt at the end of their education, which isn’t necessarily a good thing at all). In any case, though, as an American student approaching midwifery education here in the UK, I must admit that I am absolutely floored (flabbergasted! Amazed! Delighted!) that my education will be covered by the NHS, as I would never in a million years dream of free tuition in the States for any degree. It feels completely surreal to me, especially as I spent years and years paying off my student debt from my US midwifery and nursing education. And I am counting my lucky stars that I am slipping in just under the wire and will have my fees covered, but at the same time saddened that this incredible system–a system that values a student’s time and energy, and understands that properly educated professionals require investment–is being dismantled.

I met a few of the students who will be in my course, though, as well as a few of the professors, and everyone was incredibly kind and welcoming. I even met a third year student who gave me her phone number (unprompted by me!) and told me that I could get in touch with her at any point if I needed help. What a kind thing to do, and such a wonderful example of mentoring.  All of it seems very encouraging, and is making me think (again!) that I’ve chosen the right university to study at. The atmosphere was warm, the students were engaged, and the questions being asked were perceptive, smart and on-point. I am very excited about learning here!

The first speaker at the seminar was the one and only Professor Cathy Warwick, CEO of the Royal College of Midwives (and how fantastic that she’s speaking at conferences at my university??). Her presentation was on the importance of challenging the status quo in order to better deliver personalised care to each woman, which is a core value reflected in the National Maternity Review’s Better Births policy, but is not always easy to implement when a woman’s desires for her birth clashes with the institutionalised norm. She discussed many of the common situations where care is provided based on ritual (i.e. we do it this way because we’ve always done it this way), rather than evidence of best practice (examples of these sorts of non-evidence based rituals include transferring women between wards in a wheelchair when they’re perfectly capable of walking, not allowing fathers to stay overnight in early labour, routine use of external fetal monitoring on admission, transferring women from birth settings in an ambulance regardless of the reasons for the transfer etc. etc.) Prof Warwick pointed out that delivering personalised care presents big challenges for midwives on a systemic level, but that in many situations massive system changes aren’t needed. She spoke, for example, about how you can begin as simply as removing the word “allowed” from your vocabulary (something I can 100% get behind). The woman in labour is the one in charge of her birth. As midwives, it’s our job to support and empower her, but ultimately she should be the one making decisions (in collaboration with her midwife and birthing team). Telling a woman she isn’t “allowed” to do something goes against this sentiment. Ideally, a woman should be able to do whatever she likes in labour and on the ward (within reason), so long as the risks and benefits of her choices have been fully explained to her and she has been given the opportunity to make an informed decision. It’s HER birth, after all. Prof Warwick also pointed out that in some cases, women are labeled as “birthing outside of guidelines” as if they are stubborn and intractable and taking unnecessary risks with their babies, when in fact they are successfully advocating and demanding the type of birth experience they want and are legally entitled to. A better question is: how do we support women who challenge birth conventions/ norms of institutions, and choose to birth outside of these norms? As a strong advocate for home birth, this is something I have encountered many times before, and something that independent midwives facilitate, as many women who choose independent midwifery care are doing so because the institutionalised care offered to them was not in sync with what they desired for their birth. (And I must admit, I found it incredibly encouraging to be hearing this from the CEO of the RCM, especially in light of the recent difficulties imposed on Independent Midwives by the NMC). Safety and risk is perceived differently by every woman, after all; what feels safe to one woman could feel like the definition of risk to another. Prof Warwick also spoke about the need for not only continuity of care, but continuity of carer, and was quite adamant that figuring out how to deliver this type of continuity is something that can only be done by midwives (and that most likely the way forward will be different for each individual midwife, in terms of case-loading v. shift work v. shared call), and that midwives need to be given the power and flexibility to find their own solutions.

The next speaker was Margaret Nyudzewira, a public health advocate and co-founder of the charity CAME Women and Girls Development Organisation (CAWOGIDO), who spoke to us about breast ironing. While I’ve been aware of the dangers of Female Genital Cutting (FGC, or Female Genital Mutilation, FGM) for years, and have encountered it a few times as a midwife in Brooklyn, the practice of breast ironing is fairly new to me. Strangely enough, I first learned about it just a few weeks ago when a midwife friend posted a link to a photographer’s riveting portraits of women and girls who’ve experienced breast ironing.  The practice involves using a tight elastic band, pestle, ladle, hot stone, shell, or even hot seeds or heated leaves, to massage and flatten developing breast tissue on young girls, and can lead to many serious medical complications, including chronic pain, scalding, burns, infections, cysts, abscesses, tissue damage, the inability to breastfeed, and of course psychological trauma. Breast ironing is most often done by the girl’s mother (but can also be done by a grandmother, aunt, or tribal practitioner), and comes from a place of love, or more specifically, fear for loved ones–fear of unwanted sexual attention directed towards their daughters, fear of rape or sexual assault, or fear that early marriage or teen pregnancy could education and curtail opportunities.  And similar to FGC, this practice doesn’t occur only in Central and West Africa, but in the UK (and the US) as well (although the numbers are difficult to track, and very few studies have been done on the rates of breast ironing in the UK). In Cameroon, 50% of girls on the coast, and 24% of girls nationwide, experience breast ironing.

But one of the things that struck me the most was when Ms. Nyuydzewira said quite emphatically: “It is NOT part of our [Cameroonian] culture to harm girls and young women.” And that is absolutely true. While the practice of breast ironing itself is brutal and debilitating, it’s really important to keep in mind that the practice and the culture are not exactly one and the same. As a (white) midwife approaching a cultural practice like this (which runs counter to my own beliefs, and feels very foreign to my own cultural upbringing), I think it’s crucial to come from a place of support rather than a place of judgement.  This is one of the reasons I have come to call it Female Genital Cutting over the years, rather than Female Genital Mutilation (which has our cultural judgement baked into the very name itself) or Female Genital Circumcision (which to me seems to condone the practice, on some level, and also equates it in the mind with male circumcision, which is a false equivalence), especially when I’m discussing it with women/ patients directly (I understand that more generally, in health policy and research, it is more often referred to as FGM). Some women brought up in cultures which practice female genital cutting, for example, may view FGC as no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it may be seen as a mark of belonging and identity, a much anticipated rite of passage, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that vaginas are supposed to look–beautiful, even, to their eyes. On a personal level, I disagree with these assertions and find FGC abhorrent, but as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations with her–that will immediately close her off to me and only serves to project my own cultural bias over her own.  Instead, gentleness and sensitivity is needed more than anything else. Rather than imposing my own viewpoint, I would have to elicit the woman’s own views on the topic first, and use that as the starting point for whatever would be most useful to her moving forward: education and resources if desired, medical care if needed, mental health referrals if she feels depressed or traumatised by her experience, or silence and non-judgement if she views it in a positive or neutral light (and should this viewpoint ever change, I can then step in at that point with whatever help or support is most appropriate at that time).  To me, this gets to the very heart of my own personal philosophy of midwifery care: LISTEN to women, and DON’T JUDGE. In any case, now that breast ironing is also on my radar, I will be more alert to it if/ when I ever encounter it, and in a much better place to offer sensitive care on this very complex issue. Overall, it was a difficult and disturbing presentation to listen to, but I’m glad that it was part of the seminar, as these things are really important to think about in advance of encountering them!

There were two other speakers at the seminar: Debra Sloam, Midwife and Infant Feeding Specialist from Frimley NHS Foundation Trust, who spoke about her MSc research on student midwives’ attitudes towards offering breastfeeding assistance (as suspected, I will most likely have a lot more time to help women breastfeed as a student than I will as a working midwife), and Dr. Kim Russell from the University of Nottingham, who discussed her action research on challenging midwifery barriers (real and perceived) to facilitating water births on the wards.  These were both interesting and engaging presentations, and I’m really glad I was able to attend the seminar.

Two more weeks until classes start!