Experience and Personal Practice

Personal experience always changes the way you practice in some way.  Anyone who denies this is probably not being 100% honest with themselves.  It’s the nature of us being human, and it’s inevitable because humans (as opposed to future robots?) provide health care, and by and large it’s a very good thing.  This can be seen most obviously because of bad outcomes, which I admit can be a very compelling reason to change your practice.  You see something terrible happen once, and after that, you’re more cautious as a provider.  Sometimes this means you call a cesarean sooner than you would have in the past (if you’re a doctor), or you start antibiotics a bit sooner, or call Peds to a birth which before you would have handled on your own.   And usually it’s like a pendulum, swinging back and forth.  Initially, after a scary experience or bad outcome, you will become overly-cautious and hyper-vigilant, and then, with time, as you see similar situations which result in good outcomes rather than bad, you begin to calm down a bit about whatever it was which was making you so nervous in the first place, and regain your perspective.  It’s not that you eventually grow lax or complacent over time, but more that gradually the personal experience gets integrated into your practice as a whole, so that you’re no longer fearful of it, and yet you have that past experience as part of your wealth of knowledge to draw from the next time you’re facing a similar situation.  It’s small things, like remembering to have a woman pee or empty her bladder before pushing because of that one time when a full bladder caused a postpartum hemorrhage.  In this way, we learn from the mistakes we make and the occasional bad outcome which occurs, and in most cases this makes us better providers

As an example, very recently for me I had a baby who needed full-on resuscitation after the delivery, and I was absolutely shocked and baffled by it.  It was a full term baby, we’d been continuously monitoring the heart the entire time she was pushing and everything was looking good (up to the last few minutes when the baby slipped under the pubic bone and it become incredibly hard to pick up the fetal heart rate…and granted, a few minutes can make a big difference if the baby’s heart rate was decelerated during those minutes, but overall the tracing had been very reassuring).  She wasn’t even pushing for that long, you would expect everything to turn out well, or at least expect the baby to pick up very quickly after some drying and stimulating….and yet, shockingly, the baby came out blue and needed not just positive pressure ventilation with a bag and mask, but chest compressions as well (which you only have to do if the fetal heart is less than 60 and isn’t picking up, and which most babies rarely ever, EVER need; prior to this delivery, I had seen chest compressions done only two other times in my 8 year career as a Labor & Delivery nurse and now midwife).  The Apgars for this baby were 1 at one minute of life (which means the baby had a pulse, and that was it), 4 at five minutes, and 7 at 10 minutes (which is certainly a decent enough score, if not absolutely perfect).   It was a full three minutes before the Peds team arrived on the scene; I was ventilating the baby while the nurse did chest compressions.  And thankfully, in the end everything turned out well; we resuscitated the baby, the baby recovered nicely and went home two days later perfectly normal, but nevertheless, it was absolutely terrifying.  Afterwards, as we were recovering and debriefing and waiting for our own heart rates to return to normal, the only issue we could see was that the mother had had chorioamnionitis (an infection of the amniotic cavity), and one of the attendings pointed out that he has sometimes seen chorio do that to a baby before.  It wasn’t something I had ever seen before, and chorio had never been something I had routinely called pediatricians to a delivery for in the past, but now it gave me pause.  And the next time I had a woman pushing with chorio (only about a week later), you can be damn sure I called Peds to the delivery, well before the baby actually came out.  With that birth, everything was fine, the baby was pink and vigorous with Apgars of 9/9, and the pediatricians were  wondering why I had called them for something as routine as chorio.  I called because personal experience had made me cautious, and has temporarily changed the way I practice.  The next time I am pushing with a woman who has chorio, I may decide to call Peds again, or maybe I will decide to wait and see.  I suspect that gradually over time it will become less scary again, and become more integrated into my overall practice, but I will always and forever add chorio to my mental check-list of reasons why we may need Peds at a delivery, and will probably make the call based on several factors, like 1) how long has she had chorio, 2) how long has she been pushing, 3) how has the tracing been overall, 4) how high has her fever been etc. etc.   And a full-on resuscitation is now always going to be one of the possibilities I consider with a woman who has chorio (although technically it’s something we’re supposed to always consider with every delivery, and it can and does happen out of the blue sometimes for no apparent reason at all); always, always, from here on out.

But personal experience isn’t always negative, or built upon bad outcomes and our responses to them.  I was writing to a friend the other day about how my practice as a midwife has changed now that I’ve given birth myself, and I also find this very interesting to stop and reflect on a bit.  The most obvious change I can think of is how I handle women in early labor/ prodromal labor. This comes from my own experience of an endless early labor which lasted for nearly 2 days.  I think in the past I was a bit more terse with women coming in to the hospital in early labor, only to be sent home again because they were only 1 or 2 centimeters dilated.  They weren’t in active labor yet, and that was that.  Which isn’t to say I wasn’t sympathetic and sweet about it, but I didn’t spend nearly as much time talking with and encouraging these women as I do now.  Now my heart goes out to them so completely because I can so well remember what that’s like.  It’s not like my contractions were irregular and mild—they were strong and regular and painful to me, at the time.  Albeit they were nothing compared to the contractions that were yet to come, but since it was my first time laboring, I had no idea of what was yet to come, and in the beginning, the early labor contractions were PAINFUL.  I spend so much more time with these women than I ever did before in triage, going through what’s normal and what’s not, reassuring them, talking about what (limited, because nothing really helps that much) comfort techniques they have at their disposal.  I’m even more patient with them, and even more understanding.  In this regard, I think empathy is quite valuable–which isn’t to say that you can’t be a good provider if you haven’t gone through it yourself—but I do think it adds another layer to my care which wasn’t there before.

Strangely enough, though, if I’ve become much more patient with women in early labor, I’ve become much more practical and maybe even a bit tougher when it comes to second stage.  In the past, having never pushed a baby out before, and having no idea what that actually felt like, I was incredibly sympathetic to the agonies of pushing.  I would allow women to say things like “I can’t” again and again during pushing while I calmly and unflaggingly told them again and again and again that they could.  For me, this was the epitome of midwifery care—this spoke to the very root of my calling, helping women to find their own strength in the moments when they were convinced that they had no strength left, helping women to climb the mountain that they thought they couldn’t climb.  However, having now pushed out a baby myself, I feel like I cut to the chase much more quickly during the pushing phase than I ever used to in the past.  I can remember just how excruciating the pushing was, and I know all too well that there’s no cure for the pain except to GET THE KID OUT, and I no longer hesitate to use tough love to help women buck up and PUSH, or hunker down and PUSH, or get to work and PUSH, if it seems like that is appropriate and will be effective.  It’s become another tool in my arsenal.

Granted, there is a time and place for everything, and there are certainly some women who will always need a softer touch, and as a midwife you are always acting like a chameleon; in a way, that’s the hallmark of what good midwifery care is.  Because women are so different and because labors are so different, what works in one situation doesn’t work in another situation. There is no cross-the-board answer.  I can get away with saying something with one woman which I would never dream of uttering with another woman,  based on my personal relationship with that woman, and on who she is and on what is needed minute by minute.  And often the situation itself dictates the tone; sometimes the energy in the room is very high, and you can joke around and be loud and loving and teasing, other times the mood is very subdued and quiet and she is working hard and inwardly focused, and what is needed is a soft touch or a single word.  You have to know how to surf the different energies at different times.  But now, thanks to my own personal experience of birth, I try to get women through second stage as efficiently as possible, to try to keep the pain from being drawn out longer than it needs to be.  Because man oh man is it painful!

Experience can be both a blessing and a curse, but it’s all of these little moments strung together which makes you a better provider.  This is the reason you seek out providers who’ve been doing this for awhile, who’ve seen the good, the bad and the messy, and have learned how to integrate it into their larger view.  For all my midwife sisters out there, how has your personal experience changed you?

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