Work? who needs it.
Let me tell you about how our Midwifery Group Practice is supposed to work (most of the following is taken from an article we did for 'Practising Midwife' lat year, on how we try to keep things normal):
I work in the National Health Service. There are 6 of us in the MGP (4.8 whole time equivalent) and I am the only full time (37 1/2 hour week) midwife. We cover a predominantly rural area in Devon. Our home birth rate for last year was 18%, our normal birth rate is around 60% (And by 'normal' I mean unassisted vaginal birth - 'abnormal' would include Caesarean Sections and Instrumental Deliveries).
Our Trust has a model of care which embraces “Changing Childbirth” in its totality. We have the ability to provide midwife led care throughout pregnancy and birth, from first booking contact and referral to a midwife led antenatal clinic, through to 28 days post partum, leaving our obstetric teams to concentrate on higher risk women.
We have excellent support from our managers, supervisors, and obstetric teams, where two-way communication is facilitated. We may refer women to an obstetric team for second opinion and they are referred back when assessed as ‘low risk’. General Practitioner support has taken time, but we now have their confidence, and it has been agreed that they do not have intrapartum care involvement unless they wish to.
Policies and Guidelines are evidence based and have midwifery input. From the outset of pregnancy we emphasise the MGP philosophy and aim to build the confidence of the woman and her family in the normality (or otherwise) of her pregnancy. Risk assessment is ongoing and discussed openly and honestly with women enabling them to make informed choices. Any request which falls outside hospital guidelines (e.g. home VBAC) is not dismissed out of hand, but involves the whole team: woman and family, managers, supervisors and obstetric team agreeing and documenting an action plan.
Although the group have very different personalities we share the same philosophy of care. We are confident, autonomous practitioners with a sound belief in women’s ability to give birth and put the safety and welfare of their baby first. We are confident at homebirth, water birth and suturing. Most of us have taken the 'Neonatal Life Support' course. We do not take the hospital mentality into the home but vice versa. This is helped by labour rooms at the Maternity Unit having the bed pushed aside, shower rooms ensuite and mats, beanbags, stools and balls available. We aim to combine the Art and Science of Midwifery by watching and listening during labour, being patient and not interfering unless action is required.
Home intrapartum visits are offered to all women to encourage them to keep their options open. They can change their minds regarding place of birth depending on risk assessment at time of labour. If intrapartum transfer is warranted, we follow by car or accompany in the ambulance, as appropriate, then continue care in hospital.
We carry pagers and mobile phones to facilitate contact with women and each other. The Delivery Suite Coordinator will provide professional support and coordinates the provision of a second midwife once requested for home birth. Equipment for home birth is serviced regularly and we know how to use it. Paramedic support is readily available. We do not feel alone.
We support the use of simple ways of enabling women to cope in labour – distraction, massage, water, heat, cold – rather than opting straight for pharmaceutical or epidurals. Caring and touch go a long way. However, we also care for women who want ‘high tech’, epidural hospital birth and still aim for vaginal birth.
All this sounds ideal. Meeting the needs of women means we have to be flexible and have supportive families and friends. We write our own rota and support one another to be able to attend a school play or similar. Long-term sickness and staff shortages in the unit or other teams may often require us to cover other areas, hence our women may receive care from other teams too. Pay back time can often be difficult to achieve, therefore the system then relies on good will to keep going.
MGP does seem to work most of the time and thereby facilitates normal birth. Despite covering a large area, we have raised the home birth rate, and maintained good mortality and morbidity statistics.
This is us on at our post Christmas dinner... Don't we look happy? (I'd come straight from work so I hadn't dressed up).
HOWEVER the unit is sooo short at the moment, we're being called in to help willynilly, which means our work in the community is being neglected and piling up.
Last Saturday I worked all day 'till 4pm doing postnatal visits, prebirth antenatal checks etc. Then I get asked to come in to the unit to transfer a client to a hospital 35 miles away. I get in to the Unit and while I'm waiting for the ambulance crew to arrive I acquaint myself with the woman I'm escorting. She was being transferred for very sad reasons which I won't go into on this public forum but was not likely to give birth enroute so I didn't take any of my equipment apart from my doppler.
On the way, the paramedic in the front of the ambulance sticks his head through the hatch and says "There's a woman in advanced labour not 5 minutes away and we're the closest crew - do you mind assisting?". What could I say? So we divert to a farm in the middle of nowhere - and I leave the woman I'm travelling with in the ambulance reading a mag., and venture into the house with the crew. There is labouring woman, obviously pushing, head in dogbasket, kneeling on cold quarry tiles in the kitchen. I check: yes, this baby is most certainly on its way! We try and make woman slightly more comfortable (yoga mat to kneel on) and fetch warm towels. The ambulance crew have a very basic maternity delivery pack - no syntometrine. The baby arrives not 5 minutes later - a healthy boy! This lovely baby, no worse for the experience, is placed skin to skin on mum and draped in towels while we wait for the umbilical cord to stop pulsing. Mum is rhesus negative and the ambulance crew don't carry blood bottles (thinks to self, next time I bring ALL my gear regardless of wether woman is likely to deliver or not) - I take a syringe of blood from the cord and hope it'll do. Mother delivers placenta and membranes easily and we help her to sofa in front of roaring fire, looking much more comfortable and very very happy and the baby latched on to her breast and suckling well.
I write down times and history of this labour in notes as best I can (a woman can have her baby in 5 minutes but it still takes over an hour and a half to do all the paperwork) while the ambulance crew check mum's routine observations of BP and pulse etc - and then hang around long enough to hand over care to the midwife coming from the Unit (about 20 minutes later).
We all then carry on our way - and what the woman in the ambulance thought I don't know but I gave her a big hug. By the time I get a taxi back to the Maternity Unit in it's now 11pm and I'm starving and eager to get home. But NO - there are no more midwives available (everybody and the world is having their baby tonight) and a woman who has previously had quick births is contracting and wanting a home birth. Plan, I go out to review her and the Delivery Suite coordinator will ask another midwife to relieve me as soon as possible. What can I say? So off I goes (in the opposite direction to home) to see this woman. She is certainly in labour so I set up all my equipment just in case (no more surprises, thankyou!) and wait to be relieved. The Dad to be takes pity on me and gets me a cheese and pickle roll (mmm). I can see the mother is progressing well, and, after a couple of hours I phone unit and ask where my relief midwife is - she has been delayed. I tell them that this baby will have arrived in half an hour so they'd better get someone out to me quick! Sure enough, baby arrives - lovely normal birth of another boy, all is well. Relief midwife arrives just in time to see the placenta into the world. By the time we finish notes and I get home it is 4am. Sunday I recuperate.
I have Mondays off to do my art class - the midwife on our patch is called in to Unit to help as they are still incredibly busy and staff are going off sick (surprise). Midwife doesn't get home until 8pm and people who should have had visits are missed and the answerphone in the office is ignored. We spend rest of week catching up and I don't finish earlier than 7pm on any day. I have MUG tattooed across my forehead.
On Thursday I get a parking ticket. The job isn't always like this, otherwise I'd resign tomorrow. Thank goodness I'm off for a couple of days now. This is why I haven't updated my blog.