Mothering Forum banner

compromising principles to get through nursing/midwifery school?

604 Views 10 Replies 10 Participants Last post by  sapphire_chan
I once spoke with a student nurse midwife who was conflicted over having to do procedures such as episiotomy when they are unnecessary. She said she would not practice this way when on her own, but justified doing so now because, first, she would in some way get in trouble (for instance, get a bad evaluation) if she were to refuse, and if she didn't do it it would be done anyway by someone else, so she may as well so that she can learn how.

I wrote in response:

But how do you reconcile the fact that in order to not do a disservice to future women, you must do a disservice to other women now? These women are not just objects for practicing on. Every single one of them matters, as much as the ones you will not be practicing on in the future. The women who need an episiotomy and deserve to have it done well do not have more right to that than others' right to not be unnecessarily cut. You are making the choice for them that they will make the payment for some other person's gain.

Here's a thought: I wonder how many who believe in unnecessary interventions for the sake of education would volunteer to have them done on themselves?

I'm not saying you shouldn't have instruction in how to cut episiotomies. I'm saying they shouldn't be done on real, live, feeling women only for the sake of learning about them.

It's a slippery slope when an end is meant to be accomplished by the means of not obeying one's conscience, because the more we do what our conscience tells us not to, the more we seek to justify it in order to not be in pain ourself -- that's human nature. And also the more you do something the more you become desensitized to it. I'm not saying that happens to everyone, but it happens often enough to perpetuate these procedures and this type of educational system.
Further thoughts?
See less See more
1 - 11 of 11 Posts
I so agree. It's why going to nurse-midwifery school never appealed to me.
See less See more
That's why I could not go to medical school. I might go in saying "I'll only do what I have to do" but what if I forgot? What if I got indoctrinated and didn't think the right way was the right way anymore. I just didn't think I was strong enough to get through residency, even if I thought I'd make a good physician. I admire anyone's personal strength to get through that intact. I might question their judgement, but I admire the strength.
Personally, I would hate to be in that position that the nursing student is in... there are so many grey areas. While I appreciate your well-worded response, I still feel for students in her position.

On one hand it is nice knowing that there are nurses who at least think about these unnecessary procedures... we need more nurses like her.
This issue is part of the reason I'm a family doc and not OB - I became convinced that I couldn't make it through the residency doing all that unnecessary stuff.
That said, I still regret some of my training experiences. I don't think I ever did a procedure myself simply so that I could do the procedure, but since I trained in such a medicalized environment, I did some things that I thought were necessary that I know now weren't. And there were certain things that I absolutely could not change because I didn't have the power to do so, like continuous monitoring. It was not within my power to choose to use intermittent monitoring, or to limit cervical exams, or many other things.
I got myself into trouble more than once for doing things differently, though. Once, I was helping a medical student to catch his very first baby with a lovely first time mom who had labored beautifully. The medical student was also a very lovely person, and had been very supportive and helpful with this mom and was just in awe of her ability to birth her baby, so it was as nice a training situation as you can have (although still, how absolutely awful to have to birth your baby with a medical student and a medical resident you've only known for a few hours, in a horribly medicalized environment where you are tied to the bed with numerous wires. Blech.) Anyway, as the baby was crowning nicely, the attending OB who was required to attend all births came in the room and started screaming at me like a banshee that I needed to cut an episiotomy right away. This poor mama was in a nice labor groove, and pushing when she wanted to, and suddenly the atmosphere went from loving and supportive to frantic and argumentative. I argued with the OB for a while, and since she didn't have gloves on, she couldn't move fast enough to take over. "She'll have scarring for life! The baby is just ramming his head against the perineum and will be damaged! Why are you just staring at me stupidly, cut now! Cut now!"
I turned my back and drew up some local very, very slowly, and while I was still messing around the student said "Um, doc? Um. The head seems to be out?" So I just turned back around and helped him not drop the babe on the floor. No epis. But she did have a small second degree tear, which was easily repaired.
That OB didn't let up all shift either. She wouldn't let me do any more teaching or catching, and spent the whole day lecturing me on how I'd just probably caused this mom and baby permanent damage. The only reason I was able to put up with it was that I had already done a lot of research on my own (and also birthed my own first 3 children already) and I knew she was wrong and someday I'd be in a position where I didn't have to listen to that kind of thing. I argued with her all day, but I know I never changed her mind one little bit.
I still feel bad about situations like that, and all the births I witnessed that were so traumatic. In general if someone above me wanted me to do something I knew didn't need done, I would refuse. Frequently, I worked with some nicer supervisory docs who would tolerantly "let me try it my way." And I even had 2 OB attendings who truly didn't believe in unnecessary procedures like episiotomy or instrumented deliveries. It would make me ill to hear an OB resident saying to a supervising attending "Room 4 has a dense epidural. What do you say we put on forceps?" And then that mama would have forceps so the residents could practice, and probably end up with a horrible extended episiotomy also.
I still don't know if the ends justify the means. It is very hard to get through modern medical training and there is a lot of pressure to do things the standard medical way. I feel bad that I couldn't protect so many women from unnecessary interventions, and yet I wasn't in a supervisory position to protect them. I don't know still if there was any way to change things - like reporting the unnecessary forceps routine? I think it would have been very easy for the docs in question to defend themselves that way in our medical legal climate.
Mostly I just feel bad that standard medical care is what it is. And that I didn't realize along the way that even many of the things that I thought were inevitable parts of having a baby were actually interventions that totally changed the birth experience for so many mamas.
See less See more
Hey, I just had this great idea- what if all of us here are MDC went into the medical field, or some other sort of mainstream area, toughed it out, did as little damage as possible and still get through, and then, once we're all docs, nurses, PAs, CNMs or whatever, what if we all revolutionized modern medicine? It's gotta start somewhere, and I don't see it changing any time soon they way things are.

See less See more
I have a midwife friend who is convinced that I am meant to go to medical school. I am fearful of it, of the wounds that I will recieve and the risks that I would take to protect women from unnecessary harm. I couldn't be a docile student, and my instructor's opinion would never supercede the fact that it was not plastic models we were cutting but real live women. I have a lot of concern about who I would be at the end of that. However, I do feel like I can do a more direct job in helping women acheive all that I wish that we all felt when we gave birth- empowerment, responsibility, joy, ownership, triumph!

I'm still on the fence, and while I try to figure it out I think we'll just make another baby to pass the time.
See less See more
doctorjen, I always look forward to your responses, I always love what you have to say.

I think about this a lot as well. The state I am moving to and going to be practicing in is an illegal state. Right now it is a misdemeanor which I am cool with but if legislation moves forward it will become a felony which I am not cool with and I will have to become a CNM.

Sometimes I lay awake at night and fear that year of L&D nursing required by so many CNM programs. I think about the horrid transport we just did and imagine I am the nurse being forced to amp up the pit and tell the mom to lay back down. Shudder.
There are small ways to make yourself - and the women you are working with - feel better. As a medical student and resident, I couldn't stop continous monitoring, but I could hold the monitor on a mom's belly for and keep adjusting it every time she changed positions whenever I had time to allow her freedom of movement.
When an anesthesiologist fellow anxious to get their epidural numbers up would say to every newly admitted laboring woman "This will be the worst pain you've ever had in your life, and whatever you're feeling now, it will only get worse. I have time now, but I may not be able to come back, so you better get the epidural now." I would be whispering that I had my first baby in 6 hrs from first contraction to baby, and the pain never got worse once I was in good active labor.
When a laboring woman was there who wanted a low-intervention birth, I could sometimes spend my whole shift laboring with her and provide labor support. And since I was helping the primary nurse then by keeping the monitor adjusted and the IV full, and what-not, I was not only tolerated but encouraged. Having someone there who believes you can do it helps at least some.
As a resident, I had primary clients, and I had 10-12 visits to encourage them and educate them. Since almost all of my clients were young, single, and poor, I felt at least better knowing they would have some support, and a friendly face at their birth.
I read and read and read when I was a resident. Midwife stories, and feminist ethics, and critiques of the American way of birth. It helped some, and made it possible to know there was another way. I also read and read the real OB literature, and could then argue intelligently with the OBs who supervised me,l and that helped.
Maybe not enough, but it all helped me sleep at night - that and the internal promise to do things differently when it was up to me.
See less See more

Originally Posted by doctorjen
This issue is part of the reason I'm a family doc and not OB - I became convinced that I couldn't make it through the residency doing all that unnecessary stuff.
Off topic: You're a family doc? Cool! That means I can say insulting things about OBs all the time and not have to worry that you'll think it might also be refering to you.
1 - 11 of 11 Posts