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What its like to be a midwife in the UK – tales from a bootstrapping entrepreneur

Life as for an bootstrapping entrepreneur can quite often mean there is another job to hold down. On Quora a reader posted the question What is it like to be a midwife? And this being my ‘other’ job, it was good to answer the question and share with you what I do by means of bootstrapping in-between chasing my entrepreneurial passion.

Originally posted as an answer on Quora

bootstrapping entrepreneur Darcey Croft

7 and a half minutes into the New Year

This is an average day, in my experience, of a UK midwife working in the delivery suite of a busy London Hospital serving a geographical area of mothers with high risk medical obstetric conditions and social issues. 

There are many things that we do that I haven’t covered but it gives you a flavour of our working day. We work a minimum of 12.5 hour shifts, 0800 – 2030 and night shifts 2000-0830. The post is written in the same chronological fashion as our documentation. 

0800: Shift starts with a team muster of the day shift. Here a board is wheeled in to our staff room with the details of who is in each of our 11 delivery rooms, our recovery unit, the high dependancy unit and who is in any of the two theatres (operating room). The night Registrar/Midwife Coordinator brief us with details and information we will need to seamlessy change care. We each are assigned to a woman, a unit or theatre duties as a cesarean section midwife.

0820: Go to room, introduce myself to woman and birth partner. Take handover in the room from night midwife, using a SBAR technique. This is a rapid way to assess a picture of what is going on.

S. is for Situation, here I note the mothers parity (how many times she has given birth) her due date and gestation, how she is in labour, is it spontaneous or are we inducing it and the reasons why.

B. is for background, this is a review of medical, obstetric and social history noting any events or risks to to the current situation. This could be anything from a large BMI, diabetes, asthma, cardiac problems, previous traumatic birth, mental health issues, domestic violence or language barriers.

A. is for assessment, here I detail her blood results, her blood group, serology, infections, immunities,  iron, white cell and platelet counts. I ask if we have a valid blood transfusion group and screen result. If we need to request blood or have to go to theatre this is important. I assess when the labour started, if her membranes have ruptured and how long the waters have gone, were they clear, bloodstained or discoloured with meconium. How many contractions she is having, how painful they are and how long they last. If she has been examined what position the baby is in, how dilated her cervix is. What analgesia for pain is she having or would like. If there are any factors in her urine that could affect the labour, keytones, protein etc. Her observations, blood pressure, temperature, saturations, and pulse. If she is on continuous monitoring, what the base rate of the fetal heart is, has there been decelerations, accelerations and is it a reassuring trace. Her mental and emotional state, is she coping well, who is supporting her and are they coping well.

R. is for recommendation. Here I note a plan of action. Following our labour protocols. This might be a vaginal examination to assess progress, canulation for IV access, due IV antibiotics if she has GBS positive status, she might be requesting an epidural or if we are inducing her I might need to ARM her (artificially rupturing her membranes to hasten progress) or put up a hormone drip to regulate and get her contractions going.

0845: I spend some time chatting to the mother getting to know her and her partner. I tell them about myself and find the common ground between us. It is important to establish trust early, as her confidence in my abilities will affect her emotions and postively impact her experience. While we are talking I take a fresh set of maternal observations and look at the CTG (Fetal heart and uterine contraction monitor), it is not picking up contractions and the fetal heart is faint so I reposition the toco’s and belts to find stronger signals. Then I arrange the room,  dimming the lights and take away the clinical feel from the room as much as I can. check the resuscitaire is working and has all the tools I need in an emergency.

0900: Update the partogram, a sheet detailing all aspects of labour. Record an assessment of the CTG and document observations in main notes. On this day my mother is being induced she already has an IV drip running and has an epidural insitu for pain relief. I document the dose and rate and ask how the epidural is working as she is showing signs of pain. She requests an epidural top up. I note that she will need to catheterised as her as her legs are feeling heavy, she cannot walk to the toilet and it has been four hours since her last void.

0910: Knock on door, Consultant, Registrar and Coordinator are waiting for situation brief. Update them and introduce to parents. Make note of any action plans from consultant.

0915: Update partogram. Leave room, collect keys for controlled drug cabinet. Find another midwife to check drugs.

0925: Return and administer epidural top up. Measure blood pressure every five minutes for the next twenty minutes. Listen to CTG maintaining constant beat.

0930: Update partogram. Increase dose on hormone drip. Document. Keep an eye for changes in contractions and fetal heart rate. Set up to catheterise.

Emergency alarm goes off outside the room. Check my mum is safe to leave. Run to room four doors down from mine. I am the first to arrive, the midwife tells me there is a fetal bradycardia, the heart rate has been down for 3minutes, begin to assist the woman into a new position. The room fills with people available to assist. The coordinator tells me to go back to my room.

0935: Catheterise my mother and empty her bladder. Document in main notes.

0945: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions.

1000: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions. Fill out fluid balance chart. Record detailed assessment of the CTG and document maternal observations in main notes. Note draining urine is concentrated and encourage mother to drink water. Increase drip rate on bag of hydrating fluids. Document in main notes. Chat to parents. Offer Dad a cup of tea (Mum is on water only).

1015: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions.

1020: Request from mum for epidural top up, she is feeling painful contractions. Leave room, collect keys for controlled drug cabinet. Find another midwife to check drugs.

1030: Return, check CTG and administer epidural top up. Measure blood pressure every five minutes for the next twenty minutes. Document in main notes. Assess CTG and update partogram with fetal heart rate, hormone dose and contractions.

Progress assessment due, discuss with mother and gain consent. Palpate position of foetus, perform vaginal examination assessing position of fetal head and dilatation of cervix. She is fully dilated. Explain to mother that we will wait one hour for the fetal head to descend and get in optimal position and then we will start pushing. Document in main notes, partogram, leave room inform coordinator and update the board.

1045: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions.

1053: Emergency alarms sounds outside room, leave room to attend. A mother  in  the room opposite has given birth and is bleeding heavily, I am requested to put a Massive Obstetric Haemorrhage emergency call out and get the emergency drugs. Make call and see someone else return with the postpartum haemorrhage trolley and drugs. Consultant now in room with many others giving care, leave to attend to my mother.

1100: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions. Record detailed assessment of the CTG and document maternal observations in main notes. Mother feeling pain and requesting epidural top up. Explain to mother that we will commence pushing soon and I’d like her to be able to feel when she has a contraction so she can push effectively.

1115: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions. Mother is not happy about pain and we discuss alternative coping methods.

1120: Arrange the things I will need for a delivery, leave room and collect drugs for a active third stage delivery of the placenta and vitamin K to give the baby.

1128: Change the delivery bed into a chair like arrangement positioning mother to use gravity to assist. Demonstrate when and how she should push. Recommend Dad into position and suggests ways that he can support her. Brief them both on what I will be doing and show Dad the buzzer should I require an extra pair of hands he is to press. Explain that although I am not expecting to use it, if I should ask him to pull the red lever it is because I require immediate assistance and that a lot of people will turn up quickly, probably filling up the room and there might be a lot of activity. I reassure them that this is unlikely to happen, but it can appear shocking to those who aren’t expecting it however it is normal procedure to ensure the safety of mother and baby. Research shows that especially Dads, powerless to help in emergency events can suffer post traumatic stress after witnessing these events, but if he knows what is happening he is better prepared and included.

1129: Feel a little fatigued and thirsty, make a mental note to drink water when I leave the room next.

1130: Assess CTG and update partogram with fetal heart rate, hormone dose and contractions.  Document that pushing is to commence. Wait for contraction.

1135: Contractions appear to have stage fright. Wait for contractions.

1138: Contraction felt, pushing encouraged and directed, due to the epidural interfering with the sensation normally felt. Note fetal heart after contraction and how baby is coping with the pushing.

1200: Mother is tiring and feels like she can’t do it. Use motivational techniques to encourage her to keep going.

1220: Baby is tiring and decelerations of heart rate are concerning me during contractions, they recover well each time but they have my attention. The baby’s head has descended but is still higher than I would like. Dad is being very supportive, but looks particularly anxious, I distract him and ask him to give her a sip of water. I note the time and motivate mum with praise and encouragement.

1230: The mother has been pushing with everything she has for the last hour, this combined with little sleep for the last two days on the antenatal ward and very little food means she is exhausted. I can see her face is drawn and there is nothing left in reserve, she looks at me and weakly says ‘I really can’t go on, I need you to help me get baby out’. This time, I can see she has passed a mental point and quit, she has rung the proverbial bell. There is a difference between someone who thinks they have quit and someone who has absolutely quit and it is very clear to see the difference.

At this point I am assessing the medical factors, the signs the baby is not coping as well as I would like, the mother is exhausted, her last baby was a very big baby and she had had a previous traumatic birth experience, this baby head is still higher than it should be, we have been pushing with an inducing hormone for an hour and we still need a few big pushes to get baby out.

I make eye contact with her, smile and tell her that I will get the doctor and he may decide to put a little cap on baby’s head and help her deliver. She looks relieved and I fetch the doctor.

1240: The Doctor reviews and decides because of the sitution and the last big baby to deliver in theatre, he will try an instrumental delivery but there is a strong chance of a c/section.  I get Dad scrubs to wear and prepare mum for theatre and give her pre-meds in case she needs general anaesthesia.

1250: We are in theatre, I assist her onto the theatre bed, and attach the CTG. While the anaesthetist is topping up her epidural I check and prewarm the resuscitaire. Go through the theatre checklist and lay out my theatre garb should I need to scrub in.

1300: The consultant has put a suction cap on baby head and with each contraction he assists the maternal push. I bleep the neonatologist and request their presence. I notice Dad looks faint.I find a chair and put him next to his wife.

1310: A big baby girl is born with a strong lusty cry, the consultant delivers her onto mum and while he clamps and cuts the cord I dry the baby with a towel and pass her up to mum for a quick kiss and take her over to the resucitaire and waiting neonatologist, beckoning Dad over at the same time. He has tears of relief and joy, I feel myself welling up too.

The Doctor has left a long cord, I reclamp it and Dad cuts the cord to a more appropriate length. We weigh her, a whopping 4.5 kilos and I give the baby a small injection of vitamin K, handwrite baby labels, check details with parents and put then on baby. Take baby over to meet mum and wrap them both skin to skin to promote bonding, breastfeeding and maintaining baby’s temperature.

1330: I check the placenta is complete, the membranes are not ragged and the umbilical cord has three vessels and document the birth details in the main notes.

1340: Assist her into recovery unit bed and transfer to recovery unit.

1345: Assist mum with first breastfeed. Handover to recovery unit midwife, grateful to be able to sit for a minute while registering the birth on the computer.

1400: Complete birth registry, print baby labels swop the handwritten ones with them. Mum and Dad are both very happy, they tell me it was an amazing birth experience compared to their first time and thank me over and over for helping them. This gesture makes my day and it is what I aim to achieve each time, no matter what setting or situation we find ourselves in.

Evergreen business, bootstrapping entrepreneur

1420: Go back to theatre, clean and restock resuscitaire.

1430: Request from coordinator to go to Postnatal ward and give baby vaccinations as they have no trained midwives on today on the ward able to do this.

1700: After vaccinating eleven babies against tuberculosis I return to delivery suite and the coordinator gives me a woman in triage who is 8cm dilated, a first time mum, not coping well with the pain and requesting epidural. Mention that I am feeling faint and could use a break, the coordinator tells me she will try to find someone to relieve me but she is short of midwives at the moment. I go to the triage unit and take handover from Triage midwife and document SBAR

1705: On my way to room call anaesthetist to arrange an epidural to be sited. Informed that anaesthetist is in theatre and not available. Enter room introduce myself and reassure that anaesthetist will be here as soon as possible. In the meantime we will use other coping methods.

1710: Listen into fetal heart every five minutes using a handheld device. Record on partogram. Follow labour protocols to continually assess maternal/fetal observations, deciding and taking action if there is any deviation from normal.

1720: Have mother mobilising in room, using birth ball. She is very distressed with pain and focusing on her need for an epidural. Use NLP techinques to distract her from the pain. Dad begins to get frustrated with the no-show of anaesthetist. I explain they are in an emergency and will be with us as soon as they can. Use NLP techniques on Dad to keep him calm and show him ways he can help mum.

1800: Mother is extremely distressed, Dad is working with me now and now we feel like a team. He uses distraction techniques and I go to find an anaesthetist. They are both in theatres, I go in and explain the situation he tells me he should be there in 15 mins. I tell mother he will be there in 25mins.

1830: No anaesthetist, Dad is pleading with me, mum is in tears. I go to theatre again. He assures me five more minutes. On the way back the emergency bell goes again, I run to room but thankfully a false alarm, I switch off the alarm and go back to my room.

1900: Mum’s demeanour has changed, she is quieter and coping better I wonder if she is progressing faster than expected. She begins to vomit and I do my best impression of an NFL football player and catch it with a bowl just in time.

1910: She makes involuntary grunting sounds and tells me she thinks the baby is coming. I quickly assess her and see that baby is indeed coming. I ring the bell and request someone to fetch a drug to limit risk of bleeding with the placenta delivery.

I grab sterile gloves and manage to put one on as the head is crowning, I support the perineum with my gloved hand and in-between contractions manage to get the other one on, listen to the fetal heart – baby is doing well, Im telling her to not push anymore and wait for her to stretch. Then I ask her to blow out candles, little puffs. The baby’s head delivers and we wait for the next contraction. I tell her to give me a really big push and with a leg soaking gush of amniotic fluid I guide the baby out onto her abdomen. I grab a towel and dry baby, the baby is slightly shocked with the quick birth but the cord is still pulsing providing oxygen to baby and there is good colour and tone, with some stimulation finally he lets out a big cry. I take a much needed deep breath as well. I ask Dad to tell mum what they have, he looks like its the most difficult question he’s ever been asked and unconfidently tells her its a boy.

I cover mum and baby with a warm dry towel and take a small moment to see their joy. This has to be my most favourite part of the job watching parents meet their newborn and bond as a family. I saviour the moment then get back on with the job. The cord has stopped pulsing so I clamp and offer Dad to cut, he doesn’t want to so I cut the cord and baby is free.

The placenta delivers quickly and I assess to see if there are any tears to mum. She has a small tear that will need only a few sutures.

1920: I prepare  a sterile area and lay out everything I need for suturing. Put mum into position, remember that I didnt get that drink of water and I feel a bit faint again. Take some deep breaths and my head clears. I suture the perinuem, clean and put mum into a comfortable position.

1935: I weigh and examine the baby and give vitamin K, return baby to mum and support first breastfeed.

1945: Begin my documentation.

2000: Register the birth, go to get baby labels. Make tea for parents on the way back.

2010: Put on baby labels and finish documentation. Encourage Mum to get up for a shower.  Tidy room and put fresh sheets on bed.

2015: Waiting for night staff. Emergency bell goes off. Run to room where mum is giving birth but the baby’s shoulders have become stuck. I lower the back of the bed flat and raise the mothers legs in to a position with another midwife to help free the shoulders, all emergency procedures are being utilised and this is a extremely dangerous event, the room is full of people mum and dad are in a state of shock and thankfully the baby delivers not long after and in good condition.

2030: Handover to night staff is complete. I go to the changing room and half way there remember to go back and get that glass of water.

2200 Home.

Darcey
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Darcey