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 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.