 Excellent. So I feel honored to be able to welcome Selene LeMay to give presentation number five, session number five here for VIDM tonight. Selene, Dr. Selene LeMay is a midwife for over 30 years in Quebec. She has been actively engaged for legalization of the midwifery practice there in Canada. She is the past president of Quebec's Midwives Association and a member of the board of La Horde de Saar-Schwemme in Quebec. She has a bachelor's in nursing and MA in anthropology and her PhD in applied human sciences from the University of Montreal. She has been teaching as a senior lecturer in the bachelor program and practic Saar-Schwemme for 10 years at the University of Quebec in Quebec Canada and she has three children and four grandchildren. Welcome Selene. Yes, hello everybody. Good morning, good evening, good night. Where you are, I'm pleased to take a few minutes to share with you my some reflections about the physiology and wisdom. So I will be talking about our context of practice with some characteristic of physiology and what contrast can be lived with in the context. Why do we need wisdom, what is practical wisdom, what kind of challenges we can face with that and then the potential of practical wisdom for midwives. So what is the context we know a lot of midwives are practicing in we in in one way there's a promotion of normal birth as you know part of the definition of a midwife. We insist on the importance of putting the patient at the center of care, personalized care, promotion of respect and all that and in many as your addiction in countries but we can see that birth is medically driven and mostly in hospital and characterized by routines, algorithms, protocols and guidelines and all that. So we have the culture of evidence-based medicine or evidence-based practice as a major movement with when then we see you have a lot of clinical guidelines, recommendations and expectation of conformity to apply the guidelines. So it's leading most of the time to standardized care. So if we want to promote normal birth and physiology birth what can we see as a characteristic? So basically physiology is the default model of the body function in order to keep human beings alive and functioning you know it's not it's a little bit sad that we think that it's a good idea now to promote physiology. It's not a goal it's the the mean basic thing that from the evolution keeps us alive. So it's a little bit sad that at some point we think it's a it's a goal we have to attain. So childbirth is defined as part of normal physiology of the female body. So some characteristic is unique because each body and each woman as a person is unique but each body is unique. Every surgeon and every doctor knows that you know we are not robots so it's there's something there and there is variety it's it's always varied it's a characteristic of the living. So what can we see is that we understand that mutual adjustment of the mother and the baby during the process of pregnancy childbirth and breastfeeding the notion of endogenous competencies of the mother and of the baby is so beautiful because they together they provide a kind of endogenous security for both of them. So it doesn't come from the exterior it's not about something else it's inside and we are in a complexity realm. Really it's we physiology is amazing and we need to understand much more than we know already about the beautiful complexity well in of the all the process. So what what does it bring you know I I made some kind of table and I I'm worried that we we put that in opposite but it's not that it's just a contrast so I want to to explain some of contrast you know we are used to calculate hours and minutes uh uh when we're working but physiology needs us to take time we're used to do surveillance but physiology needs us to use variance you know vigilance we're used to think about risk physiology needs us to think about the potential we are used to search for certainty sorry physiology needs us to tolerate uncertainty we're used to treat childbirth physiology needs us to respect childbirth we are used to think about results physiology needs us to think about processes we're used to think about pathology physiology needs us to think about health we use to calculate physiology needs us to balance we're used to technological imperative physiology needs us to relational temperature we're used to control physiology needs us to accompany we're used to think from simplicity physiology needs needs us to think from complexity we're used to procedural practice physiology needs us to a relational practice we are used to best practice but physiology needs us to consider good practice and we're used to work from group average physiology needs us to work with individual we're used to consider the body as a machine physiology needs us to consider the body as a complex system we're used to consider normality a posteriori and physiology needs us to consider normality a priory we're used to use our gaze physiology needs us to be in relation we're used to consider care as context and dependent physiology needs us to consider care as context and situation dependent we are used to trust only what we can see or measure physiology needs us to trust women even if we don't see or measure everything so with all the contrast when we work what what should i do when we are with a woman in childbirth that the the issue is not about too much or not enough it's not about just doing less intervention because there's a concern in many countries uh there's too much c-section too much intervention so the people think that if we stop interventions we then we gonna physiology will appear it's not like that that is working physiology leads us to a different place of mind beliefs and practice it's not about doing this or not doing that it's it's something different that's why we need wisdom why do i i'm talking about wisdom and like if physiology is unique and varied the cut the care of a childbearing woman should be unique and varied with physiology you cannot push the river and control the processes from the exterior childbirth is a process of transformation and there's a biological and personal time involved each situation is a moment in the unfolding of an existence there's two meanings in the in the word situation we are used to consider a situation like it's a case you know it's the there's a time the favor the the stage the pushing phase and all that and we measure but it's it's different there's a existential meaning of the word situation we are in a world of values and emotions so and we need practical wisdom when we navigate in complexity so the simplistic the simplistic summarizing of knowledge within clinical guidelines neglect the fundamental relevance of context and the and marginalize the importance of interpretation and judgment no standardized care can capture the richness plurality and particularity of human interaction when we simply apply guidelines or protocols the woman becomes an object of care this is far from the ethos of midway free so favoring physiology can put it to care can and should put into question practices rooted in a technical and mechanical vision of childbirth with physiology it's about variations and human understanding it cannot be encapsulated by universal rules it requires consideration judgment and choice so procedural plans and the consensual practice have to be revisited really we think that the woman is having her baby because we are there we forget that we are there because she's having her baby you know it was a kind of shock for me to realize that it's a whoa I I was trained you know to be a practitioner and do things and that and and then the woman is having her baby but if I consider physiology the woman alone in the wood uh even without me she will have her baby you know and probably everything will go right you know it's physiology so there's something I don't know where we come to to think about that we are necessary for a woman to have a baby but there's something when we think about physiology or normality that we forget so it brings me humility what is wisdom you know I don't want to um uh to talk about you know wisdom like philosophy a big thing in the the clouds and all that I I talk about practical wisdom so it's very uh practical the Greek uh Aristotle was talking about phronosis you um you can have a lot of articles on that uh phronosis even in medicals community and and the importance of wisdom too so wisdom is about finding what is the best thing to do to whom when and for what reasons wisdom has to be situated and taking in account the background the context so it involves deliberation and discernment practical wisdom is relation relational so practice then is informed by situated you judgment of practitioner sensitive to contacts and particularity it cannot be the contextualized and replaced by general procedure wisdom recognize the highly viable non-reproducible and contingent faiths faces of our world so wisdom is about responding to life challenges it is about what to do in the human realm and its fundamental uncertainty fundamental wisdom is the capacity to act by mediating between the general and the particular um it's the capacity for reason reasoning that depends on the context in a way that protocols do not so it's the capacity to cope with the unique the uncertain and complex situations of practice and it's about taking in account different dimension of of a situation which you don't have when you have guidelines so nowhere nowhere we can define correct judgment and the definition of wisdom cannot be you know encapsulated you know on a phrase it's discussed in many many community and very disciplined too so it's just about I want to to bring some ideas about the wisdom that can we understand in our practice so we can understand that judgment based approach approach is different from technical based approach practical wisdom require a situation reasoning and human understanding it gives place to values emotions dialogue is the capacity the capacity to make deliberative judgment and not calculation there's an exception of the uncertainty so being attentive to the process and not just oriented by the result and the the work of Holly Powell Kennedy just uh uh confirmed that for midwives the process is as important as the result so maybe we can try to put more wisdom in our practice there's many challenges uh about using or having wisdom in our practice because with the physiology is asking asking us to review our relation with uncertainty it's the ability to combine both general rules that guide or or practice with a more sophisticated sophisticated ability to discern the unique characteristic of the particular context so we don't have to replace rules or routine or general procedure but they they cannot replace a situated comprehension and judgment we don't have to choose between one or the other and that was my preoccupation by giving you the tables uh before it's not one or the other but we can see uh how we can create attention and ethical tension uh for midwives that or even doctors or nurses that want to um to favor physiological childbirth it's not simple it it will ask um a change of mindset something something different so the challenges is knowing how to remain focused on achieving the good for individual patient in ever-changing situations in a context of institution institutional and systemic pressure it's not it's not easy so challenges is valorized good practice really can't quantify a bow and not easily general viable and in a context full of best practice recipe algorithms and protocols we love that but when we want to consider physiology it it's more organic you know it's it's a garden it's a dance something different so uh the challenge is developing ethical reasoning and judgment-based practice in a context context oriented by technical based practice so standardized automatism routine so we have to change mindset start to think that it is the person instead of the technique that is producing change routine can be beneficial but routineize routineize practices are more likely to remain unexamined uh if if everybody's doing routine it will never be uh examined and and reflect so we need to understand the strengths and limitation of evidence-based practice because you will never provide all the practical answer that we need there's a strong pressure to conform to guidelines and recommendation and i'm i will not develop that but i'm try to find the links between this pressure to conform to medical vision and evidence-based practice with the notion of what um um oh my god i forgot the the notion of manufacturing consent of no one shamski so for midwives i think there's something there uh so the potential there's a the the potential of practical wisdom is leading the way uh to reflecting practice we have sharing stories and reflecting and learning from experience it can help the practitioners not to be simply executive technicians but to stay in relation in every situation it helps us to be human practical wisdom will help us to enlarge the notion of competence it can cultivate it will cultivate a culture that promotes both reflection and ethical responsibility so and we we can understand how practice uh should not be constantly referred and subordinate to science because with wisdom we we have to work with our eyes ears touch to speak with our heart so it's not about just science it's about human realm and relation and dialogue so it's it's quite different and we can develop ethical competency in professionalism with uh the the practical the practice of wisdom and for midwives i phronosis or practical midwives uh practical uh wisdom cannot be explicitly thought but it's a disposition toward practical wisdom that can be encouraged uh it will never fully are being fully articulated you know as a goal objective and all that but it can be felt as a guiding force for midwives and it can lead for a more coherent and satisfying midwifery practice the will to promote normal physiological birth can be a path for an appropriation of a midwifery ethos being a wise woman a stash farm which i am i am proud to be a stash farm because wisdom is part of my professional identity so uh it it helps me and it questions a lot about how can we bring that um being a midwife but in a context which uh doesn't allowed for um ecological vision of our practice and it helps us to be a wise woman and being wit woman so but the practical wisdom it is touching the art of being a midwife in a more meaningful way it's a place for values and emotion and uh it may be letting the story working on us instead of working on them then we can touch uh also the transformative process of birth because we are in the experience at that time we're not the the woman is not an object of care so we um practical wisdom we then consider the dialogic possibilities implicit in the interpretive practice dialogue with the patient with the colleagues and with others it it's the the the potential of stories and potential of learning by experience it can be shared so professional competency would eventually include professional wisdom so practicing professional professional practicers wisdom has the potential to resist to the standardization of practice and emotion work of midwives leading to burnout loss of meaning and quitting the profession so I have a few reference here um and this is five minutes old baby and so thank you thank you mostly so if you have any question or commentary to share I'm glad to hear from you thank you so much I think we're all completely inspired and a little mesmerized after that um particularly if you've been in the last few sessions which have been talking about burnout this is this feels like a solution which is um really inspiring so if anybody would like to ask a question you can raise your hand you can um you there's been some great feedback in the public chat just a few of the things that I've noticed is um you know people commenting on this idea that physiology is the default and not the goal just reminding us about that um and it's just really some of your your I think your table was really um powerful for a lot of us as well um really showing that and the idea that it doesn't have to be contradictory but it's um a contrast just to kind of check in with ourselves for those of us who are midwives um so I mean I hope that you're still unmuted so you can just continue talking and sharing your wisdom yeah for sure oh yeah it's I don't speak about wisdom because I consider I'm wise but it's for me it's like it's a light you know it's something a point of reference and I have to um listen uh to what I know about science but about this woman and my heart and my intuition and we you know with the same clinical portray I would do something with one woman and some other thing with another there's no answer and there's no solution unique so it honored the unicity of human beings and and me as a human being you know so and as a professional I can um be accountable for my kind of clinical reasoning but my what I my um portray of a situation uh I I know when I'm there you know can I have um somebody ask about the um the reference but I don't uh I'm not able to um touch the uh oh you want to go back yeah that's it I was I was like in shock one years ago then there was a conference for doctors uh it was in UK I think and the title of the conference was medical wisdom and I was in shock because they were uh ready to discuss the the the place of wisdom in medical practice for two days and me as a midwife as a wise woman I I never hear that in uh in a conference so I had I missed that I missed that part which just bring the difference I'm not against you know technique or or medicine or science it's not the point is I'm in another um another world it's going in another place it's not fighting it's it's not about that so um that I wonder how for those we do have a few students on and those of us who teach students particularly in in trying to think about this pendulum you know there's this big push to evidence based practice even in midwifery care to kind of gain credibility to prove ourselves to prove that midwifery is you know doing the right thing and so a lot of that comes through research and really making sure we have the numbers and quantifying things and it does take the individualization out of it and I wonder if you have any thoughts about how to integrate all of that push for for trying to put ourselves into the world of um you know the literature and the evidence while while balancing the the um you know kind of our roots and where we come from yeah it's such a good question I think that there should be that first students should learn to critical thinking and not just be good girls and evidence base is really a kind of way to do science first just one one way to do science and and it's used to I think to confirm the status quo of medicalization finally and um I'm I think that evidence base should be with a lot of rigor there should be a work of deconstruction of evidence base because uh it's it's it brings something that is not healthy uh for especially for childbearing women you know it's it's it brings forward the medicalization of uh of a childbearing woman and midway through practice so it's it's not easy to um to to to go in that and to read science differently and to not to oppose but we have to go elsewhere and physiology it's can be a tool to explore a different way of doing things just because of the characteristic you know it is it's it's amazing and this notion of endogenous competencies of the the mother and of the baby I I like that a lot because um you know it's honoring these powerful uh reproductive powers of women and I'm not sure that evidence basis is confirming that I work with a lot a lot of articles science and epidemiology and what I found is that it it makes me angry in fact it is at the what I call what I call the silent conclusions of a lot of research is that the women's bodies are not well well fit women's are like uh handicap biological handicap persons it it's not working you know they are too old too big too whatever so it in where will I get the confidence and the trust of me as a professional but on women and babies it if I don't have that you know the the basic paradigm of the potential of pathology is so powerful that we we we continue to follow that and physiologies like stretching the elastic okay we try not to do many things but we're not sure it's about beliefs so our context doesn't believe in physiology really so if this it's a big challenge and I think that wisdom can help uh just to to stick with that woman and working our relation with uncertainty and accept that if we're not doing that as midwives how can we help women and mothers to deal with that our fundamental situation as human beings so yeah yeah excellent I noticed that Irene who's going to be presenting next so she's probably not still in the room but she commented that her work I know she presented last year as well she works in China that there there's a there's a bit it's a bit easier she feels when she's working in some of the systems because there's a fundamental belief in this physiology premise like the holistic approach from the from the beginning and I'm wondering if anybody from the rest of the world has any comments or thoughts and and what you feel Selene about the difference in that I know here in the US we're so driven by you know social media and so also we we have conflict with our patients who are also reading evidence and and kind of searching for the right way to do things and getting further and further away from this physiology themselves of trusting themselves yeah I know this is a what what one thing that is quite sad is that now as a a group a woman they don't trust themselves anymore you know to being able to just to protect and nourish a non-born baby and to bring him into the world they fear and they believe that it's so so dangerous and there are so many risks just the you know the evidence base and now the even the we're talking and thinking about risk all the time so finally everybody is is believing that is you know it's it's a chance if we're alive you know after that it's quite a sad and my preoccupation is is I can understand that a woman has a lot of fears about you know the the pregnancy and the childbirth but what preoccupies me more and if midwives start to have those fears so as a professional I don't you know I question me if we are not confident and trusting women in the processes why should they you know so I don't know how we um midwives will build the trust and confidence in the context of medicalization and the the the definition of birth is so amazing you know in the williams obstetric how they define birth you know it's it's crazy it's like the the expulsion or the extraction of a fetus of out of the uterus after 20 weeks of gestation so and you know they don't talk about a placenta this is insane and they learn that doctors are learning that so physiology it's it's not just physiology the the definition of of uh pregnancy and childbirth is a medical one and it's it's it's too poor you know the problem of biomedical knowledge is not because it's dominant it's because it's insufficient and by far to help us to understand and and work at the moment of birth it's a social and it's transformative process and it's it's it's not anywhere in the books and in hospital and in the discourse uh so there's a lot of work to do so you know I I'm just try to find the potential of physiology and wisdom and it's is there a tool for midwives maybe to regain things about their ethos of their profession yeah and we have a lots of comments just really talking about the depth of your presentation just really stirring and and I think pretty moving for a lot of us Lorraine comments that look at any pharmacological research or even safety equipment design these do not take women into consideration at all there could not be the an all women's spacewalk because they did not have the right spacesuit so this idea of you know the paternalistic nature of this as well and you know even the evidence base with a lot of you know the the recommendation in though those guidelines are not construct with women they are absent of of the guidelines and they they expect to us to apply the recommendation it's not even build with with they will they build with women as patient as guinea pigs and you know where did you research randomized control trial but what about you know the ex existence of of of people there's a lot of things missing in the in the portrait so the physiology is not just about doing less intervention we're touching something that is different um yeah oh there's sorry there is a comment that this extends not only into the the physiology of birth but also into breastfeeding and I would say probably mothering and the rest of our women have as well yeah yeah thank you for talking about breastfeeding because now it's it's amazing you we the women have to take some uh course and be educated so how is breastfeeding and how it's a technique and you have to to teach her like that and she's stressed and it's a performance and breastfeeding now is the evaluation of the good mother and so it's it's not yeah it's not easy uh it goes um it's a lack of the internal yeah you're right the internal wisdom of the woman body to take care protect and nourish the baby excellent well I I think that we um that we all just feel inspired and then we'll be looking at your literature and your resources and you guys that are here in this session I'm going to go ahead and