It’s a morning shift, the ward is a long, large L-shape with six bays (four beds in each) seven single rooms and two soundproofed bereavement rooms.
Looking in from the entrance there’s a hive of activity. Cleaners mop, wardies push beds, partners look for loved ones, midwives wheel babies in cots, trolleys jostle for space … blood collectors, meal delivery, laundry and obstetricians with their piles of precariously teetering charts.
Voluminous blue curtains surround each bed giving privacy but it’s noisy with the chorus of call bells, IV pumps, women in early labour, babies crying, private conversations, staff chit-chatting.
Behind the curtains are the women, some with pregnancy complications … pre-eclampsia, premature labour, bleeding or maybe a complex medical condition … others having labour induced … the rest already with babe in arms, 38% delivered surgically by Caesarean.
Healthy women with low-risk pregnancies birth in this huge hospital alongside those needing high-level complex care. Small cozy maternity hospitals deemed not financially viable closed years ago. Were women consulted? Doubt it.
The team is huge, obstetricians, physios, social workers, pharmacists, paediatricians and 24/7 midwives, the constant for the women.
The main go-to person, the team leader midwife is notified of every adverse event, backs midwives on the floor, supports junior staff, coordinates medical emergencies, is interrupted constantly by the ever-ringing phone.
Bed managers need beds, staff call in sick, birth suite is calling, theatre is calling. It’s never ending.
A support midwife spends most of her time managing discharges, there’s always a shortage of beds, no flexibility for women who would love to stay just one more night to help boost parenting confidence, or who lack a good home support network.
This shift is a typical scenario, eight women, seven babies (fifteen humans) cared for entirely by two midwives. The UK’s maternity care assistant role doesn’t exist in QLD Australia.
Babies never leave mums side (where they should be) but in this medicalised maternity system with it’s high intervention rates they often need extra care, their mothers extra support.
Yet, the hospital receives NO funding for the babies existence, no extra staff for the extra care.
The ‘mucousy’ baby at risk of choking. The late preterm struggling to feed. The jaundiced needing phototherapy. The ‘work of breathing’ after caesarean. The one on IV antibiotics, tiny cannula insitu.
Emotional, sleep-deprived, shell-shocked women, especially first-time mothers benefit enormously from skilled midwifery time and care (obvious! No?) The system appears not to value this. Not at all.
Nor does it seem to value empathy or kindness. Speed, efficiency, checklists, enumerable amounts of paperwork take precedence demonstrating to the organisation that ‘care’ has been given, midwives, ‘with paperwork’ rather than ‘with woman.’
Working in this system the midwives have no choice but to become multi-tasking pros adept at giving bursts of attentive care trying to make everything seem less conveyor belt for the women, less tick, tick, tick, NEXT. Always in predictive alert mode too, anything can happen.
Many work on rotation between here, birth suite and antenatal clinic, some invaluable core staff, others casual, many early in their career.
Many frustrated by the limitations and constraints of the system keep turning up anyway, doing their best for the women and babies.
0645 – Bedside handover, midwives squeeze in behind the curtains or peek through, eyeballing each woman and baby, introductions made, smiles, quick chats about the birth, baby’s feeding, plans for the day, any issues. Emotional states, pain levels noted too. An important few minutes.
A quick hour-by-hour plan is written … a necessary ‘taskification’ …. observations, medications, priorities, ensuring vulnerable babies are fed, who is for discharge?
The emotional support women need is difficult to quantify, doesn’t slot into a neatly written plan and of course complications happen on a ward like this.
All. The. Time.
On paper this professional care looks doable, in reality it is not, the allocation of two midwives barely adequate, becoming apparent as they work.
(The team- leader is quickly notified, does her best to help and find extra staff)
Three women are of immediate concern, need immediate 1:1 care. A competing priority situation.
The first a readmission with mastitis and possible abscess (can you imagine?) tearful, sleep deprived, in utter agony, breast hard and tomato red, temperature high, attached to an IV antibiotic drip, nil-by-mouth, theatre is a possibility.
The midwives manage her pain, help pump the affected breast, hand baby over to feed from the other, communicate ongoing symptoms to obstetricians, blood cultures are taken.
The second has unstable pre-eclampsia, a dangerously high BP and headache, an acute concern. Obstetricians consulted, more anti- hypertensive drugs given, she’ll need close monitoring.
She’s also wailing, loudly, uncontrollably. It’s all too much, her baby is not latching. she didn’t plan ANY of this, is desperate to get home.
Much time is spent giving emotional support, facilitating skin-to-skin, helping her syringe feed baby till her husband arrives.
The third woman birthed by emergency caesarean only a few hours ago after a long labour, exhausted and sleep-deprived, had endured management of a haemorrhage just as she was admitted to the ward. Bleeding has stopped but she’s nauseous, dizzy and in pain, still needing 1:1 attention ( a return to birth-suite request by the midwives is denied, they’ll have to manage)
Confident hands – on husband helps her feed, changes nappies, keeps bub snuggled to his chest in between (thank god)
The five others .…
A teenager chatting loudly to friends on speaker phone, unaware of her room-mates need for sleep. Proud of herself, breastfeeding with ease, looking adoringly at her bub, wanting to leave asap but domestic violence in her home needs investigation. Will she and baby be safe?
They go missing at one point, a search party is commissioned, she’s found wandering with baby in the newsagents downstairs, couldn’t understand the fuss? Why shouldn’t she?
Mum of 36 week jaundiced baby waits for blood results, keen to leave the confines of the blue curtained bed, her noisy neighbour, the chaos of the ward.
Another having labour induced, walks up and down increasingly anxious, tired waiting for the elusive bed on birth-suite to continue the process.
Frequent heat-packs are supplied, she visibly relaxes when the midwives sit with her, listen to baby, have a chat, keep her informed.
Woman with twins is fine, a second time mum, both babies just above the 2kg’s now, feeding beautifully , both awaiting blood results, may have to stay a further night.
And the last one, a third – time mum with healthy babe, feeding well waits patiently for the paediatrician newborn exam, for reassurance that her precious bub doesn’t have a heart murmur or dislocatable hips.
One paed, ten babies means she’ll wait a while. The hours tick by slowly.
Once immediate concerns are dealt with the midwives carry on, don’t stop, hovering as parents learn the intricacies of newborn care, watching them figure it out for themselves, reassuring, listening, trying to respond … in the limited time they have … to what each individual women needs, maybe clarifying information given on ward rounds, often not retained, discovering hidden issues.
Documenting all care in the innumerable pathways (no box for “did this woman feel safe?”) care plans, early warning observation tools, education lists, progress notes and online discharge summaries.
They aim, by end of shift, for all women/baby dyads to feel supported, well cared for, physically and emotionally safe and functioning optimally but sometimes (often?) inadvertent harm is done despite their best efforts.
They feel the harm too, the term ‘moral injury’ sums it up perfectly, knowing the care women need and not being able to give it can cause huge distress, in the moment or by tiny ongoing increments.
Our current hospital maternity systems are deeply flawed, (reported birth trauma rates on the rise) relying on altruistic, hard-working, non-complaining staff to keep them functioning.
But midwives are not superhuman, don’t have endless emotional or physical reserves, the angel/hero label is problematic.
They don’t want fluffy labels , they want adequate staffing, resources and respect for their role, to be able to come to work and do a good job. Sometimes that is lacking.
They learn that complaining to colleagues or family or the unit manager, or worse blaming themselves for the system inadequacies, won’t change anything.
They submit workload concern forms, explain in detail how the system has failed the women, babies and midwives that shift.
Evidence must be gathered.
Midwives deserve better, they need to speak up.
Women deserve better, they need to demand more.
Lindsey Crossan Registered Midwife, Registered Nurse