Student Midwives - what do you think?

[mears]

As most of you know I am a midwife and am based in the labour ward. I have a real passion for midwifery and wish to impart my knowledge and enthusiasm to student and junior midwives.
I have real concerns that student midwives are not gaining enough experience as they train to be confident midwives on qualification.
How can students get proper labour ward experience?

Often midwives and students feel uncomfortable at asking women in labour if both can perform a vaginal examination in order to learn, so the student goes without the learning experience. You also don't want to ask someone for permission to do examinations etc. when they are obviously sore.

What do you think is the best way round this issue? Should women consent to students antenatally before coming into the hospital to show that they understand that there are students under training? They obviously would be able to opt out of having students participate in their care.
Any thoughts will be gratefully received.

Mears, I think part of the problem is the way in which students are introduced. I am a big believer in letting students participate and am always happy to have students sit in on my hospital/doctor etc. visits. As long as my health isn't being jeapordized I would be happy to be examined by students as well. However, in my experience in England (vs. the usa) on numerous occasions I have had students or young doctors brought into consultations with hardly an introduction and never have I been asked if I minded. I'm sure you don't do this, but there does seem to be a general culture of treating the patient like they are not smart enough to even make the decision of whether a student can be present at their consultation. Given my experiences here, I don't think that I would give an advance blanket permission to have students sit in on/participate in my labor etc. Perhaps, patients need to be better informed about the importance of student training. Also, an effort at having the student present for a while and talking to/interacting with the patient before asking to do procedures. Sorry, if I'm not sounding very helpful (it's late and i'm off in am). I do think it's really important for students to have hands on training. What happens when they do ask women in labor if they can do an examination. Are they usually turned down? Or do they never ask because they feel uncomfortable?

Often students will just not ask. I tend to actually do the examination and if the woman has not found it too uncomfortable will then ask permission for the student to feel what I am feeling. I hate to think that women feel they are being 'practised on' though.
It is easier to ask when a relationship has been built up but students ( and junior midwives) lack experience in actually diagnosing labour which is obviously done within the hour usually of admission, prior to any relationship having been formed. No easy way round it really.

Message withdrawn

I'd go with the "as long as you are asked" line. I have no embarrassment as far as medical matters are concerned, so wouldn't really have minded who had asked - male or female - but would have wanted (expected!) the courtesy of the request.

I suppose it helps coming from a medical background - my dad is a doctor and my best friend and her husband are GPs, so I understand the need for hands on experience while training. I'm also pretty assertive, so have confidence that if I DIDN'T feel I was getting the appropriate respect, I would say so.

mears,

perhaps the best way to deal with this would be for the hospital to give women more information about students and their training needs right at the beginning of ante-natal care rather than 'spring' it on them when they're in labour. I don't necessarily mean ask them to decide whether they would consent to a student being present at labour there and then but just make them aware of students' needs and of the fact that they might be asked if a student can be present later on. This way they can make a considered choice although obviously if they decided to change this decision it should be respected. Also, I would suggest that maybe only 2nd and subsequent time mothers be asked as it's very difficult to make this decision when you don't really know what labour's going to be like and how you're going to feel.
When I had my dd I was asked if a (male) medical student could be present at the labour. I had no objections and in fact he delivered her but I would have liked to have been told earlier on that students being present in the labour-room was a possibility.

I wouldn't want a student suddenly sprung on me late in labour, but we had been introduced at an earlier stage then I don't think I would mind too much - after all, they need to learn.

A friend of mine who had a home delivery was very glad she had a student present - the baby decided to put in a sudden appearance and the student was the only one who got there in time to catch the baby!

Just read gillymac's posting again. I think she's got a point about asking 2nd time mums - I was very unhappy about the idea of having a student present the first time around, whereas with no.2 I would have been far happier about it.

Mears, my 3 labours have all been simple and the last 2 were pretty quick (and painful) only lasting 1 hr each from start to finnish. TBO, I couldn't have cared less who was in the room, examining me etc. as I think I was too out of it to notice (not with drugs but just with that incredibly intense 'giving birth' feeling!). I completely understand though that there are women who are not comfortable with this.

BTW, 2 of my children were born at home and I would have been very happy for student midwives to be present (I think one of the midwives who delivered my first child could have definitely done with more training herself, but that another story!)

TBO should have read TBH ! Honestly, my spelling is all over the place these days

Our community midwife discussed what student midwives do with us at our parentcraft classes (I think there was a student with her at the time at the class!) and suggested we think about it and include it on our birthplans.

By the time I went into hospital I had had a chance to think it through and was unsurprised when I was asked (it's not a time to be thinking through new ideas, let's face it). I was really relaxed at my initial examination and was more than happy to be examined twice (first by student then by midwife). Then shifts changed and I had a student midwife with me all through my labour. She was great although clearly a little unsure about me not just lying back so she could do all the monitoring she needed - but the other midwife was very encouraging of my taking control of my labour so frankly I didn't mind making life difficult for the student!

Admittedly I had a very easy and short labour, I might have felt completely different if things had gone on a long time and I'd been in a lot of pain. It was obvious that the qualified midwife realised this was the way my labour was going to go and therefore gave the student more responsibility than she might otherwise have done.

I thought they were both great - it was a pleasure having them both there with me.

Thanks for your quick replies. I am heartened you are not anti-student. Interesting about the student being present at the last minute.
That regularly happens when there are only a couple of students on duty with a number of women delivering. Because they need 40 deliveries to qualify they can be running from room to room on a busy night.
40 deliveries does not sound a lot but in reality it can be difficult to achieve in the time they are actually in the labour ward.
Medical students turn up when you least expect them! We ensure that throughout labour there is only one student present so for a last minute student entry it will have been a midwife looking after the mum. Those midwives get pretty p**d off having a student arrive to 'nick' the delivery I can tell you. They forget theywere once in that position and that we are a teaching hospital.

Just to add a slightly different perspective: I do understand the need for training and experience for both student midwives and student doctors esp since lots of family on both sides are medical including dh who is a dr. However, especially for my first labour I needed to know that whoever was there really knew what they were doing and I was able to say antenatally that at the labour I didn't want students of any description which helped me feel more relaxed than I otherwise would have done. I was quite happy to see the plethora of students throughout my pregnancy esp since I was in and out of hospital and a "good teaching case" for management of hyperemesis. But, having known many student drs through dh's time at medical school and heard not the sensationalised stories but the real, oh my goodness, I feel awful, I did x,y,z and this dreadful thing happened (usually 3rd degree tears) that I absolutely didn't want to be the practice case, the one bad one that every student seems to have. I think asking antenatally is preferable, and probably at least 2nd time mothers who know a little more about what to expect. HTH

mears, I met a number of midwives from a team during ante natal visits, and was lucky enough to have one of them with me in the labour ward. the student with her was obviously inexperienced (thought i was 2cm when i was 8cm!!) but I was more than happy to let her gain some useful experience. both women were sensitive to my needs - and when things got hairy (baby was delivered by emergency c-section because she'd become acidotic) they knew it wasn't the time to let the student loose on me!
mears - one of my friends is having her second ds soon who's breech..and i believe she'll be 'encouraged' to have a caesarean, because midwives gain so little experience of breech deliveries these days. I know they're higher risk deliveries, but I'm sure some women would opt for a vaginal delivery if teams were willing to try.

I've had students MWs at 2 out of 4 labours. The first was 27 yrs ago when patients were 'seen but not heard' so I had no real choice in the matter. However, it was her first delivery and she was really grateful. I had a horrendous labour and the man-in-the-moon could have delivered me, for all I cared. I like to think that she still remembers her first delivery, all those years ago, even though DS was born flat.

I agreed to an internal when I was in hospital before DD1 was born and then had a student throughout labour with DD2. But I was having a community MW delivery, so it wasn't exacty crowding out the place. She was lovely and cried her eyes out when dd arrived - was in a worse state than me!! I had a physiological 3rd stage, too, which is pretty unusual these days.

My attitude is that they have to learn somewhere and I think the suggestion that mums-to-be are informed about the need for students to learn is excellent. I think the comparison between MWs and dr's is not quite the same, as MWs tend to be much more 'hand off' than dr's. It's MWs who are the childbirth experts, not Dr's!!

hi mears

like phillipat, at my nct class we were encouraged to state our willingness to have students be part of the process of labour/delivery on our birthplans. my view was no problem in theory, but i did not want a whole stream of people banging in and out the whole way through. as the hospital portion of my labour lasted through three shifts, i had this anyway, lol! i live in inner london so my catchment area hospital(s) are big teaching hospitals, so there are many students around.

i think a good way of allowing student participation would be to have the student shadowing the experienced midwife throughout the labour - that way the student sees most of the process, end to end as it were, and the mother has a chance to get used to the student being around with the experienced midwife.

they've got to learn somehow!

Hi Mears

I had a student and qualified midwife with me when I had my DD. Barbara (qualified) introduced me to Anna and asked me whether I'd be happy for Anna to do some of my examinations, etc. As it was all explained, I had no problem with this. Both Barbara and Anna were with me from being induced until DD was born - some 10 hours later. They were both excellent and I hope that Anna found her experience useful. The nice thing about my hospital (Farnborough, Kent) is that I was always asked.

Ok- this might be a bit controversial but I think as long as we're relying on a free NHS system to deliver our babies safely we shouldn't have any choice in the matter! Student midwives and doctors can only learn by being there and doing the business. As long as a team is working to give women and babies a decent standard of care, I think it should be a given that well-supervised students will be a valued part of that team and we shouldn't mind about being "practised on". After all, who will be delivering our children's children if we refuse?

Incidentally Mears, I was really surprised at how few internal examinations I had during labour (admittedly only in the hospital 3 hrs before dd arrived) - I was pretty much expecting them every half hour but actually only got one in my whole time. Certainly in the earlier part of labour before I started squirming, I wouldn't have minded more if it had helped a student learn. Obviously no one likes having internals but childbirth is a bit of a special case!

Forgot to add this to my earlier message. My pregnancy was managed via midwife & GP - and I only went to hospital for booking in and because I was 10 days overdue. I saw the same midwife at the surgery and had a student present on one occasion - again was asked if I minded. Saw three different midwives when I was sent home - they were very short staffed and extremely sorry that I wasn't able to continue with my surgery midwife. However, it was never a problem, as at all stages people explained and asked if I minded. I think if they'd just arrived, examined and left - then I'd have been a bit miffed. Still it can't have been bad as DH and I are considering another

I'm afraid I had quite a bad experience with a student - my ds was booked to be induced, and in fact the day I was booked in, I went into labour anyway. But, being a first time mum I didn't know that was the case - he was lying posterior so the contractions were mainly in my back - so I went in, and the student was solely responsible for the induction. Having done a trace, and seen that I was having contractions every 2 minutes, she then decided to induce anyway! I probably should have said something, but was nervous, and so I was stuck in the induction ward with no pain relief until I begged to go down to the delivery suite, at which point I was 7 cm (from 0 in 1 hour). I then needed an epidural, as the contractions were so intense, and happily this slowed things down a little. But I do think it was not right that a student was allowed to make that decision.

Scummymummy, the NHS isn't exactly free, surely we pay for it with our taxes?

Yes, students have to learn but childbirth is an intense and personal experience (although I recognise that "couldn't care less if the man in the moon delivered" feeling) and, for me, wasn't the time for making new friends (to paraphrase Sheila Kitzinger).

Mears, I wouldn't mind if a) I was asked and b) depends on the procedure. Not sure I would want an inexperienced person stitching me up for example, although I do recognise that students have to learn. I had a student fit my coil a while ago and didn't mind at all, since I was asked in advance and gave my consent. I agree that maybe 2nd time + mothers might be happier to help. I certainly would next time if I was asked.

When I was induced, the hospital midwife assigned to me explained that she had a student and asked if I was happy for her to be involved, which I was. The student midwife stayed with me the whole time, and the experienced one made regular checks and then stayed when necessary. It was great, as it meant that I had at least one midwife with me throughout the whole labour which was a wonderful luxury. I also felt that I benefitted from the fact that the more experienced midwife was explaining things in great detail to the student. Not sure how I would have felt about being stitched by a student though, although I'm sure some students under expert supervision would do a better job than some doctors!!

I know what you mean, WWW, especially about the intensely personal experience of childbirth. I wouldn't be particularly keen on being flooded with more than one student at a time during childbirth. And I definitely agree that students shouldn't be doing tasks way beyond their experience...
On the taxes front- there is no way that all the taxes I've ever paid- and that feels like quite a lot though I know it's a pittance really!- would cover more than a minscule amount of the NHS care I and my boys have received since their conception. I do think it would be good if students were generally accepted and welcomed as part of a small midwife (and doctor, if necessary) team. And from most of these responses it sounds like they are- if the situation's handled sensitively.

I hypothetically agreed on my birth plan beforehand to have students present and when the time came I was indeed so focused on the birth process that it would have been fairly incidental.

However since they left me waiting until I was 9cm dilated before they examined me there would have been no time to build up a rapport. I would certainly be happy to have students present at any future birth.