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.

Chocolates mean nothing

Grumpy Midwife has been extraordinarily busy for the last three months; hence her silence. But she would like to take a few moments to share a recent Damascene conversion experience.

GM is of the generation that attended Sunday School and confirmation classes so she knows all about Saul travelling to Damascus in Syria (in more peaceful times, around 2000 years ago, give or take) and experiencing en route an event that so upset his life that he changed his name and stopped prosecuting Christians and starting preaching. According to an article in New Scientist (April 25, 2015), the bright light and thunderous noise (and temporary blindness) experienced by Saul/Paul may have been caused by a meteorite – which is really interesting but the means need not distract from the outcome.

No meteorites involved in Grumpy Midwife’s conversion – just a couple of conversations with a wise woman and a lightbulb moment so mundane (in retrospect) that it is almost embarrassing to devote calories or kilobytes to the sharing. But here goes.

Midwives must listen to women. And not just listen: midwives must embrace what women are saying. Which actually sounds terribly dated, doesn’t it? As dated as Changing Childbirth (1993) in fact.

As she types this, Grumpy Midwife can sense the protestations: “But we have Family and Friends! We have birth afterthoughts and birth reflections! And MSLCs and PAT and CQC and LWFs! And complaints and debriefs and cards and chocolates! Lots of chocolates!”

Okay, so we are asking (closed questions, tidy tick boxes) but we are only asking because we are told to do so, by Cameron, by the CQC, by our commissioners. And, yes, we do listen, but only to a select group of women – and (again) because we have to, because they have complained or we think they may complain. So we listen – but with arms folded and minds closed, composing our replies, defending our practice, limiting the damage.

Buying anything online nowadays – a book, a pair of knickers, a holiday – invites an onslaught of pop-up surveys, requests for feedback, suggestions to share the experience. Because sellers know that if we don’t like what we buy, or the experience of buying it, we will look elsewhere. Yet when it comes to having a baby (arguably an experience marginally more life-changing than a couple of cinema tickets), consumer engagement is an add-on, begrudgingly and half-heartedly requested, if we have time. Satisfaction and due gratitude are, arrogantly, assumed.

It’s as if the maternity services operate in a 50s time-warp, harking back to a generation of users grateful for the largess of a public health service. Amongst midwives there seems to linger the notion that we all work jolly hard and modern mums are jolly lucky, let me tell you, epidurals blah blah, nappies blah blah, in my day blah blah. Grumpy Midwife is aware that midwives are an ageing workforce but this is ridiculous. Get with it, ladies!

The context for GM’s personal conversion was a gentle debate over the involvement of lay reviewers in the auditing of statutory supervision of midwives. Many midwives (including GM pre-Damascus) are aggrieved by the concept of a lay reviewer listening to a handful of new mothers and then having the audacity to contribute to an official report on that service. Grumpy Midwife would like to charitably assume that this antipathy is reflective of a lack of understanding of the validity of qualitative research sampling techniques but, sadly, having witnessed the response of midwives (often very senior midwives) to proposals to engage with women, she knows this is not the case.

Chatting to new mums in Children’s Centres; setting up a Facebook page to gather opinions; shadowing women and partners through clinics; sitting on beds to listen to birth stories; asking mothers for feedback on their midwives for annual reviews. So simple, so cheap, so normal – but such suggestions are met in too many maternity units with apathy and arguments and (sometimes) downright antagonism.

Of what are we afraid? Releasing an unstoppable genie of ingratitude and discontent? Learning stuff about ourselves and our service we would rather not know? Opening the gate to complexity and change and real-life messiness?

Chocolates, incidentally, don’t mean a thing. Women give midwives chocolates for the same reason we tip mediocre service in restaurants; because we are nice, polite people, who want to be liked. And may make a return visit. Especially if there is nowhere else to go.

Supervision of Midwives: if we didn’t have it, would we invent it?

Grumpy Midwife has been meaning to write about supervision of midwives for a while now; in fact, ever since the Ombudsman’s report rattled teacups and got knickers in a collective knot back in December 2013.

It all dates back to the Midwives Act of 1902, designed to bring all the dirty, illiterate – but oddly effective – village midwives into the fold by making it illegal to practice midwifery without a certificate. And so the Central Midwives Board was born (later to morph into the ENB, the UKCC, and finally the NMC, all four of which – to her horror – GM remembers), and moves were made to standardise training, punish misdemeanours, and generally whip the profession into shape.

A system of supervision was established, administered by county councils and other civic bodies. The first supervisors were called inspectors and most were doctors – which is about as logical as asking vets to supervise dentists and probably contributed to the next 100 years of rivalry and ill-feeling (continued to this day, albeit generally masked by good manners on both sides and the liberal gifting of doughnuts by obstetricians).

The inspectors’ early duties included checking midwives washed their syringes, wore suitable dresses, and kept satisfactory case records. A century later, Grumpy Midwife and her fellow supervisors still rummage through community midwives’ bags looking for dog hairs and out-of-date ergometrine, obsess over uniforms, and are neurotic about record keeping.

Today’s supervisors are experienced midwives, chosen by a ballot of peers, prepared for the role by six months of post-graduate training, appointed not by NHS managers but by a parallel structure of Local Supervising Authorities. The stated purpose of statutory supervision remains much the same as in 1902: to protect women and babies by actively promoting safe standards of midwifery practice. The subtext is regulation of the profession on behalf of the NMC: annual, individual review of practice; checking evidence of professional updating; monitoring of medicines safety; intervention in difficult situations; investigation of errors and incidents; implementation of remedial action.

At best, Grumpy Midwife and her colleagues are respected and inspirational leaders of the profession: chosen for their wisdom, approachability, professionalism, and fair-mindedness; supporting midwives in ever-more complex practice situations, engaging with women in developing a responsive service, enabling exemplary standards of midwifery care.

At worse, supervisors are worn out by their own practice and the extra demands of supervision, mistrusted by midwives, misunderstood by risk managers, out of their depths with the forensic skills demanded by investigations, terrified by the prospect that decisions made and reports written now may be torn to pieces in the future by inquests and professional hearings.

So why do midwives need statutory supervision? And note that we are not talking here about clinical or educational supervision; mentoring,  coaching or buddying; empowering management – but a relationship mandated by law, determined by statute; an extra layer (comfort blanket or barbed wire, depending on your perspective) between modern professionals and their regulating body. What’s so different about midwives?

Yeah, midwives are autonomous practitioners – but so are doctors. Midwives have the potential to harm people in their care – but so do police officers. Midwives deal with difficult clients – but so do social workers. Midwives face increasingly complex clinical situations – but so do ITU nurses. Midwives are burdened with increasing expectations from the public – but so are teachers, heaven help them. Midwives can supply and administer drugs on their own authority – but so can chiropodists. And a handful of midwives work outside the NHS – but so do almost all dentists.

Grumpy Midwife is running out of arguments.

Perhaps it really is time for midwives to interface directly with the regulating body; to take personal responsibility for the nuts and bolts of practice; to be fully exposed to the wrath of managers and the distress of complainants; to develop skills of self-awareness and self-criticism; to find dynamic and demanding mentors; to inspire, nurture, and care for each other.

Perhaps it is time for the profession to grow up.

[Towler, J, Bramall, J (1986) Midwives in History and Society, London: Croom Helem]



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?

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.