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.

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.