Grumpy Midwife’s Swansong

Grumpy Midwife is moving on.

There may or may not be future posts – so (just in case this is a finale) here are Grumpy Midwife’s three wishes to the Good Fairy of maternity care.

Please make midwives listen to women.

Don’t just do this as part of a damage-limitation exercise; do it because women – those having babies and those whose babies have long since grown up – are the reason midwives exist. Women want what is best for themselves, their babies and their families; physically, emotionally, socially. Midwives exist to articulate, negotiate and realise these needs – especially for those women who are otherwise voiceless and powerless. That is the function of midwives, whether we are designing a new maternity unit, writing a policy or assisting with breastfeeding. End of.

Please make midwives get along better with doctors.

When GM started out many moons ago, obstetricians were seen as the enemy; it was obstetricians who oppressed midwives, stymied women’s choice, and thwarted natural childbirth. Thirty years on, midwifery is a strong, autonomous profession turning away applicants, women’s choice is embedded in national policy, and natural childbirth – well, Grumpy Midwife is not too sure what is happening to natural childbirth but she worries equally about Musketeer Midwives and defensive, policy-bound practice.

Sound professional relationships depend on mutual respect and whilst there are shining examples of confident, inspirational midwifery leadership Grumpy Midwife sadly feels that midwives do sometimes let the side down. We seem to take an almost masochistic pride in being busy; too busy to review and reflect, too busy to consider if we could be doing things better – so busy in fact that being busy is now embedded in our culture, our expectations and our management of ourselves and our services.

This attitude has to change if midwifery is to command respect as a critical, intelligent profession. Professional development is not a skive; it is necessary and integral to sound practice. Midwives should demand (and mangers should facilitate) time for audit, research and reflection. Training and development should be priorities rather than add-ons; academics and educators should be welcomed rather than marginalised – and all midwives should have the skills to understand and promote midwifery research with authority and pride.

Please make midwives be nicer to each other.

Grumpy Midwife is terminally fed-up with the perpetual, relentless bullying of junior midwives  – and part-time midwives, community midwives, independent midwives, specialist midwives, older midwives, thoughtful midwives, slow midwives (possibly any midwife whose heart doesn’t leap with joyous excitement at the sound of an emergency bell on labour ward).

This bullying is insidious and ubiquitous. It poisons relationships with women and wrecks careers and lives. It disrupts teams and impacts on service provision. It is perpetrated and condoned from the highest levels and is an embarrassment and shame to the profession. It has to stop.

UK midwifery has much to celebrate in the early 21st century – but there are no grounds for complacency and significant reasons for concern.

Good luck.





Training – but not as we know it

As one career door closes for Grumpy Midwife and another creaks cautiously open, she would like to make clear one thing: training is not always the answer. (And here GM has to declare an interest, having recently departed a post in, er, training.)

Or (to put it another way): The answer to life, the universe and everything is not training.

Or (just in case there is still any lingering doubt): There is more to prevention and remediation of mistakes and misjudgments than training.

Medication errors, muddled decision-making, poor inter-professional communication. Up and down the country – in risk meeting minutes, in unit action plans, in incident investigation reports – the response is the same: “review training”, “add to mandatory training”, “attend training”. (Have you noticed how even “poor communication” is now considered to be amenable to training? Millenia of linguistic diversity, the infinite nuances of human body language, and several centuries of sexual and social indoctrination reduced to SBAR and RSVP – and job done.)

Time for a bit of adult educational theory*. Fear not, much of it stems from Maslow – and we all know what Maslow’s about, don’t we? (In a nutshell: even if Brian Cox is leading the seminar on particle physics, it would be all in vain if Grumpy Midwife’s bladder is full or she knows a £90 parking ticket is about to be slapped on her car.)

In order for adults to learn, there has to be an element of human agency. It’s about participation not just attendance – which is why the NMC’s revalidation plans include a requirement for 20 hours of continuing professional development in the company of others (meaning we need to watch Call the Midwife a couple of mates for this activity to count). The trouble is, engaging learners – encouraging stories, listening to fears, checking understanding – just takes so damn long and we’ve still got to fit in hand hygiene and fraud and the iv update and god where’s the day gone maybe we could just give a handout for blood transfusion…

Adult learning is all about understanding and solving real-life problems. Processing a fetal blood sample is not a real-life problem to most community midwives – but dealing with fierce dogs and speaking at child protection case conferences most certainly are. Think how much time could be saved on mandatory training days if we focused on what really matters to practitioners.

Acknowledging and building on past experience and knowledge is critical to adult learning. Which is why one-size-fits-all e-learning modules and PowerPoint lectures are doomed – and why being belittled by a know-all teacher or colleague on a training day back in 2000 means we’ve never asked a question since even though we don’t really get all this acid base stuff at all.

Adult learners’ values, attitudes, and beliefs influence their learning. A maternity care assistant won’t see the point of learning how to do supra-pubic pressure if she doesn’t, deep down, feel part of the team. Similarly, an obstetrician is not going to engage with learning how to facilitate a standing breech birth until he’s had chance to unpick his belief that all breech babies should be electively delivered by CS.

The context of adult learning is more important than any one variable. Even Brian Cox – or an internationally-renowed CTG expert or the scariest of scary risk managers – alone won’t alone change practice if clinical guidelines are confusing and badly written and midwives and obstetricians don’t respect and listen to each other.

Adult learners are capable of self-motivation and self-regulation. Missing signs of septic shock, confusing the emergency bell with the fire alarm, and loosing ones registration are intrinsically pretty motivating – so why blame the managers or the practice development team for non-attendance? Why treat grown-up professionals like primary school kids? (Yeah, yeah, Grumpy Midwife knows: vicarious liability.)

Finally, the ability to reflect is critical to effective adult learning – BUT reflection is neither natural nor intuitive. Teach a midwife that iv antibiotics should be given every four hours and you tick a corporate box. Teach her or him to reflect with insight and intelligence on why she forgot during a busy night shift and you save a career (and possibly a life).

It’s training, but not as we know it, Jim.**

*Kaufmann, DM and Mann, KV (2010) Teaching and learning in medical education: how theory can inform practice. In Swanwick, T (editor) (2010) Understanding Medical Education, Wiley-Blackwell, Oxford.

**Apparently, Spock never actually said this (with reference to life) in Star Trek. What he actually said was: “It is not life as we know it or understand it, Yet it is obviously alive, it exists.” So now you know.

Grumpy Midwife has given birth

Grumpy Midwife is ridiculously proud to announce the birth, after a 12 month gestation, of a brand new smartphone app for midwives, obstetricians, maternity support staff, midwifery and medical students. Funded by a grant from NHS Thames Valley Health Education Midwifery Fund and imaginatively entitled Childbirth Emergencies, the app gives step-by-step management of the Big Five of obstetric emergencies – plus sepsis. There is also a nice little section on support of women and their families and staff caught up in traumatic events. It’s available totally FREE to download from the Apple App Store (and, no, sorry, there are no immediate plans for an Android version; the money has run out). Follow @MidwifeApp on Twitter to find out more or just search “childbirth emergencies’ in the App Store.

Grumpy Midwife hopes that her baby will now make it’s own way in the world, spreading enlightenment, giving encouragement, empowering maternity care staff everywhere (although written for the UK, the content is pretty ecumenical). In the meantime, she would like to use this blog to do what all good midwives do: reflect on the experience and draw out some pertinent learning points. (In doing so, GM has, of course, blown her cover since her real name is all over the app – although it was only ever two clicks on this site away for observant readers.)

First: Working on this app has made Grumpy Midwife appreciate the maternity services: the infrastructure; availability of basic drugs and equipment; opportunities to train; expectations of cure; the knowledge that help will come running when we press that emergency call bell. Others who care for mothers and babies across the world are not so lucky.

Second: Grumpy Midwife didn’t think she would ever say this but communication in the NHS is easy. We speak a common language, based on culture and shared history, sprinkled with jargon, abbreviations, and innuendo. We laugh at things that gross other people, know our place in the hierarchy, act according to expectations. Talking to normal people is hard work, littered with potential for misunderstanding and confusion.

Third:  The NHS does not have a monopoly on working hard or long hours. Grumpy Midwife’s early morning texts and nocturnal emails to her app developers were frequently responded to by return. Nor are we the only ones stressed by exacting bosses and moving goalposts.  We in the NHS may feel daily dealings with life and death set us apart on some sort of moral high ground but the work of others is equally valid and life-affirming. We are fortunate to do work we love but not special or entitled in any way.

Fourth: Engaging other professionals to check content is necessary and reassuring and Grumpy Midwife is eternally grateful for all the suggestions, corrections, and requests for clarification. But there comes a point when one starts going round in circles trying to please everyone, endlessly referring and deferring. Teamwork is all very well but someone eventually has to take control, accept responsibility, and move things forward.

Fifth: In the last few days of this project, after a week of immersion in haemorrhage, sepsis, and ruptured organs, one of the techies told Grumpy Midwife of his impending marriage. Screens of coding quite suddenly took on a human dimension and GM was reminded how childbirth touches all of us.

Six: There is never an easy way to start talking about vaginas and buttocks and perineums to young men half your age.

Seven: Apple Macs really are things of great beauty and extraordinary function.

And finally, on the wall of the meeting room at at the app developers is a framed poster, in the style of vintage ‘keep calm’ notices. This one instructs employees to “Work hard and be kind to each other”. Nuff said.

The Invisibility of Midwives

Throughout last year, Grumpy Midwife facilitated a (frankly, brilliant) interactive training session on obstetric haemorrhage based on the tragic story of Princess Charlotte.

Princess Charlotte of Wales was the only child of the future King George IV. Had she lived, she would have displaced Victoria as Queen of England etc and so changed the course of European history. Tragically, Charlotte died in childbirth in 1817, at the age of 21.

Contemporaneous record keeping leaves a bit to be desired but we know that this was Charlotte’s first baby and the pregnancy was probably post-term. Her labour was long and inefficient and she birthed a large still-born baby boy after several hours of second stage. Shortly after, she started to bleed so her attendant performed a manual removal of placenta; the bleeding stopped but Charlotte collapsed and died three hours later. Cue, 200 years later, an excellent opportunity for inter-professional professional discussion on the possible causes of her death – and small group work on we would do today to manage the situation. (It is not known exactly why Princess Charlotte died, although Grumpy Midwife’s money is on a ruptured uterus. Or sepsis.)

Poor Charlotte was cared for in labour by Sir Richard Crofts. He not an obstetrician but a “man-midwife”; a male specialist in childbirth and the choice of wealthy women of the day (the alternative being a village midwife). By all accounts, Sir Richard was a skilled and compassionate practitioner but, at in a time before oxytocics and antibiotics, he could only watch and wait as tragedy unfolded. (Ironically, village midwives had probably been using raw ergo(metrine) for a couple of centuries but doctors did not approve.)

The country reacted to Charlotte’s death with (according to accounts) emotional bordering on hysteria, prolonged mass mourning, and profound anger – directed principally at Sir Richard. Three months after Charlotte’s death, whilst attending another woman in labour, Sir Richard apparently lost his nerve, left the room, and shot himself. (Grumpy Midwife recently visited Croft Castle in Herefordshire, the family home of Sir Richard. It was a poignant experience.)

Given the pressures of caring for royalty in labour, Grumpy Midwife can understand why four eminent doctors of various specialities felt it necessary to hover anxiously during the labour of the Duchess of Cambridge yesterday. She has a fond image of the men huddled together in a pocky staff room – drinking espresso, checking their phones, adjusting their ties – jumping every time the door opened. Meanwhile, two experienced midwives got on with the job, just as other midwives were doing at that moment  in hospitals and health posts and homes all over the world.

Waking up to gushing headlines this morning, Grumpy Midwife was initially irritated by the absence of midwives from this modern-day nativity. Surely a missed opportunity to spread the word about midwives as lead professionals in low-risk childbirth? A vehicle to celebrate natural childbirth and skilled midwifery care? A chance to redress the negativity of Morecambe Bay and Guernsey?

Then, after a while, GM calmed down and realised that – no – this is how it should be: midwives with women, quietly, reflective, nudging, guiding, supporting, protecting – but ultimately just there as the woman herself, princess or pauper, births her baby. Because it’s her show, not ours.

On home ground

By day, Grumpy Midwife is, amongst other things, an educator. She is rather proud of one particularly innovative session which she facilitates 2-3 times a month with multi-professional groups. Her opening slide is of a Pre-Raphaelite painting (Thoughts of the Past): a vision of smokey eye shadow, blue velvet, and tumbling auburn locks, dripping with the cloying sentimentalism beloved by Victorian intelligentsia, full of arty symbols; grey clouds of gloom, crumpled violets, sickly plants. Grumpy Midwife uses this and other images of increasing ickiness to demonstrate the importance of holistic assessment, of seeing the whole person, of context, of listening, touching, smelling. 

GM then interjects Vermeer’s exquisite Girl with a Pearl Earring – all naked expression and vacant background – to represent how we hospital-based midwives and doctors see the women for whom we care; stripped of their own clothes, belongings neatly stashed, tidy on a narrow bed, partner sitting to attention. 

The session seems to work. At least, nobody falls asleep. Even after lunch. 

Another of Grumpy Midwife’s day jobs is that of Supervisor of Midwives; part-time hours, full-time headache. Part of the remit is helping to reconcile the needs and desires of individual women with the realities of risk-adverse, cash-strapped, modern-day maternity care. In this capacity Grumpy Midwife recently went to visit a woman at home. (Needless to say, details have been blurred to protect the privacy of everyone concerned, not least GM herself.) This woman (let’s call her Shirley – or Sherry) wanted to give birth to her third (or maybe fourth) child at home, in spite of having a well-controlled medical condition with the possible potential of repercussions on the well-being of herself and her newborn baby. 
Grumpy Midwife wasn’t exactly wearing a twinset and pearls (I think she was, in fact, wearing fitted black, ankle-grazing trousers and tan loafers) but she felt like should have been thus garbed; sitting there, at Sherry’s dining room table, surrounded by Sherry’s family photos, being sniffed by Sherry’s dog, with a sheaf of clinical guidelines and risk assessments, pen professionally poised, prepared to be firm but – ultimately (since Sherry had the law on her side) fair. It was therefore rather a shock when Shirley (or Sherry) and her husband, rather than exhibiting due gratitude at GM’s magnanimity, refused to sit meekly and proceeded to tell GM how the midwives had ruined this pregnancy with their probing and testing and warnings, until Grumpy Midwife began to feel … not nervous … but decidedly uneasy. 
The Francis Report (2012) recommended a period of hands-on caring for nurse applicants. Grumpy Midwife would like to suggest that what we all really need to do is get out there and see our so-called patients in their homes, with their loved ones and loved things to realise the extent of the emotional vacuum in which we work in hospitals and clinics.