Grumpy Midwife at her grumpiest

Grumpy Midwife is at her grumpiest when faced with a clinical shift. She spends most of her working time teaching and training, moaning in meetings, writing reports, and putting money in the swear box in her office. Then, once a week (less if she can get out of it) she pulls on unflattering scrubs, sticks a pen in her pocket, and stomps off to labour ward.

Why is Grumpy Midwife so particularly grumpy at these times? Because she has many more important things to do (like updating the training database and cleaning her keyboard) – and is secretly just a teeny-weeny bit nervous that she may get caught up (and shown up) in some hideous obstetric emergency.

But when she gets to labour ward, has a cup of tea and makes people laugh in handover, she starts to feel better. This has a lot to do with the folks with whom she works: the dramatists and divas, the thrill-seekers and the timid, the unflappable care assistants, the scary ward clerks. The gossip! (“Have you heard? No! How awful!”) The stories! (“I had a woman who …”) And aren’t SHOs fun? (Just like GM’s sons’ friends, except with stethoscopes.) And registrars so generous with their knowledge. And consultants so, well, grumpy …

Which is all very encouraging because, as a study reported in the Harvard Business Review concluded, it’s the energy and engagement of workers outside formal meetings that builds teams, and the NHS managers who recognises and facilitates this are wise indeed.

Then there’s the women and their families.

As followers of Grumpy Midwife on Twitter will know, she likes to work in labour ward triage. She takes peculiar satisfaction, first thing in the morning, in lining up the monitors, stocking up the specula, and preparing paperwork – and is actually quite peeved when patients arrive to mess up her beds. But not for long.

GM is no saint; she is therefore genuinely surprised each week anew to rediscover how incredibly rewarding is contact with women and their partners, mothers, fathers, friends (but not their toddlers; GM draws the line at toddlers). For it is one thing to speed-read 800 pages of NICE’s draft guidance on Intrapartum Care and quite another to actually start thinking about what this would mean to the woman sitting in front of you.

It is easy, for example, to write a nicely referenced guideline on latent labour with the correct emphasis on encouraging women to stay at home for as long as possible, bouncing on balls, eating oat cakes and timing contractions on their smartphones; far harder when a woman is crying down the phone after a few hours of niggling labour pains.

Similarly, when a girl staggers into the ward, red-faced and tearful, it may look like established labour, sound like labour, feel like labour but, if her cervix isn’t four centimetres dilated, it’s not supposed to be labour.

Away from the bedside, midwifery becomes technical and scientific; it is only with women that the full artistry becomes apparent.

A recent personal piece in The BMJ attacked competency-based medical training as a box-ticking exercise that reduces doctoring to “the mechanics of procedures”; an absurd situation akin to an artist being assessed on how they hold a paintbrush rather than use colour and form, depth and perspective to produce a picture.

It is only with women that midwives can see the whole picture – messy, moving, disturbing, inspirational – and this is why the busiest manager, the smartest lecturer, the grumpiest midwife should jolly well get out there, once a week, to palpate bellies, take pulses, test urine, wipe tears and put the humanity into those damn policies we spend the rest of the time writing.

And those real-life obstetric emergencies? Needless to say, Grumpy Midwife has long since mastered the tick of walking purposefully and confidently, but very slowly. To give other midwives a chance to shine. Obv.

 

Midwives, Medics, and Professional Identity

Grumpy Midwife is still obsessing with issues of professional identity. She has concluded that, like patriotism, a strong professional identify and pride in that identity is a good thing – but only in moderation and only when the end justifies the means.

Recent research conducted by the General Medical Council amongst doctors in training revealed that over 13% had experienced bullying and nearly 1 in 5 had witnessed somebody else being bullied in the workplace (which suggests that being bullied is under-reported). The same survey concluded that 26.5% of the 50,000 respondents had been subjected to “undermining behaviour” from a senior colleague, undermining behaviour being defined as “persistent and deliberate belittling or humiliation” that eroded “professional confidence or self-esteem”. So far, so worrying – but now it gets personal.

Trainees in obstetrics and gynaecology are more likely than any other speciality to report bullying or undermining. And the perpetrators of such behaviour? First consultants, and second “nurses and midwives” – by which we mean midwives since there are virtually no nurses in obstetrics and nurses in gynaecology now seem to be lumped in with surgery and, in any case, seem far too harassed and busy and nice to waste time and energy belittling anybody. Yes, midwives are officially the Bitches of Birthing.

Incidentally, the nearest rivals for the toxic distinction of Nastiest Speciality is pathology. Isn’t that interesting? Obs and gynae is probably the most visible of specialities, with women and families witnessing almost everything we say and do (contrary to popular belief amongst staff, labour ward doors are not soundproof) – whilst pathology is arguably the most invisible (GM knows virtually nothing about working in pathology but imagines a tense and silent lab full of microscopes and anxious people in white coats being constantly interrupted by phone calls from clinicians too impatient to wait for results on the intranet).

So what is it about midwives? GM was recently invited to attend a talk on unacceptable behaviour on the labour ward, delivered by an obstetrician tasked with addressing this issue in maternity units. (The occasion was a Deanery educational event attended by around 100 obstetricians. And three midwives. GM is nothing if not brave.) The speaker (a charming woman of around GM’s vintage) ran down a list of factors that may contribute to unpleasantness in maternity care: stress, shifts, demanding training, risk of litigation, traditional attitudes, lots of female and overseas doctors – and midwives; “midwives are [palpable pause and carefully choice of words] not like nurses“. Cue nervous laughter around the auditorium.

Not like nurses? Meaning… Autonomous practitioners fully accountable for the care of mother and baby throughout normal pregnancy, labour and the postnatal period (Midwives’ Rules, 2012)? With continuing responsibility even when obstetricians are involved to provide “holistic support, maximising continuity of carer and promoting … normal physiological processes” (Safer Childbirth, 2007)? Confident professionals with a long and honourable history? That’s good, surely? Well, not if “autonomous” = insular, “holistic support” = colluding and obstructive, “promoting normality” = blinkered and short-sighted, and “confident” = bullying and belittling.

This isn’t a new or isolated issue. Our Code of Conduct (NMC, 2012) stipulates that midwives “work cooperatively within teams and respect the skills, expertise and contributions of … colleagues”; very similar words to those used in the GMC’s Good Medical Practice guide (2013). Meanwhile, the International Confederation of Midwives in a position statement makes clear that autonomy does not mean working “alone or in isolation from the woman or colleagues” – and this warning brings us back to what really matters in this whole sorry mess.

A strong professional identity – yes – so long as we remember what that identity is and for whose benefit. Midwife = “with woman”; “with woman” not to feed our professional ego but sensitively, skilfully, humbly with each woman. If we place women genuinely at the centre of care there would be no room for bossing or bullying or belittling, just calm professional conversations to plan the best possible care for each and every mother and baby.

Well, that’s Grumpy Midwife’s theory anyway.

 

Midwives do not have the monopoly on maternity care

Across the world, 40 million women each year give birth without a trained attendant. Two million of these women are totally alone.

In the UK, it’s all about one-to-one midwifery care in labour, 40 hours of consultant cover on wards, and epidurals within 30 minutes. For 50% of women in sub-Saharan Africa, it’s about a modicum of privacy, a clean blade to cut the umbilical cord, and skilled hands to stop bleeding.

As a Supervisor of Midwives, Grumpy Midwife spends more than her fair share of time dealing with issues of professional accountability and autonomy, blogs about how proud she is to be a midwife, and is embarking on Masters research looking (in part) at the impact of midwives’ professional identity on collaborative care. Across the globe, the title of ‘midwife’ is reserved for those appropriately qualified and legally licensed and, in the UK at least, it is a criminal offence for anyone other than a midwife or doctor to plan to deliver a baby (Dimond, 2013).

Meanwhile, in parts of the developing world, there are fewer than two registered healthcare practitioners per 10,000 people; in some places because of absolute shortage, in others a reflection of unequal provision as specialist healthcare workers (not unreasonably) vote with their feet for a living wage and personal security.

Midwives do not feature much in remote villages in Africa and Asia. Women are attended in childbirth by nurses – public health nurses, nurse midwives, nursing assistants – or traditional birth attendants. Or nobody. Most of these nurses also give antenatal care and immunisations, treat malaria and snakebite and diarrhoea, resuscitate the newborn and tend the dying.

A recent editorial in the African Journal of Midwifery and Women’s Health (Iliffe, 2014) warns against “colonial” attitudes on the part of Western donors and advisors who link funds to “one particular way of doing things” in terms of health practitioner roles and regulation. When you’re five hours from the nearest midwife or medic, it’s not the status of the birth attendant that matters but her skills and her access to lifesaving medicines and transport.

Yes, midwives are the experts in normal childbirth and – yes – of course we should be leading on this; educating, innovating, inspiring, driving up standards. But ours cannot be a mindless monopoly on the care of mothers and babies.

Save the Children Fund (2014) Ending Newborn Deaths: Ensuring Every Baby Survives

International Confederation of Midwives

Dimond, B. (2013) Legal Aspects of Midwifery. London: Quay Books

Iliffe, J (2014) Beware nursing and midwifery colonialism. African Journal of Midwifery and Women’s Health, 8(1), p.6

Why do midwives do this?

This won’t be a very long post because for once Grumpy Midwife doesn’t have any clever answers.

A few years back, when Grumpy Midwife was involved in a birth reflections service, a woman told her she was unable to go to the gym since her baby was born nine months ago. Why? Because she couldn’t bear to see the exercise balls, lined up all pink and purple ready for girly sit-ups, because they brought back such terrible memories of her labour. But it wasn’t the pain she recalled – or fear or indignity – but, specifically and horrifically, the two midwives who cared for her during those hours.

Some time later, another woman told Grumpy Midwife, not entirely in jest, that she felt about midwives as other people feel about bankers or traffic wardens or tax collectors because of how she was treated in labour.

Then, early this January, another story: this time a fellow student on a course; a consultant surgeon whose wife had just had their first baby. Labour was induced on the antenatal ward and contractions started almost immediately. Tentatively, politely, aware of how intimidating it can be to care for doctors and their families, this gentle man asked the midwives to attend his wife; once, twice, three times, for six long hours of patronising platitudes, until her waters broke and she started to push and suddenly it was all her fault for not using her call bell.

Why do we behave like this? How do we manage to inspire at once gratitude and adoration – and fear and loathing?

Proud to be a Midwife

Grumpy Midwife is proud to be a midwife. She’s proud of the whole second-oldest-profession-in-the-world thing. She loves the idea of being the latest in a long line stretching back to Biblical times; presiding over the primordial mess and raw emotion of an event that levels princesses and paupers, prisoners and pop stars.

Grumpy Midwife is even secretly rather proud of Call the Midwife; lynchpin of the community, respected by men, revered by women, keeper of secrets, defender of the weak, wise woman, witch. She likes the fact that when people ask what she does, she can simply say “midwife” with no need for explanation or elaboration. What other profession is thus so nicely defined?

If she had more time, there is a risk that Grumpy Midwife would find herself quite overcome by the sheer pathos of birth: her hands the first to touch this brand-new, blood-streaked little body; her words at this time remembered forever by the mother; her protection of this infant during the most dangerous moments of his life the first of step of his journey to nobility, Nobel prize, or notoriety. She still sheds a few discrete tears at every birth she witnesses, secure in the knowledge that these will be unnoticed in her general bustle and bossiness.

There have been times when this pride has been dented; by Grumpy Midwife’s own cynicism and discontent or by events or the opinions of others. But not for long – and never so much so that she has managed to walk away. And certainly not since she was recently reminded – by healthcare workers listening intently to her every word in a dusty, dilapidated classroom in a remote corner of Kenya – of the importance of midwifery skills, stripped of all romance and pretension, to millions of women across the world.

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.

The B Word

Sadly and shamefully, allegations of bullying rumble intermittently throughout Grumpy Midwife’s workplace like distant thunder on an otherwise pleasant summer’s day. The fact that her particular corner of the maternity services is not unique in this experience and that bullying permeates the NHS (see, for example, NHS Staff Surveys and the Francis Report) is no comfort nor justification; GM is just terminally fed-up with comforting tearful juniors belittled in front of patients, care assistants alternately excluded and unappreciated, and doctors feeling bamboozled by bossy midwives.
 
A busy labour ward is possibly one of the most challenging places to work within the NHS: pace of work and interface with the public akin to A&E on a Saturday night, skills and technology to match that of HDU, inter-agency working reflective of an inner-city health centre, personalities that make the Bolshoi Ballet look boring. And senior labour ward midwives are necessarily a tough breed, juggling the demands of the services (limited beds, limited staff, limited time) with the needs of patents promised “choice” throughout childbirth. Back in the day, Grumpy Midwife tried to be tough, but wasn’t very good at it.
 
On the other hand, labour wards are also surely the happiest of places to work! Midwives are well-trained and motivated – and queuing up for jobs. Management is tight and professional supervision excellent. So what is the problem?
 
One of the most exciting, most innovative, most sensible papers on leadership Grumpy Midwife has read recently (and, believe me, she’s read a lot) is Followership in the NHS by Keith Grint and Clare Holt (available on The King’s Fund website). To cut 22 pages short, there are three types of problems: tame, wicked, and critical.
 
Tame problems have arisen before and are likely to do so again. They require a management solution; implementation of standard procedures and routine actions (although this is not to diminish the skill required); covering for unexpected staff sickness, for example, or getting the labour rooms cleaned quickly for women waiting for admission.
 
Wicked problems are more complex; they are deeply rooted in context, and there is no clear relationship between cause and effect. Wicked problems are often intractable; drug errors in spite of endless training, poor team working in spite of communications sessions, unhappiness at work in spite of (let’s be honest) fairly good pay. 
 
Critical problems are self-evident; fire, haemorrhage, collapse of mother or baby. Midwives are good at critical problems; the emergency bell goes and everybody runs and generally mills around shouting until the crisis is resolved. Critical problems require a command response from an decisive, authoritative figure. Senior midwives are judged by their command abilities and technical competence in a crisis. “Good in an emergency” is the ultimate accolade; “flakey” and “not robust” the ultimate put-downs.
 
Grumpy Midwife reckons that a busy labour ward probably has just one or two genuinely critical problems a day – and lots and lots of tame ones. She thinks therein lies the issue of bullying: such is our love affair with crisis that every problem is treated as critical and handled thus; brusquely, briskly, with little time for civility, compassion, or questioning of self or others. 
 
The result is a pervading sense of crisis, a nagging undertone of anxiety, vague unease – or downright misery if you’re one of the less “robust”. All rather exhausting. And unnecessary.
 
 

Geeky Midwife

Grumpy Midwife has been scanning the journals. She sees a theme developing. GM likes themes.

 
First there was an article was in The Times (July 30): “Geeks in jeans are the Treasury’s new heroes”Whitehall is bringing technology back in-house and employing youngsters as young as 17 to help government catch up with the internet age. No suits here; it all “hoodies typing furiously at Apple Macs”. Grumpy Midwife wonders if that should be “on” Apple Macs, but decided to defer to The Times subs. She does, however, particularly like this rather pleasing sentence: “Sir Humphrey Appleby would be horrified but the hero in Holborn is the Apple founder Steve Jobs”. GM likes a bit of alliteration.
 
Then a piece appeared in The Health Service Journal (July 17): “All NHS boards should have members under 30”. Why? Because this is the so-called Generation Y that has grown up with digital technology; instantaneous, inclusive, and without hierarchical boundaries. This generation has a “just do it” spirit that doesn’t wait around for committees and working groups. Grumpy Midwife immediately took issue with the notion that only the under 30s can have this energy and enthusiasm (and tweeted thus when she first read the article) but appreciates the basic premise.
 
The theme of impatience and frustration was echoed in two letters to the BMJ (July 30) from self-confessed “geeky doctors” fed up of top-down solutions, begging to be let loose with the data and devise their own systems – but stopped at every turn by entrenched and timid IT departments and the “triumvirate of information governance, confidentiality and clinical safety”. They should have joined the NHS Hack Day reported earlier in the HSJ (June 18); a gathering of 120 “geeks that love the NHS” who got together to devise “disruptive digital health technologies”. 
 
And then, finally and depressingly, one of those “10 Steps” features; this one in the HSJ (June 17) urging women interviewees to “never, ever” start with an apology for cack-handedness with IT equipment. In similar vein, Grumpy Midwife would like to remind midwives of a certain age to never, ever express doubt when handling electronic devices in front of patients. How (she asks them rhetorically) would you feel if you got on a plane and the pilot complained that he hadn’t flown one of these for ages / didn’t normally work here / hates technology?
 
Meanwhile, Grumpy Midwife seriously fancies the idea of spending her days typing furiously on or at her MacBook Air.
 

Partograms and Partographs

Grumpy Midwife’s break for freedom has taken a leap forward: she has joined the Liverpool School of Tropical Medicine (Maternal and Newborn Health Unit) slash RCOG project to deliver training in obstetric emergencies in developing countries. She’s got fond memories of West Africa in the mid 80s: the smell of baked earth and woodsmoke, drums in the night, big, starry skies, free love, lashings of Star beer. This time it’s only for 2-3 weeks a year. Which is probably just as well.
 
Her orientation session earlier this month included a session on teaching the use of the partogram or (more correctly in this context) the partograph. This session was memorable for two reasons. Firstly, the startling discovery that obstetricians are totally rubbish at filling in any kind of chart and second, the realisation that the modern partogram is an oedematous travesty of the original tool developed by the WHO. 
 
The bespoke partogram in the labour notes where Grumpy Midwife works is a busy A3 chart in tasteful shades of blue. The core section where she plots cervical dilatation and passage of the baby through the pelvis against time is squeezed between a complex maternal observations area and a bewildering grid of lines and boxes devoted to gathering information on maternal position, pain relief, epidurals, birth partners, birth balls and other comfort measures (water and music being the defaults). 
 
By contrast the original partograph, as used sporadically across the developing world, is a sparse document slashed through with two parallel lines: Alert and Action. The first assessment of cervical dilatation is plotted with a cross on the Alert line; progress thereafter should progress up this line at a rate of one centimetre per hour. Any deviation skews the graph towards the Action line four hours to the right which, once reached should – in theory and provided the roads aren’t flooded or mined and the husband agrees and there’s money for fuel – prompt carers to transfer the labouring woman to the nearest health post or hospital.  
 
One of the bright young things on GM’s orientation session asked why the partograph takes no account of NICE’s 2007 dictate that cervical dilatation of half a centimetre per hour is acceptable. The trainer patiently explained that in most parts of the world, obstetricians tend to be 50 miles away rather than slumped in the coffee room playing on their smartphones. 
 
Grumpy Midwife’s biggest fear is not ticking the right box; for most women in the world the fear is obstructed labour, ruptured uterus, sepsis, vesicovaginal fistula, and death.

Life Skills

Grumpy Midwife is trying to find a way out. A way out of the NHS after over three decades of intermittent but faithful service. As she passes the midpoint in her life (she plans to live to be 110), she has woken up to the fact that there is a whole new world out there; a world of lunch breaks and creativity and good coffee and getting things done in less than 12 months without policies and committees.

So, with the help of an old friend and a couple of glasses of really very nice Rioja, GM started to think about transferable skills: resuscitating infants, mending photocopiers, extreme bladder control, black humour. (Actually, delete black humour. It doesn’t transfer. People get upset.) But then, as the old friend talked about her life on the outside, it dawned on GM that, like grass yellowing under a bucket on the lawn, the NHS has actually stunted three crucial life skills.

Firstly, Grumpy Midwife is incapable of bull-shitting. If it’s not evidence-based, peer-reviewed or enshrined in policy, GM feels very nervous. Her colleagues are similarly afflicted. There is no place in NHS maternity care for anecdote, gut instinct, or blue sky thinking. “What does the guideline say?” is a phrase guaranteed to kill the liveliest of professional discussions; second only in deadliness to “But NICE says…” (This is not to say that everything that GM says is totally correct. She has long ago perfected the art of making up journal references and ball-parking statistics. Luckily, her hospital has no WiFi so facts cannot be readily checked by others in the few moments available before the next phone call or emergency bell.)

Secondly, Grumpy Midwife cannot believe she is actually good at anything. Completing the ‘skills and expertise’ section of her Linkedin profile was a slow and painful process. Thirty years of certificates and competency documents has eradicated any ability to self-congratulate. The fact that so-called competency documents merely record a frozen moment in time and MS Publisher can churn out pretty certificates means nothing to the NHS. Neither does the reality that most professionals are many times more self-critical than educational box-tickers. If its not assessed, appraised, supervised, and signed-off then it didn’t happen. And you’re certainly not good at it.

Thirdly, Grumpy Midwife has no appreciation or understanding of commerce. She’s delighted with the 12 new CTG monitors that recently arrived on the labour ward but can’t be doing with all this budget and business plan stuff. Like all of her NHS generation, she is disgustingly spoil – and a terrible snob. The best people make their living by serving others: delivering babies, defending the realm, putting out fires, passing laws. Making stuff and selling it is, well, rather sordid by comparison. A few years ago, in desperation, GM applied for a job at Waitrose; they saw through her immediately. She suspects that she is a dying breed in this aspect, since the younger midwives seem only too happy to flirt with reps and eat their doughnuts.

Grumpy Midwife is feeling a bit deflated.