Thursday, October 18, 2007

Honesty and experience

Navelgazing Midwife has written honestly about her lack of experience with certain skills:
I suture a couple of times a year. I've done an IV twice in the last 4 years. When I have to check a woman’s vagina, I am nervous that I am going to have to pick up a suture needle and cut through her skin - worried that my skills are going to suck and her vagina isn't going to go back the way it should... I need more practice.
Indeed she had to transfer a patient to the hospital for suturing of a tear:
You see, I had a birth a couple of weeks ago and my mama tore pretty badly. She pushed mightily to get her baby out despite my wholehearted attempts to slow her down; she needed her baby out to feel safe and I don't blame her at all for that - I would have done the same thing. When I looked at her bottom, my first impression was, "This isn’t something I should do," ...

Once at the hospital, two docs came in and opened mom’s vagina up but good and looked hard. They were talking about her as if she wasn’t there (and I’d asked mom already if I could learn and she said yes) and they began pointing to what was her exposed sphincter muscle. I could have just as well been looking at the starry sky and trying to see a constellation for all I didn’t recognize what a sphincter muscle looked like...
I will note, as an aside, the Navelgazing Midwife blamed the patient for her tear; I guess if there's no obstetrician around, the only left to blame is the patient. She also included the obligatory nasty comment about the doctors. Then she contemplated the issue of experience again.
I want to be able to see a tear and know exactly what I am seeing and exactly how to fix it. I want to own those instruments and be able to repair a third degree tear.

I can practice suturing on a pillow until I am blue in the face, but until I see dozens/hundreds of torn vaginas, I am just not going to have that (what I call) Helen Keller moment (that moment when spelling w-a-t-e-r in the hand a thousand times suddenly MEANS "water" in all its forms). Until I feel that needle and thread going through the flesh myself, it isn’t going to connect completely and I won’t be the as wonderful a midwife as I want to be.

Same with IV’s. I can do them when I have to. I can start one in an emergency if I have to, but I shudder when I think about having to and I don’t want to be afraid of any skill I want to be able to do with aplomb. I want to be strong and sure-footed and jab the arm with the same body memory I have for poking a baby’s foot. And I can never get enough practice in a homebirth practice, even when practicing on family and friends. I need volume...
I agree completely with her assessment and am impressed with her honesty. However, it raises very serious questions. She sutures only a few times a year, and worries that she cannot do it properly. She probably sees even fewer shoulder dystocias each year, has done fewer expert resuscitations (perhaps none), and sees fewer emergencies of all kinds. So if she can't even suture with the experience she has, and she has less experience with emergencies (which are even harder to manage), how will she be able to handle an emergency? How can she represent herself as someone who can safely manage an emergency, when she knows, if she is honest with herself, that she doesn't have nearly enough experience?

The is the crux of the problem with homebirth. If there is an emergency, the direct entry midwife will not have enough experience handling it, and the baby has a dramatically increased chance of dying because of that. How can that possibly be acceptable? Shouldn't direct entry midwives be obligated to share that information with their patients? Doesn't honesty require a direct entry midwife to explicitly inform her patients: "I don't have much experience with emergencies, so if something goes seriously wrong, your baby will be in terrible danger"?


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