It has been suggested that the growing proportion of left-handed people—or, more specifically, the greater acknowledgement of left-handedness over the past century—may be the result of fewer left-handed people being ‘forced’ to use their right hand to conform to the ‘norm’, rather than a greater incidence of left-handedness (McManus, 2002). There are approximately 27 000 midwives in the UK (Royal College of Midwives (RCM), 2015); however, there is no official data as to the proportion of midwives who are left-handed, nor research into whether they practise with left-handed dominance.
This article was inspired by hearing the experiences in practice of first-year student midwives who are left-handed. It also documents the experiences of Julie Quilter, a left-handed senior lecturer in midwifery who trained in the early 1980s. Questions raised by this article include:
Reflections on being a left-handed midwife: Julie Quilter
On commencing my midwifery training in late 1982, I was greeted the first morning by a senior tutor asking if anyone in the group was left-handed. I raised my hand and her words to me were: ‘Don't let them put you off… I'm left-handed and I'm still here. Tell them on labour ward that you are left-handed.’ At no time in my nurse training had the issue of being left-handed been raised as a potential difficulty with clinical skills, so this identification of my ‘difference’ was both surprising and puzzling.
When the time came for my second clinical placement, which was labour ward, I duly stated to the senior midwife that I had been told to inform them that I was left-handed. However, the reply was not one of accommodation but, instead: ‘Well, you will learn right-handed!’
The main issues that I envisaged were those of performing vaginal examinations (VEs) and episiotomies. I had already attempted a VE on the antenatal ward, using my left hand from the left side of the bed; however, I did quickly adapt to using my right hand and working from the right side of the bed in order to facilitate births and perform catheterisation and VEs. In 1982, the delivery rooms were set up to work from the right side of the bed, i.e. location of the delivery trolley, the cot and so on.
The main issue was in performing episiotomy, as routine episiotomies were the norm, with up to 96% of primiparous and 71% of multiparous women having routine episiotomies (Sleep et al, 1984). To infiltrate and perform a right medio-lateral episiotomy using your left hand was nigh on impossible because of crossing over your arms, i.e. inserting your right hand to protect the perineum while holding a syringe and then scissors in your left hand. The scissors themselves were designed for a right-handed person and, therefore, did not provide a clean cut. Yet I was not allowed to perform a left medio-lateral episiotomy as I was told that this would (a) ‘make suturing difficult for a right-handed person’ and (b) leave a scar on the left side, with the potential for another scar on the right side in future deliveries. I tried cutting with my left hand but holding the scissors differently to avoid the ‘catching of my arms’ but this was not satisfactory. I then tried to increase the strength in my right hand for infiltration and performing the incision by practising infiltrating an orange and cutting a piece of paper with my right hand. Of course, the best option was to avoid performing an episiotomy at all! This was easier said than done, given that such a high percentage of women—especially nulliparous women—routinely received one, and the decision to perform one was with the supervising midwife. Once I had qualified, however, it was my decision to avoid episiotomy at all costs; this is considered by Chapman (2009) as a reason why left-handed midwives perform fewer episiotomies.
According to Verralls (1993), midwives who had been appropriately trained in perineal repair have been permitted to do so since 1970 in the UK, although this was not routinely taken up, with perineal suturing still falling to the obstetrician. However, when suturing was introduced into the pre-registration midwifery curriculum in 1984 (Lewis, 1994), suturing by midwives in clinical practice became more common. This provided me with the opportunity, after qualification as a midwife, to be trained in suturing; again, this can be more difficult for left-handed midwives when taught by a right-handed midwife. However, I was not deterred and, in many ways, I was pleased to be able to repair perineal trauma for those women whose babies I had delivered. It now became clear to me that the rationale given previously for performing an episiotomy as a right-handed person was not justified; I had to suture left-handed whatever perineal trauma presented, and I couldn't see the problem.
The other issue, which perhaps worked in my favour, was supervising students undertaking deliveries—although I was now standing on the opposite side of the bed i.e. the left side, I could use my left hand if infiltration and episiotomy were required.
On reflection, I have become a ‘right-handed’ working midwife in that I prefer to undertake abdominal examinations from the right side of the bed or couch, and this is also reflected in the use of models in the clinical skills laboratory when teaching. This may have evolved in nursing when undertaking sterile techniques, which did seem to be predominantly from the right side of the bed or couch.
Thirty years on: What has changed?
Julie's experiences are probably typical of most left-handed midwives of her era, with anecdotal evidence suggesting there was a culture of conforming to entrenched practices rather than adapting practices while ensuring women and their families received high-quality care from a competent and confident midwife.
At the University of Northampton, a first-year module in the pre-registration midwifery curriculum focuses on the application of theory to practice, with the assessment strategy including an oral examination where students demonstrate manual dexterity skills such as abdominal examination, active management of the third stage of labour, and examination of the newborn. During the preparation for this assessment, left-handed student midwife Lottie Blunden shared some issues she was experiencing both in practice and simulated learning.
Reflections on being a left-handed student midwife: Lottie Blunden
I tend to find that rooms are arranged to enable right-handed practice. For example, though the bed is in the middle of the room on labour ward, when the right-handed midwife performs a VE she approaches from the right side of the woman; whereas it makes more sense to me to approach from the left. I have performed two VEs so far and for the first one, I followed my mentor's demonstration and did it with my right hand. I found it hard to connect what I was feeling to my brain to interpret it. The second time, I used my left hand and while I still didn't have much understanding about what I was feeling, I could process the physical experience more easily.
Sometimes I have felt a little awkward when my mentor demonstrates a clinical skill such as catheterisation or abdominal palpation and invites me to participate, as I have to move the trolley to a different position, or walk around to the other side of the bed to be on the side most natural to me. When mentors pass instruments such as cord clamps, they pass it to your right hand, and you have to take it with your left and then move to a different standing position so that you can use it properly.
On the postnatal ward, I notice that my natural tendency is to hold a baby with its head in the crook of my left arm. When passing babies between women and myself, they almost have to turn the baby round the other way, for a natural feeling hold for them (I am assuming they were right-handed).
Taking blood has been a challenge; not only are the table and the woman usually on the ‘wrong’ side for me, but the mentor's demonstration has to be understood and then converted to left-handed. My mentor in the community asked me to hold the needle as I would hold a pen when she first explained about blood taking. I hold a pen really strangely, almost in a backwards angle hold—not a good blood-taking position! When she realised I was left-handed, she was very patient. I have tried to take blood with my right and left hand, with different hands being the bottle-changing hand or the Vacutainer-holding hand. I am doing a peculiar mixture of both at the moment and I haven't practised changing the position of the woman, the table or even myself—I copy my mentor's positioning.
In relation to record-keeping, I am used to using a computer mouse with my right hand but I wonder whether I am slower at completing maternity records on the computer using my right hand to tab and return on the keyboard.
What is most confusing to me, as a left-handed student midwife, is that the physical environment and the visual demonstrations are right-handed, which makes it difficult to follow my natural ‘lefty’ instinct. I often start to try something right-handed to see if it's easier and then, before I know it, I have totally confused myself and made myself look really clumsy in the process!
‘Are left-handed students appropriately supported in practice? Performing abdominal examinations, facilitating deliveries and performing episiotomies are still issues for left-handed midwives’
My tip for other left-handed students would be to rearrange equipment, furniture, and even people if possible, before you start any procedure so that your left-handed dominance can happen naturally. If you write with your left hand then you will probably be better giving injections, performing VEs, and clamping cords with your left hand—so don't even try to use your right! Also, you should tell your mentor about being left-handed. I found Chapman's (2009) article about being left-handed really useful, and may show it to my next mentor to help explain my difficulties. Left-handed people tend to be clumsier than right-handed people—this is definitely true of me—but I wonder whether it is partly the right-handed world we live in that makes it so.
Supporting students
After hearing Lottie's reflection of her experiences to date, it seemed a good idea to find out more about the experiences of left-handed student midwives to see how they can be best supported both in the classroom and clinical practice. Box 1 includes some of the responses from student midwives on the pre-registration programme.
The Nursing and Midwifery Council (2009) states that midwives must be ‘fit for practice’ at the point of registration. It is worth asking whether the issues identified in this article are addressed in the current curriculum, and whether left-handed students are appropriately supported in practice. Performing abdominal examinations, facilitating deliveries and performing episiotomies are still issues for left-handed midwives and, while there is potential for flexibility of approach to perform abdominal examinations and facilitate births, guidelines for performing episiotomies are more prescriptive, indicating that the type of incision should be medio-lateral or medial (Royal College of Obstetricians and Gynaecologists, 2007; Royal College of Midwives, 2012). More than 20 years ago, Verralls (1993: 59) identified controversy not only about the use of episiotomy but also about the direction in which the incision was made, stating that the ‘student must be aware of the policy within her own unit’. In fact, while recent midwifery textbooks state the incision should be medio-lateral with no reference to left or right, their diagrams clearly indicate a right-handed approach (Kettle, 2011: 556; Johnson and Taylor, 2016: 239). This has not changed since textbooks in the early 1980s suggested that the left hand is inserted behind perineum. The right-handed bias continues in a recently published clinical skills textbook which states that ‘it is not appropriate to perform the episiotomy to the woman's left’ (Johnson and Taylor, 2016: 239), although it does not provide supporting references for this statement.
To adapt or conform?
Current left-handed student midwives' experiences of practice do not seem to be significantly different to those experienced by Julie Quilter in the 1980s. The issues identified by Chapman (2009) persist. Having read students' comments on how their left-handedness impacts on their practice, it is clear that more needs to be done to ensure left-handed students are supported in developing their manual dexterity skills—whether it be to help them adapt skills to work better with their left-handed dominance or to support them to ‘conform’ to a right-handed approach if this is their choice. In the classroom, this means lecturers should be aware of the potential differences left-handed students may have in the way they process information with regard to performing clinical skills, particularly if the skills are being demonstrated by a right-handed practitioner. In addition, when students are using clinical equipment in simulation they should be encouraged to experiment with positioning and techniques.
This article has highlighted the ongoing issue of being a left-handed midwife in a right-handed clinical environment. It has underlined the need for a partnership approach in pre-registration midwifery education between the university and clinical placement provider to ensure left-handed student midwives feel accepted and supported. With approximately 12% of the world's population being left-handed (Bletchly, 2015), their uniqueness should be celebrated, not suppressed. Famous ‘lefties’ include Albert Einstein, Barack Obama, Joan of Arc, Winston Churchill, and Neil Armstrong—and just look at the impact they had and their incredible achievements!
Join the debate
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