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.

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.