Hi Mary,

This is a very interesting discussion.
I do have a few thoughts, 
- yes our learning of observing women's signals start from day one but are not formally assessed or necessarily acknowledged in a midwifery education program and hence are given no value by the student. The information may be lodged in the subconscious and only given value once the midwife becomes an experienced autonomous practitioner with the ability to be confident within herself.

The other point is the development of the 'half hearted' vaginal examination. Vaginal examination does have a purpose in practice when labour is not progressing in what ever context and non invasive signs such as the purple line, verbal or non verbal signs from the woman, palpation and descent cannot give us a full picture. In these cases the vaginal examination needs to include all the relevant information and for the purposes of continuity for the woman she has the right to expect that the midwife she has developed a trusting relationship with will be able to undertake such an invasive procedure.

The main issue I have with vaginal examination ( one on a long list) is that so much essential information is missing when midwives and junior doctors record and document them. Yes dilatation will be mentioned, effacement and station of the head, if you are lucky position may be mentioned but more rarely is the description of moulding of the baby's head or capput.

It is this hybrid of VE that has become a routine part of normal labour practice so that we can see 'where you're up to dearie'.

One of the most valuable lessons I have taken from my ability to practice autonomously within the new Zealand midwifery system ( and there have been so many) is that it has enabled me to trust myself as a practitioner. I have not had to yield to the questions of, "so what's your woman doing on VE?" this has led me to be less invasive and more trusting of the women's own body and ability to birth. On the other hand I do have valuable practice experience from other places which have meant that when a complication or a woman is more complex, I have been able to provide her with the continuity she deserves and is entitled to expect from me. In these circumstances I have undertaken the invasive VE and given a complete picture in the handover of her care into secondary services.
The other potential issue is the interface between obstetrician and midwife. It was extremely, extremely rare for the obstetrician I was working alongside in the secondary care setting to come along and repeat the VE I had already done to confirm my findings. If I felt it was not in my capabilities to get the information necessary for the obstetrician I was making a referral to then I would discuss it with the woman and explain that the obstetrician needs to make the assessment. 
The point I am making is that where the woman is the priority and the centre of care the interface between midwife and obstetrician must be without conflict and should demonstrate confidence in each other as professionals.
I, was shown mutual respect by the obstetrician because they were confident in my abilities as a practitioner which also enabled me to open their minds (sometimes) to a non biomedical approach. 

Thoughts early in the morning
Pam Harnden 



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On 4/11/2010, at 12:48 AM, "Stewart, Mary" <[log in to unmask]> wrote:

> need: