You are reading the original 2008 version of Birth Emergency Skills Training: manual for out-of-hospital midwives -free online!
Buy the 2025 version here!

CHAPTER 1: CRITICAL THINKING IN EMERGENCIES 
Chapter 1: Critical Thinking in Emergencies
A Systematic Approach
OBJECTIVES

• By the end of this chapter, you should be able to
•   Explain how the beginning provider processes information differently from the expert.
•   Describe a situation when home birth would decrease risk to mother and child, and one when it would elevate risk.
•   List three antepartal conditions that would necessitate co-management with a physician or transfer of care.

 
When pregnancy and labor are normal, it is easy to be lulled into assuming that they will remain normal. This assumption is true most of the time and so comforting that it is easy to discount the early signs that a problem is evolving. 
Knowledge of pathophysiology is important, but in order to recognize a problem from its earliest presentation, the provider must become a detective who pieces together a story, a pattern, or a diagnosis. Textbooks usually give the most typical presentations of disease processes along with their statistical likelihood. Statistics derived from populations, however, apply to populations, not to individuals. As often as not, when the women and babies in your care develop unexpected problems, their symptoms will not match the textbook, and signs will present with various degrees of ambiguity. Clinical judgment depends on the context of a particular situation. Although life-threatening problems are uncommon, they carry the highest stakes. When evaluating a problem, always ask yourself, “What is the worst this could be?” and rule out life-threatening conditions first.
Clinical information is processed differently at each level of expertise. Patricia Benner (2001) observed that the novice takes a rule-based approach to a problem, moving though an internal checklist with little awareness of context. The advanced beginner is more sensitive to the nuances of the situation at hand and understands underlying principles, but needs help setting priorities. A beginner able to pass a test on clinical manifestations of disease may struggle to translate this knowledge into practical application. Beginners often feel overwhelmed and suffer incapacitating anxiety when faced with something new. Much of the beginner’s discriminatory thought occurs at the conscious level. Beginners are also susceptible to tunnel vision that causes the task to become more important than the client.
The competent provider feels a sense of mastery based on experience and plans goals purposefully. She has a strong grasp of clinical know-how and understands the “why” of what she does.
The proficient provider develops a holistic perspective. She recognizes immediately when situations deviate from normal and can grasp the long-term implications of problems.
The expert provider transcends rules and trusts the intuition that arises from deep internal wellsprings of knowledge. The expert is flexible, inventing workable solutions though leaps of creativity and improvisation. Expert midwives attune to clinical data that are difficult to quantify or describe; they fit new situations into old frameworks to formulate innovative solutions. Intuition pieces the clues together into a whole that is flashed intact into the mind, not reached in an obvious linear progression. The expert does not often think consciously about her reasons for choosing actions, and she is usually unaware that she is processing knowledge at all. The salient facts just stand out. Often the flash of clinical insight may occur before quantifiable cues are identified.
The human brain has long- and short-term memory, and these two are as different as the RAM and the hard drive in a computer. Short-term memory, like RAM, is the processing space where you manage current information. It can hold about seven separate ideas (or clusters of ideas) at once. Additional input begins to erase information already stored. Long-term memory is stored on the biological equivalent of your “hard drive,” often for a lifetime. Like a file on a computer, this data is more easily retrieved if it is stored systematically. Beginning practitioners, like computers, rely on data, rules, and checklists.
Unlike computers, however, people filter information through emotions, intuition, and empathy. Reason is usually held as the standard for gathering knowledge, and emotion is often dismissed as a hindrance to reason. In truth, when providers emotionally attune to a situation, meaningful aspects stand out as important and guide their interpretations. The practicing midwife relies not just on data, but also on analyzing the situation, consulting sources, evaluating possible outcomes, taking intuitive leaps, weighing emotional responses, making tactile discriminations, considering contexts, acting on a disposition toward what is good and right, and forging empathetic connections (Benner, 2001).
DIAGNOSIS THROUGH CRITICAL THINKING
To treat appropriately, the provider must first arrive at the correct diagnosis. Accurate diagnosis involves fitting data into a coherent picture. Even seemingly incontrovertible data must be examined critically. Critical thinking generates creative ways to formulate solutions and raises questions about the strength of evidence for a given conclusion. In emergencies, this processing must be done at high speed, but not at the expense of accuracy.
Like a landscape artist, the provider must fill in the general outlines first and then refine the details. When a problem arises, the provider must consider all possible causes and develop a list of likely explanations without overcommitting to any of them. The provider must consider all relevant information before forming a working diagnosis, or she may miss data that would lead to a more accurate impression. The provider systematically analyzes and incorporates new data and notes whether it supports one hypothesis or eliminates others.
Periodically reflect on the big picture: Have all possibilities have been explored? Does the clinical impression still make sense? Are the conclusions based on evidence? Take care not to inflate the importance of clues that support your clinical impression—or ignore those that do not support it.
Remain alert to clues that contradict your working diagnosis and listen when your instincts reveal that something is not adding up. Even experienced providers can make mistakes or have blind spots. Unease about your own diagnosis often means that key elements are missing or that your original impression was inaccurate.
Do not discount intuition. Intuition is an unconscious recognition of patterns based on experience, assembled by the subconscious mind, that seems to burst into consciousness effortlessly or from an external source. Because the processing is unconscious, the experienced provider who relies on intuition often has trouble pointing to specific data that support her conviction though it tends to be highly accurate.
Sometimes, however, intuition can be hard to distinguish from other unconscious currents. Sometimes the vague unease that a midwife feels about a variation in a client’s labor, for example, is simply a focus for free-floating anxiety about her present surroundings (perhaps a remote farmhouse in a blizzard), the politics in her office, or the antics of her own teenager. Sometimes it is based on an old memory of some unpleasant event.

---

Midwives are geared philosophically toward nonintervention in the natural processes of pregnancy and birth. A normal labor treated as normal, for example, tends to stay normal, and every intervention in the normal process is likely to engender more interventions. Midwives often prevent obstetrical emergencies by employing gentle, natural ways of correcting a problem in the early stages.
Even while attending a normal low-risk woman in labor, the midwife should always consider the possibility of a developing problem. Through every labor, the midwife should continually ask four questions over and over in the back of her mind:

•  How is the mother?
•  How is the baby?
• How is the labor?
• Is everything still normal?

Her emphasis is still on keeping birth normal, but her attention is drawn to any change that may herald an emerging problem. By attuning to subtle deviations from normal, the midwife can recognize and solve problems as they arise and ensure that they do not deteriorate into life-threatening emergencies. If a critical situation arises, the midwife responds by providing timely interventions or transferring care.