From MIDWIFERY MATTERS, Issue No.107, Winter 2005
I HAD BEEN OUT OF MIDWIFERY For fifteen years prior to my return to practice
(RTP) course in November 2003. I had qualified in 1983, the first of the 18
month trainees, being already a nurse and health visitor. I worked for five
years, with short breaks to have my two eldest sons, at the same small midwifery
unit in the city where I live. I was already a 'radical midwife' and chose to
have my first son (and subsequently all five of my children) at home. This desire,
as I look back, was fueled more by a deep fear that if I was in hospital I would
end up asking for an epidural and then all the rest would follow, than any intuitive
notion of it just feeling that home was the right place to be. I managed to
weather, with reasonable equanimity, comments such as: "Are you mad?"
and "Surely as a midwife you should know better?" from everyone who
had an opinion. I was also inspired and reassured by both professional and personal
experiences of other colleagues and supported magnificently by a community team
which I cannot fault for one moment. I was also lucky enough to be taught self-hypnosis
for childbirth, free by a local GP who was interested in the subject.
Back to work
Even though I reduced my hours after my first two sons were born, I very soon
got a reputation for being 'into' natural birth. I was always the one at whom
Sister waved the long birth plans, when anyone came in who was vaguely assertive
about how they wanted labour to be. I taught hypnosis for childbirth to a few
friends and occasionally during that time just used it in labour when women
were not coping, with very good results. I enjoyed it all mostly but do remember
the usual gripes about seemingly unnecessary medical intervention and too much
paperwork. I left the unit in 1988, to go back to health visiting, mostly for
convenience with childcare and also for the fact that I could reduce my hours
and still have a pay rise! I did a course in hypnotherapy and a lot of personal
development, but I do remember feeling sad that I may never deliver a baby again.
I left health visiting in 1992, when it became apparent that I was not superwoman,
no matter how hard I tried, and could no longer juggle three young children
with the job, with any satisfaction in either area. During this time I did some
private hypnosis for childbirth classes and also got into analytical hypnotherapy.
Then I went on to have my fourth and fifth children, girls, both born at home
in birthing pools, supported again by magnificent community midwives. By then
I had made the decision to home educate them all, so for a long time I was sure
I would never return to work at all never mind to something so emotionally demanding
as midwifery.
Why Return?
To be perfectly honest it was mostly for money! I thought a lot about how I
could earn money and I kept coming back to this desire to be involved again
in the magic of childbirth and knowing I had skills I could still use, especially
in helping people relax and challenge deep-seated fears about birth.
I loved almost every minute of my return to practice. My placement was at a
huge consultant unit in the centre of the city, with approximately 7,000 births.
I was pretty impressed with how far we had (apparently) come since I last worked,
with evidence-based practice supporting almost all of my own intuitive beliefs
about labour. I was very impressed with the support network of supervisors who
were available for you to bring your personal and professional problems to,
to nip in the bud. I was equally delighted to see that home births were more
common, midwives were responsible for them in the community supported by their
Supervisor rather than as, 20 years ago, a reluctant GP who could and probably
would, veto it anyway. I felt there seemed to be huge moves in legislation to
support all the stuff that I was passionate about 20 years ago, when I was considered
an oddity. I also thought it was a good course. There were a few niggles but
I enjoyed being treated as an adult(!) even though I was learning. My opinions
seemed to be valued and respected and I felt I was bringing a wealth of experience,
not just from my professional life, to the course and hence into practice. I
felt valued and respected and I enjoyed being able to devise my own learning
experiences based on what I felt I needed. Some people complained about the
lack of structure but I loved it. I announced I needed to have more experience
of normal midwifery and I was placed in the appropriate place. I wanted to get
back into parent-craft and I arranged to sit in on classes and do some myself.
I was greeted with enthusiasm by many of my ex-colleagues, many now in senior
positions, who now work in the large unit since the closure of my old hospital.
I worked (and still do) in a very busy large consultant unit, with loads to
learn… and I mean mind boggling amounts which I still haven't got on top
of. However, during my RTP, I loved being in the thick of things (but not having
the responsibility), I loved labour ward and constantly asked to "take
a baby" or if I could observe and be involved. I loved the fact that we
had two birthing pools and they did get used. There was (and still is) a committed
group of midwives, who probably would not call themselves radical but were totally
committed to midwifery led care and developing it within the unit. I was impressed.
I was constantly allowed to get to know someone who was obviously going to deliver
normally so I could be involved in the delivery - I saw more normal deliveries
in the three months of my RTP than in all my time since reregistering. I rekindled
that deep respect of the birth process and my humble satisfaction in being allowed
to take part in this awesome miracle of birth. I was constantly filled with
joy that I was coming back into a profession where you get paid to be involved
in such a momentous and special moment in some family's life. Yes I absolutely
loved it all.
Crowning moments
There were two crowning moments during that time. The first was when I was working
on 'Midwifery Led Care' (MLC) and the midwife I was with had asked her woman,
a pri in early labour, if she minded a 'return to practice' midwife looking
after her. Unusually, she had said "Oh no, I don't want that." I was
a bit peeved, but reminded myself it was her experience and nothing personal
to me. Sue (not her real name) didn't want any intervention and later in the
shift the midwife looking after her had to leave her for half an hour for a
break, so Sue was persuaded to allow me in just to 'keep an eye on her'. She
was actually beginning to lose it a bit and despite feeling 'pushy' her cervix
was thick, loosely applied and only 5 cms. Sue moaned, "Oh I really, really
didn't want an epidural but… I can't stand this… Oh no, here it comes
again…" You know the sort of thing.
I decided there and then that I was going to teach her self hypnosis, so I just
gently offered to talk her through some breathing and she agreed and within
three contractions she had it sussed. "Down and down, down and down and
the more you relax the less you will feel of your contraction... no listen to
my voice and do exactly as I say… we are going down and down and down and
the deeper you go the less you will feel of your contraction…"
After she got the hang of it I suggested that her partner try to talk her through
it. By this time I could tell he was pretty impressed with this "return
to practice" person. He refused and said "No… no, you carry on,"
and she was gripping my hand and breathing between gritted teeth, with her eyes
closed, "Don't you leave me… no, you can't."
It was time to reduce her reliance on me and hand her back her control. It took
only about 20 minutes to get the two of them in tune with each other with him
supporting her self hypnosis, but she was a natural. By the end of the half
hour I had also talked to her about the possibility of using the pool. Sue said,
as her grip on my hand was becoming less desperate, "Oh yes I wondered
about the pool but no-one suggested it… is it free…. could I really…."
(She had been so overwhelmed by the pain that she hadn't been able to think
straight to ask for it.)
By the time her midwife came back from her break I am afraid I had intervened
totally and was filling the pool. Then I retreated and left them to it. I had
another mother to care for by then. This was at about 4 am and at 7am, with
a change of shift, I decided I would hang around and see if I could be involved
again. By this time Sue was totally within herself… in another world, really
just as she should be late in first stage and beginning to have expulsive contractions.
I crept in and sat quietly by. She went on, soon after, to have a beautiful
normal delivery, a lovely little boy, quietly and calmly in the pool and was
overwhelmed by the experience and her ability to birth naturally. She later
left me a bottle of champagne and a special note apologising for initially not
wanting me there and thanking me for my help.
I felt that this experience summed up for me what power we have as midwives.
Our confidence rubs off, without even realising it. And, of course, the reverse
is also true. Because I had confidence in her she picked it up and in just that
half hour she was empowered to take back control and the whole experience was
transformed. I came back into midwifery for this and I was fulfilled.
Later when I had only just retrained I had another pool delivery totally alone
with the woman and her husband. The mother had initially said, when I suggested
the pool…. "Oh I don't know … I suppose I could try it…"
She went totally into herself with some help from me but mostly just her and
her partner and the dark and warmth. I felt really calm and confident and reluctant
to have any other, potentially anxious, energy in the room.
Sometimes things just work out because outside in the ward it was busy and despite
pulling the bell for a second midwife, at delivery (as per protocol) it all
happened so quickly that no-one disturbed our tranquil little threesome (and
then foursome) until after the placenta had delivered.
The Learning Experience
I found that I really enjoyed using my brain again after being at home with
the kids for eleven years. I enjoyed working for my own sake rather than trying
to facilitate my kids' learning. And, I think almost most of all, I enjoyed
the fact that I had my own money, for the first time in eleven years. (Even
though it was a bursary and we all had problems with actually getting it through.)
When everyone else on the course was complaining about not receiving it, I was
just delighted to be earning anything again. The icing in the cake for me with
my RTP was that occasionally, I would support a woman throughout her labour
and help her deliver her baby normally.
Mostly the bread and butter of it all was learning how to be an obstetric nurse,
to work machines, to give out drugs, to do observations and to learn all about
different policies, procedures and guidelines. Then there was the constant need
to fill in an interminably long book, and get it countersigned to prove that
I knew how to do a postnatal, take a blood sugar, monitor a patient with an
epidural, do an abdominal palpation, etc, etc, most of which I was pleased to
find came back very easily to me.
Then I had to write all about it all in a reflective daily diary. Even though
some of it was tedious, as it was new to me and I thrive on new experiences,
I really enjoyed it and my confidence was high. I even did my reflective study
on use of Shiatsu in labour, inspired by an friend and colleague who uses it
regularly and successfully. I optimistically finished my study with the plan
to do a course in Shiatsu as soon as I had really got myself established back
into practice.
Looking Back
However, when I look back now, most of the enthusiasm and confidence that I
had when I did my RTP was because of a deep belief in a woman's ability to give
birth herself. I had developed this personally by having all my children at
home and being supported so well by community midwives and also by my experiences
of hypnosis. I have to say, it was not because of anything they taught me.
I also realise that being super-numerary meant I could devote time to other
areas of the job that have got lost since. For instance, I feel that it is crucial
to follow up a mother I have delivered, for my own sake as well as her's. I
feel the good and bad experiences need to be discussed a day or two later, to
help integrate such a momentous occasion. During my retraining I made a point
of doing this: nipping off when it was quiet, or using my lunch break or study
day. I found that mothers really appreciated this and I wish this arrangement
was written-in to my job now. As it is, there is no time.
Sadly, I find that all this enthusiasm has been eroded steadily and relentlessly
over the past 18 months. The two memorable experiences described above stand
out as being wonderful in what has now become a blur of intervention and more
caesarean sections than I can shake a stick at. Something has happened to me
over that year and it is not good. I have become demoralised and totally deskilled
as a midwife because of the huge amount of 'necessary' other stuff that is demanded
of me as a modern day midwife in a large obstetric unit.
The supervisory arrangement never really worked very well owing to pressure
of work. I could never see my supervisor or I would have had to arrange to come
in on my days off which wasn't an option. Maybe if I'd worked harder at trying
to see her, things might have been different. I wanted to work only on MLC but
I was told that Agenda for Change meant that I had to rotate everywhere. I also
wanted to do parentcraft, one of my main passions on my return, but was told
I needed to rotate and I could do parentcraft as an extra (which I did not actually
have time for with home commitments).
So I shrugged and got on with it. I worked on consultant led end of labour ward
and HDU (High Dependency Unit) and went to theatre almost every shift. (I kid
you not!) I convinced myself that it was all good experience and I was learning.
Yes I was learning, but it was insidious and relentless exactly what I was learning.
Somehow or other over the months I absorbed the belief that women's bodies don't
work properly in labour. Even when non-intervention and other evidence based
practices were implemented, things went wrong with great frequency. It is as
if women nowadays have absolutely no faith in their bodies, or if they have,
it soon gets lost when they enter a busy unit, with staff whom they have never
met. Sadly many of the midwives also feel this lack of confidence, and unless
they work on community with many home confinements, it is no wonder.
Even the MLC seemed to fail to give me the same rewards as time went by. Lack
of staff meant it was a rare luxury to be one to one with a mother in normal
labour. The worst situation I experienced on MLC was looking after five women
alone, two of whom were in strong labour, though admittedly I did get support
before long - when I stamped my feet. However, the thought seemed to be that
if they haven't got an epidural then they don't need one-to-one care. As we
all know it is very stressful trying to support two women in full labour, both
of whom you have only just met. And when you're stressed you forget things,
or rather I do. I still feel guilty about the young woman alone and in an uncomfortable
latent phase, who asked for a jug of water and then only asked again two hours
later because she: "didn't like to bother me because I must have forgot
and I was obviously so busy." Maybe looking back I should be glad if that
really was the only thing I missed. I am sure it could have been much, much
worse. After a few shifts with this sort of relentless pressure, when I went
home and then had to ring up with several things I forgot to mention in handover,
I felt the resentment of my situation creeping in.
The Dream
I feel very strongly that once women cross our hospital threshold their labour
ceases to be physiological. Physiological labour, to my mind, is a labour that
is instinctive and natural. Somehow or other most women have swallowed the myth
that the safest and therefore best place to be is in hospital and so they book
to come in. They are already 'interfered with'. I yearn for a radical change
that means there is no room in hospital for anyone remotely normal. They are
better off at home and we have the evidence to back it up. The last thing a
woman needs when she is in that delicate latent phase, as her body is just tipping
hormonally into labour, is a trip to hospital to be told to go home again and
come back later or worse, to be 'allowed' to stay in this strange place and
then ignored because of staff problems. She needs to be at home, in her own
surroundings, with her own scents and noises and loved ones and in control of
her personal space and to feel safe there. And just let nature take its course.
Is it an inevitable part of our modern life that many women just do not feel
safe and therefore no-one can really make them feel safe? We need to persuade
women, both individually and collectively, that home is safe for birth. It's
a seemingly impossible task and one that I find distinctly overwhelming.
The Reality
Back to the real world. We have staff shortages, a lot of staff sickness and
many, many policies and protocols. We have doctors and other midwives who are
very stressed and ready to blame others if everything is not as it should be:
the rescusitaire that was not checked properly, the oversight of an antenatal
problem in a huge wad of notes and the more mundane but also potentially serious;
stirrups on beds that jam and printer paper that runs out during delivery and
there is no stock till the morning! Even when there is no overt criticism, low
morale and self esteem mean that I agonise over how I should have checked this
or that, I should have remembered that… when I know full well I had no
opportunity and I am only human and doing the best I can. On a personal level
I have a hundred and one more hoops that I have to jump through in order to
raise my grade from a paltry E, not to mention the helpful workbooks and computer
programmes I have to complete, on everything from breastfeeding to CTG monitoring,
(in my own time presumably because there is no time at work) and get signed
off to show I am doing my job properly. Is it any wonder that my focus on the
woman, the reason for it all, waivers in all this?
I (naively) actually returned to practice to do a couple of nights a week of
something I used to love, which would fit in with my girl's home education.
I discovered, perhaps because of my age, that my body does not work as it used
to at night. It wants to sleep. I also discovered that I cannot sleep in the
day, so two nights work disrupted my entire week and affected my home life,
not to say my health so profoundly that I got sick. When I returned to work,
on days, I struggled through another couple of months before slipping a disc
and being laid up for the whole summer.
The Outcome
So my experience has not been, as you see, entirely happy. I don't regret my
Return to Practice. It has been interesting and challenging. It has revisited
old places deep within me. It has been just right for me at this time of my
life, full of great change that we call 'the change'. I don't know whether it
is unique to me but I do question whether it is ever entirely successful to
go back in life. We all move on and I think I may have changed too much for
it to be a total success.
Perhaps I need to work in a small unit, or in the community. In another lifetime
maybe I'll work in a more primitive community. A colleague recently told me
about some Filipino midwives she met at the Conference, this year. They worked
in a situation where midwives: "do what they can and rejoiced in the triumph
of never losing a mother, babies yes… unfortunately, but that's life isn't
it?" There is no recrimination and no blame and mothers allow it all as
the will of God. There is huge faith in the profession and belief that they
do what they can. On this side of the world protocol upon protocol is developed
to cover ourselves, should things go wrong, and we lose sight of what we are
really about in the process.
My supervisor, when I managed to track her down, has been very supportive. Since
my long period off sick, I have more understanding of myself and what works
for me. In the short term, I have arranged to do more parentcraft and work twilights
and more on the MLC unit. I'd also like to be more involved in teaching other,
newer midwives some deep relaxation techniques. This request has been met with
some promising interest in my unit. I hope this will allow me to pass on my
skills and thus I'll feel more fulfilled. It might work and I'm determined to
give it my best shot.
Please wish me luck!
Updated LW December 1, 2006