by Leah Hazard
I often describe Triage to family, friends and inquisitive hairdressers as ‘Accident & Emergency for pregnant people’. However, unlike an A&E nurse, whose most urgent patients have already been filtered by a far-off call handler, the Triage midwife has the joy of fielding all of the panicked phone calls as well as the face-to-face emergencies. Although women are briefed at the start of their pregnancy to use the twenty-four-hour Triage hotline for serious concerns only, the concept of ‘serious’ is highly subjective. While one woman may resist phoning the hospital until she is actually hosing blood across the lino, there are another ten women who will speed-dial Triage because some faceless online ‘friend’ has warned them that one lick of a Mr Whippy ice cream can cause instant fetal distress. (To save you the Google time – it won’t.) A woman who’s worried that bleaching her roots might kill her baby can be tying up the phone lines while another woman across town is trying to get through with a question about the sizeable clot she’s just passed down the toilet. A single shift in Triage, or even an hour on the phones, can take a midwife from the ridiculous to the sublime and back again. As a wise midwife once said, it’s no wonder we drink.
Hawa: Word Medicine and the Pee Baby
A wet Wednesday morning in November, and morale in the hospital was …
Well, I could say ‘at a low ebb’, but the word ‘ebb’ suggests a wave lapping gently at a velvet-sanded shore. In reality, it felt as though a giant sinkhole had opened in the middle of the Atlantic and sucked every drop of the world’s joy into its black, churning vortex. No one in a uniform was immune; even my own usually cheery disposition had morphed into a demeanour of brooding disgruntlement, punctuated by the occasional scowl.
Maternity services do tend to undergo a natural rise and fall in activity, with one week being relatively quiet, while the next week bears the busy fruit of some event that happened nine months before – a snowstorm, perhaps, or a spell of warm weather, or even a particularly bad week of telly. September is a consistently hectic time for us, as all those messy Christmas parties and snogs under the mistletoe materialise into wards brimming with bawling babies. This peak season of births is almost comfortingly consistent, proving to midwives year upon year that yes, an extra glass of Prosecco and a Santa hat are really all it takes to get human beings to breed.
However, sometimes there is a sudden spike in the birth rate with no apparent reason or warning, and so it was that November. Labourer after labourer came careering into Triage, practically skidding through the doors on a slippery stream of amniotic fluid, and no sooner had each woman been examined than she was trundled onto the nearest bed or wheelchair and rushed up to the labour ward. Over and over again, we made the same call to the labour ward sister, phone clenched between chin and shoulder, hands still gloved and ready: ‘I’ve got a para two at fully.’ ‘I’ve got a prim at nine centimetres.’ ‘I’ve got a woman here – I don’t know her name, but she’s pushing.’ As the month wore on, each phone call was met with increasing levels of exasperation (and increasingly creative expletives). ‘I don’t have a free midwife,’ came the reply. ‘I don’t have any clean rooms.’ ‘Just deliver her.’ ‘Deliver her.’ ‘Deliver her.’
The baby boom couldn’t have come at a worse time. One lot of junior doctors had recently left to start their next placements, fanning out across the city to the fresh pastures of dermatology, neurology and the psychiatric ward, and a new group of bright-eyed twelve-year-olds (or so they often appeared) had arrived to take their places. Some of them were remarkably competent, having come from rotations in A&E with its pick-and-mix of crash calls and medical mysteries, but many of them were quite clearly terrified by the challenge of being the responsible medic in an acute environment for the first time. To make matters worse, many of the young male doctors appeared to have only ever seen naked women in their textbooks, and these poor chaps could hardly conceal their terror when presented with the real thing. Breasts swollen and hard with mastitis were approached with shaking hands, speculums were nervously squeezed into vaginas the wrong way round, and God help the virginal male trainee who comes face-to-face with his first Brazilian bikini wax under the watchful eye of a chaperoning midwife. Many a time have I had to pull a new doctor aside and remind him that he needs to wash his hands, introduce himself, and make eye contact with a patient before making contact with her vagina.
The pressures of the system were hard enough to bear for the staff who had worked within its confines for years, but for the thinner-skinned among us, it was hell. I had entered midwifery with the hope of providing unhurried, compassionate care, and as the hospital groaned under the weight of its workload, that goal became virtually impossible to achieve. Days and nights merged into one frantic blur. By the end of each shift, I had only a vague memory of the names and histories of the women I’d encountered at its beginning. Some of my senior colleagues charged blithely through this onslaught, gimlet-eyed and undeterred, and while I tried hard to follow their example, I couldn’t help feeling increasingly like a worn cog in a giant machine. I had the uneasy sensation that I was simply processing women, not caring for them, and the feeling didn’t sit well with my soul.
On that November morning, I had just thrown on my uniform and was mentally girding myself for the day ahead when I heard what sounded like a baby’s hungry cry coming from the corner of the changing rooms. My heart flip-flopped in my chest and I froze on the spot, contemplating what kind of monumental screw-up could have landed an unattended newborn in the staff area. Midwifery is full of these paradoxical moments: on the one hand, you’ve seen so much strangeness that nothing surprises you any more; on the other hand, the wonderful world of womankind continues to throw ever crazier business your way. The cry started again, softer this time, and I crept past rows of lockers until I located its source.
A young midwife sat on the far end of a bench, head bowed, weeping. I had met Trisha briefly on several occasions. She had rotated through the wards as a student, and had only recently finished her training and qualified, a couple of years after I’d done it myself. She was one of those idealistic and almost naively brave young women who had gone straight from secondary school to midwifery, and I recalled that in my few interactions with her, she had been shy but diligent, and kind to the patients in her care.
I approached her the way you might approach an injured animal: gently, eyes down, a little bit sideways so as to appear as unthreatening as possible. Crouching at her feet, I could see that her face was scarlet and raw, with tears tracking slowly down her neck and collecting in a damp ring around the collar of her uniform. It was 7.26 a.m. – nearly time for both of us to start our shifts – but she looked like she’d been crying for hours.
‘Trisha?’ I said. She rubbed her fists in her eyes and looked up at me from under a cloud of auburn hair.
‘I’m sorry,’ she said. ‘I’m so embarrassed. I’m fine, really. Go ahead.’
‘Can I do anything for you?’
‘It’s just … I can’t do it any more. I can’t face it. Even walking into the building in the morning, I want to …’ She hiccupped, chest heaving. ‘I want to scream and run away. My heart starts racing before I’ve even got to the labour ward. It’s so hard not knowing what the day will bring.’
I looked at Trisha, then down at the floor. ‘We all feel like that,’ I replied.
‘I know,’ she said, sobbing. ‘It’s so bad that I – I mean, I’m usually a calm person, but I – I haven’t been sleeping, and I’ve been having nightmares about women dying, and babies dying, and I pull the buzzer for help and nobody comes.’ This story was all too familiar. Recently, the anxiety of the job had become so all-encompassing that, like many of my colleagues, I’d been having increasingly frequent and vivid nightmares about obstetric emergencies. For the midwife with an unmanageable workload, each sleep brings fresh horror, and when it’s not your patient who’s in trouble, it’s you – delivering your own baby in an unfamiliar room, on a bus, or in a park, no help
in sight, blood running down your legs and a feeling of being completely, terribly alone. You wake with your pulse racing, dreading the beep of your alarm, knowing that in a few short hours you’ll be at another bedside, pretending to be in control.
Trisha sniffed and wiped her nose with the back of her hand. ‘When I finally told Sister how bad it was, and that I’d been to the GP and he’d put me on antidepressants, she just laughed and said, that’s fine, because pretty much everyone else in here is on them already.’ At that, a fresh wave of tears sprang forth, and Trisha buried her face in her hands again.
I remembered reading about an American lay midwife called Sister Morningstar – a half-Cherokee, self-proclaimed ‘mystic’ who lived in the Ozark Mountains – who wrote of herbal poultices, and ancient birthways, and the judicious use of what she called ‘word medicine’ to empower and heal the women who sought her guidance. I often thought of Sister Morningstar when confronted by a patient whose emotional turmoil far outweighed any physical concern. In these cases, I had found, a carefully crafted consolation or encouragement could completely transform the patient’s experience. Although words often come to me more easily on paper than they do to my tongue, I had come to appreciate ‘word medicine’ as a crucial element of the midwife’s craft.
I looked at Trisha and wished I had the right words to heal her condition, but the truth was, I had often felt as she did: the gut-clenching anxiety, the dread of what was to come, the humiliation when your superiors smell your fear and dismiss it. Already, in the short, sharp shock of my first few years as a midwife, I had learned that the only cure for this despair was a kind of brutal exposure therapy: you keep turning up, shift after shift, and you endure it, and you internalise it, and one day you find that you’ve traded fear for numbness. It is that numbness that enables you to grind away, day after day – but at what cost?
‘Trisha,’ I began. ‘The fact that you’re even here shows that you have a bigger pair of balls than most people out in the world. You chose to do this, and you’re doing it. Think of all the women you’ve helped already in your three years of being a student, and then in the months since you’ve been qualified. You’ve delivered how many babies?’
Trisha gazed at the floor. ‘Eighty-two.’
‘There you go. Eighty-two lives you’ve brought into the world. Pretty freaking amazing, if you ask me. And you could have worked in a shop, or in a bank, or whatever, but you chose to do this, and be here.’
Trisha lifted her head, smoothed her hair away from her face, and looked at me squarely. ‘Well, I’m not doing it any more.’ Her eyes were still bleary but her voice suddenly had a steely edge. ‘I can’t live like this. I can’t do this for the next forty years, or fifty years, or whenever they decide I can finally get my pension. Twelve-hour night shifts when I’m sixty-eight? You’ve got to be kidding me.’ She drew herself up, her spine lengthening as her decision was made. ‘I. Just. Can’t.’ And then, in one swift movement of unwavering intention, she picked up her bag, pulled her jacket from her locker, walked past me, and left the hospital.
What was there to say? What ‘word medicine’, if any, could have altered that outcome? How can you triage burnout? Trisha wasn’t the first midwife to down tools – in fact, she was the third midwife that month – and she certainly wouldn’t be the last. There are times when a kind word or stern pep talk can bring a midwife back from the edge – on any given shift, you will find us gathered in whispering clusters for exactly this purpose, huddled in the storeroom among a forest of drip stands, or hiding in the no-man’s land between theatres and the sluice – but Trisha was already well beyond the point of comfort or persuasion. Watching her hunched figure disappear out the door, I had something akin to an out-of-body experience; part of me remained rooted to the spot, but another seemed to slip all too easily into Trisha’s skin. As I had done so many times since that first night shift as a student, I felt the lure of the car park, the blast of fresh air and the cool kiss of drizzle on my cheeks as I stepped outside, the ease with which I could drive away and melt into the anonymity of the morning rush hour. Normal people were out there, doing normal things – changing the radio station on a dashboard, tightening the straps on a child’s schoolbag, pushing a trolley around a quiet supermarket – and I could choose to move among them, as Trisha had chosen. That urge to retreat had welled up again and again over the years, and at times the pull had almost been stronger than my sense of obligation to the women in my care. Only a nudge from a colleague – or, more often, the shameful prospect of having to explain my cowardice to family and friends – had propelled me through those other doors to the main hospital corridor and the work that lay beyond.
It was 7.32 and I was now late for my shift. I ran to Triage, trainers smacking off the freshly buffed floor, badges and fob watch flapping noisily on my chest. When I arrived at the desk, it was clear that the day’s tsunami of babies was already in full flow: both phones were ringing, there were three names on the board, and four women in various stages of labour – and degrees of distress – were pacing the waiting-room floor.
Stephanie, the other midwife on that day’s shift, appeared at the threshold to the main treatment area. Only twenty-six years old, she too had hurtled headlong into midwifery straight from school, but Stephanie was one of the lucky ones who seemed unfazed by anything this place could throw at her. Her heart was soft but her confident exterior was unshakeable even in the most acute scenarios, and her language was unremittingly, fantastically filthy. White plastic apron tied tightly around her waist, gloved hands planted firmly on her hips, she was a formidable figure.
‘All right, Steph?’
She stuck out her bottom lip and blew her fringe away from her face. ‘Piss and shit!’ she exclaimed as her fringe fell right back into place.
‘What’s happening?’
‘No, seriously, it’s piss and shit. Bed two hasn’t taken a dump in eight days, one of the side rooms is shitting for Britain and has probably given everyone in the waiting room a dose of C. diff, and the one in bed four … she’s all yours, hot lips.’
‘Piss?’ I said, nodding towards that bed space.
‘Correctamundo’, said Stephanie, breezing past me towards the phone at the desk. ‘How’s your catheterisation these days?’ she called over her shoulder.
‘Pretty sweet,’ I replied, which – if you will allow me to blow my own single-use-only, gently lubricated trumpet – is actually true. These days, I reckon I could probably whack in a catheter whilst blindfolded, in a wind tunnel, with my teeth. Unlikely, I know, but should such a clinical situation ever arise, I’m your woman.
It has not always been thus. As a student, catheterisation was a skill that eluded me, in spite of many kind, forgiving women who pretended not to mind when I missed my target and catheterised their vagina for the umpteenth time. The more I failed, the more I was determined to succeed, as catheterisation is such a useful, albeit unglamorous, skill. It’s essential for women with epidural anaesthetics, for those with bladder trauma, and for any patient whose perineum is such a mess that it’s kinder not to force her to wee directly on her stitches for a day or so after birth. The ability to pass a little plastic tube into a lady’s waterworks may not be sexy, but to paraphrase cinematic anchorman Ron Burgundy, it’s kind of a big deal.
What can be so challenging about this simple task? you ask. Dear reader, without putting too fine a point on it, sometimes just locating a woman’s urethra can be like finding a needle in a fleshy haystack. Contrary to a belief still widely held by a surprisingly large proportion of the general public, women don’t have ‘one big hole’ down there, some kind of universal two-way chute for babies, urine, penises and the odd light bulb (yes, it happens, and no, I don’t recommend it). Indeed, if you’re a female reader and this is the first you’ve heard of this anatomical complexity, I encourage you to spend some quality time with your vulva and a mirror.
My first successful catheterisation was performed on a ni
ght shift halfway through the second year of my training. The room was warm and dimly lit, and I gazed hopefully into the eyes of my patient, who was six centimetres dilated and had an epidural so effective that you could have driven a team of wild horses through her vagina and she would barely have flinched. I opened the necessary packs, being careful to keep an aseptic field as I had been taught, and shone a spotlight on my target. The whole procedure went like clockwork, my patient remained supremely comfortable, and I could actually have kissed her when I saw the flashback of golden fluid start to rush through the catheter tubing. I was so delighted with myself that I remained perched on the edge of the bed for a few more minutes, lecturing the patient in worldly-wise tones about my plans to guide her through the next stage of her labour, when I realised that a warm wetness was seeping through my scrubs. I soon realised that I had forgotten to close the tap that sealed the urine collection bag on the end of the catheter, and while I had been dazzling my patient with my clinical brilliance, I had also soaked myself from waist to toe in her urine. My mentor, silently bouncing on a birth ball in the corner of the room, had observed the whole sorry scene and said not a word until I realised my mistake. She did allow me to change my scrubs, knowing full well that I would need to access the changing room via the desk and the bunker, where all of the other midwives, auxiliaries and theatre staff could enjoy the sight of the piss-soaked student. Midwifery Lesson Number 156: always close the catheter tap. (See also Midwifery Lesson Number 157: always bring a spare pair of pants to work.)