by Leah Hazard
‘I can show you the frequency, strength and duration of every contraction Michelle’s had since yesterday morning,’ he said, beaming as he set down the suitcases.
‘Great work,’ I replied, grinning. ‘Now let’s have a baby.’
The hospital was especially busy that day (I’m aware that this statement is a bit of a running theme, but as with every other instance heretofore, it was true). When I phoned to tell the labour ward sister that Michelle was five centimetres dilated and contracting well, she replied that the unit was desperately short-staffed, there were two obstetric theatres running, and if I brought Michelle up, I would need to stay and help her deliver her baby myself. Although this scenario meant that I would be leaving my own department short-staffed, I was given little choice. And as far as Michelle was concerned, this was the best possible outcome: she would get the same midwife in Triage and labour ward, the kind of continuity that most patients can only dream of receiving.
‘There’s good news and bad news,’ I said to Michelle as I drew back the curtain of her bed space. She was on all fours on the bed, shuddering as a contraction eased its grip on her body. ‘The good news is, I’m coming with you to labour ward. The bad news is, you’re not getting rid of me.’ She laughed weakly and began to climb down off the bed while Steven gathered the suitcases he’d arranged neatly at the bedside.
As it happened, Michelle had a bit of a tough time of it, and the afternoon took her on a magical mystery tour of the some of the scariest and most remote reaches of Labourland. She was in the pool, then out of it. She was on gas and air, then on diamorphine, then crying for an epidural, then back on the gas when the epidural failed to work beyond a stubbornly dense patch of numbness along her left thigh and buttock. She was off the continuous monitor, then on it, as the baby’s heartbeat was steady, then stuttering. Finally, after a heroic amount of pushing, a technically ‘small’ but no less terrifying haemorrhage, and a complicated tear that required some tricky suturing by a particular Triage midwife who hadn’t sutured in God knows how long (and whose stomach was now growling vociferously due to missing both lunch and dinner), Michelle was wrapped up in clean blankets with her beautiful baby girl.
I busied myself tidying the usual mess while they settled into their first breastfeed. As I worked my way across the room, stuffing bloodied drapes into bin bags, tossing absorbent pads onto puddles of bloody liquor, and collecting instruments that had been flung to the floor in the final moments of delivery, I became aware that Steven was watching me from his seat at Michelle’s bedside. At first, I pretended not to notice, but as his eyes followed me around the room, I became uncomfortable, and smiled nervously when our gazes met.
‘Sorry for staring,’ he said, and I blushed at the realisation that he’d felt my unease. ‘I just can’t believe everything that you’ve done for us today. You met us in Triage, and then you came here and looked after Michelle all afternoon, and then you delivered our baby. Then you scrubbed up and did Michelle’s stitches, and now you’re cleaning. I keep thinking, where’s the cavalry? I guess I thought there would be lots of other people in the room, or along the way, but it’s just you. You’re the cavalry.’
‘Yup,’ I said, as I lifted a bale of bloody sheets from the floor. ‘I’m it.’
I tell this story not to illustrate my own brilliance; any midwife would have done the same for Michelle, and many would have done it with even greater skill and better hair. Rather, the point is Steven’s revelation that midwives do so much more than catch babies. We devise and implement plans of care; we connect, console, sympathise and cheerlead; we prescribe; we do minor surgery. You see us all the way through your pregnancy, and we visit you afterwards in your home, making sure that you and your baby are well, and reminding you that cooking and cleaning and pretty much everything else can wait. When labour goes well, we’re the only ones you’ll see in the birthing room, and when it doesn’t, we scrub for you in theatre, and then bed-bath your broken body in recovery. We believe you when you say you don’t feel safe at home, and we hold you in our care until shelter is secured. We may never have met you until the day we ride into battle for you and your baby; and, like Steven, you may not even recognise the cavalry that’s been at your back until the drapes are down and the blood has dried beneath your feet.
And yet, every day, in big-city hospitals and small rural birth centres, in clinics and wards, midwives of every age and stage are evaporating like so many puffs of cornflower-blue smoke. For too many of us, the pressure and exhaustion have become too much to bear. But thankfully, for every midwife who has left, thousands more of the cavalry remain: kneeling by bedsides, answering phones, running for buzzers, telling you that it’s fine, you can do it, you are doing it – to keep pushing. And you push, and push again. And so do we.
Glossary
A note to the reader: this glossary is intended for the lay person, and uses relatively simple terms suitable for that descriptive purpose. If you would like more detailed, clinically oriented definitions, I recommend that you consult one of the many excellent professional resources available, such as Bailliere’s Midwives’ Dictionary, Myles Textbook for Midwives, or The Midwives’ Guide to Key Medical Conditions.
Amnihook: A brand name for an instrument used by midwives and doctors to make a hole in the amniotic sac, or bag of waters. The instrument resembles a sterile plastic knitting needle with a hooked end, designed to snag the amniotic sac without injuring mother or baby and to allow amniotic fluid to flow out of the womb via the vagina.
Amniotic fluid: The fluid surrounding a fetus in the womb. Amniotic fluid is usually straw-coloured, and is both swallowed and excreted (as urine) by the fetus.
Amniotic sac: The sac in which a fetus grows inside the womb. Also sometimes referred to as the ‘bag of waters’.
Anterior: To the front. For example, an anterior placenta is located to the front of the uterus, and a fetus’s anterior shoulder is usually the first to sweep under the mother’s pelvic arch in the final moments of birth.
ARM: Artificial rupture of membranes, or ‘breaking the waters’; the act of breaking the amniotic sac with an instrument designed for that purpose (see Amnihook), often with the intention of bringing on or speeding up labour.
Auscultation: The act of listening in to the fetal heartbeat. This can be performed with a Pinard stethoscope (a small ear-trumpet which the midwife places flush against the mother’s abdomen), a handheld device using Doppler technology (see Doppler and Sonicaid), or a continuous monitor strapped to the mother’s abdomen (see CTG).
Beat-to-beat variability: Part of a midwife or obstetrician’s evaluation of a fetal heart trace (see CTG). A fetus whose heart trace shows prolonged, minimal beat-to-beat variability may be compromised.
BMI: Body mass index, which is calculated using an algorithm that incorporates the mother’s height and weight. Women with especially low or high BMIs are sometimes regarded as ‘higher risk’ in pregnancy and birth.
Bradycardic: Having an unusually low pulse.
Cannula: A very thin plastic tube inserted into a vein for administration of fluids, medicines or blood.
Catheter: A tube inserted into the bladder via the urethra, for the purpose of draining the bladder. An in–out catheter is intended to be removed after the bladder is drained as a one-off event. An indwelling, or Foley’s, catheter is intended to remain in the bladder and provides continuous, free drainage of urine. The latter is often used when a woman is unable to pass urine spontaneously; for example, if she is under general or epidural anaesthetic.
C. diff: Clostridium difficile, a bacterium that can cause severe vomiting and diarrhoea.
Cervix: Sometimes called the ‘neck of the womb’. The fleshy tube which softens, thins and opens in labour to allow the fetus to pass from the uterus into the vagina.
Cholestasis: In pregnancy, a condition related to an imbalance in the liver which can cause intense itching for the mother, and an increased risk of problems for the f
etus.
Colostrum: The ‘first milk’ produced by women after birth; nutritionally complete, highly calorific, and full of valuable immunologic substances. Many women produce colostrum in relatively small quantities in the first postnatal days; this supply can be increased by frequent breastfeeding or ‘expressing’, where the release of breast milk is stimulated by hand or with the aid of a device.
Contraction: A shortening of the muscle fibres within the uterus. A steady rhythm of long, strong, frequent contractions helps to soften, thin and dilate the cervix, and to expel the fetus.
Crash section: The most urgent form of Caesarean section, in which there is a clear, immediate threat to the life of mother and/or fetus. The mother is usually given a general anaesthetic so that delivery can be achieved as quickly as possible.
CTG, or cardiotocograph: A graphic representation, often either on a screen or on a paper printout, of the fetal heart rate, maternal pulse and uterine activity (contractions) over time. The term CTG is also sometimes used to describe the actual machine which produces the printout. This kind of continuous monitoring is often used to assess fetal wellbeing in women whose pregnancy or labour is higher-risk.
Culture bottles: Special bottles for collection of blood samples which will be sent to a lab for microbiological analysis. Where severe, systemic infection, or sepsis, is suspected, culture bottles are an essential part of the medic’s diagnostic kit.
Deceleration, or ‘decel’: A drop in the fetal heartbeat well below the usual baseline rate. While these often form part of the fetus’s normal response to labour, they can be indicative of fetal compromise.
Delirium: A mental state brought on by severe illness; can encompass confusion, disorientation and hallucinations, among other phenomena.
Diamorphine: A strong opiate drug, sometimes used for pain relief in labour.
Doppler: A term often used to describe a handheld, battery-operated ultrasound device used for auscultation of the fetal heart. See also Sonicaid.
Endometriosis: A condition in which endometrial tissue (which usually lines the womb) grows outside the uterus. This may lead to inflammation, pain and other problems with the internal reproductive organs.
Epidural: A form of anaesthesia in which painkilling drugs are injected into a space between the vertebrae, thus blocking the transmission of pain messages along the nerves of the spine.
Episiotomy: A cut made to widen the vaginal opening at birth. Although episiotomies used to be a routine part of obstetric practice, now they are usually only done for very specific reasons; for example, to speed up the final moments of delivery if the fetus is believed to be in danger, or to allow the introduction of forceps.
Facial oxygen: Medical shorthand for pure oxygen which is administered to a patient using a facemask or nasal tubes; often administered in episodes of acute illness, such as sepsis.
Fallopian tubes: Two slim tubes leading from the ovaries to the uterus.
Fetal scalp electrode: An instrument which can be connected to the fetal scalp in labour to monitor the fetal heart more accurately than a trans-abdominal CTG.
Fetus: The medical term used to refer to a baby at any time between eight weeks of pregnancy and the moment of delivery.
Forceps: An instrument for delivering babies in situations where the mother’s cervix is fully dilated, but the progress of labour thereafter becomes inappropriately slow and/or the fetus’s condition is compromised. The instrument comprises two large, interlocking spoons or ‘blades’; these are positioned around the fetus’s head by the operator (usually a doctor) and traction is then applied in conjunction with the mother’s pushing in order to achieve delivery.
Fully dilated: An expression which refers to the cervix being fully open, usually approximately 10 centimetres in diameter. Generally speaking, this stage must be reached before a fetus can be born vaginally.
Haemorrhage: Excessive blood loss. This can occur at any stage of pregnancy, labour or the postnatal period for a number of reasons.
High dependency: The area of the labour ward where critically ill women are cared for, with increased midwifery and medical attention as well as additional monitoring.
Hypnobirthing: The brand name of a style of antenatal education which focuses on the woman’s innate ability to have a spontaneous, pain-free labour and birth. Hypnobirthing encourages the use of breathing, affirmations and visualisation to reduce or eliminate pain in labour. In this style of birthing, contractions may be referred to as ‘surges’.
Hypotensive: Having low blood pressure.
Internal examination: Also referred to as a ‘vaginal examination’, or VE. An examination in which the practitioner (midwife or doctor) uses her fingers to feel the length, consistency and dilatation of the cervix. The examiner may also be able to determine whether the amniotic sac is intact, whether the baby is presenting feet- or head-first, and the position and descent of the presenting part. Many guidelines suggest that these examinations should be done at least every four hours in labour, as they can yield information which guides the midwife or doctor’s management; however, the frequency of internal examinations varies widely in practice, depending on the clinical situation, the woman’s wishes, and the shared decision-making of patient and practitioner.
In utero: Latin for ‘in the uterus’ or ‘in the womb’.
IOL, or induction of labour: A process of artificially initiating labour using a number of stages and techniques, often including ARM (see above) and the administration of synthetic hormones using both vaginal pessaries and intravenous drips.
IV, or intravenous: Referring to a drug or fluid which is administered directly into the veins, usually through a cannula or ‘drip’ in the hand or arm.
Labia: The fleshy folds of skin, or ‘lips’, of a woman’s external genitalia.
Liquor: See Amniotic fluid.
Malposition: A situation in which the fetus’s position in the womb makes vaginal delivery difficult or impossible.
Meconium: The thick, tarry substance produced by the fetus’s gut; a primitive, sterile faeces. Sometimes the fetus passes meconium during pregnancy or labour, and the amniotic fluid is said to be ‘meconium-stained’. This can be a normal event but can also indicate fetal compromise.
Missed miscarriage: An instance in which a fetus of less than twenty-four weeks’ gestation has died, but no blood or tissue has yet been passed, giving the impression of a continuing pregnancy.
Mucus plug: See Show.
Obs and gyn(ae): The commonly used shorthand term for obstetrics (the medical speciality pertaining to pregnancy, birth and the postnatal period) and gynaecology (the medical speciality pertaining to the female reproductive organs and their surrounding structures). Doctors often specialise in the combined fields of obstetrics and gynaecology, rather than one or the other in isolation.
Ovary: A reproductive organ which produces eggs and hormones (progesterone and oestrogen); in normal anatomy, there are two ovaries, each one linked to the uterus by a fallopian tube.
Paediatrician: A doctor who specialises in infants and children.
Palpation: In midwifery, the systematic process of feeling a woman’s abdomen to assess (among other things) the size, lie, presentation and position of the fetus, and the strength and frequency of contractions.
Parous, or ‘para’: Generally speaking, this refers to a woman who has previously given birth to a baby of twenty-four weeks’ gestation or more, or to a baby of less than this gestation who lived more than momentarily. A number can then be added to this description: for example, a ‘para one’ is a woman who has previously had a baby of viable gestation; a ‘para four’ is a woman who has had four babies of viable gestation, a ‘para one plus two’ is a woman who has had one baby of viable gestation as well as two other pregnancies.
Perinatal: Relating to the time around birth; for example, perinatal mental health refers to issues which may arise in pregnancy and/or the postnatal weeks or months.
Perine
um: The area between the vaginal opening and the anus.
Per vaginam (PV): Latin for ‘by way of the vagina’. Vaginal secretions such as amniotic fluid and menstrual blood can be said to come per vaginam, or PV.
Pinard: a simple instrument used for listening to the fetal heart. Shaped like the end of a small trumpet, Pinards were widely utilised before the invention of Sonicaids and CTGs, and are still sometimes used in clinics and rural or low-risk settings.
Placenta: The organ which forms in pregnancy to transfer nourishment and oxygen from the mother to the fetus. The placenta implants on the wall of the uterus and is expelled in the third stage of labour, after the delivery of the baby; hence its nickname as the ‘afterbirth’.
Placenta praevia: A condition in which the placenta encroaches on or covers the internal opening of the cervix, making vaginal delivery dangerous for both mother and baby.
Post-coital: After sexual intercourse.
Post-dates: Relating to a pregnancy which has continued past ‘term’, or forty weeks’ gestation.
Posterior: To the back. For example, a baby’s posterior shoulder is to the back of the mother and is usually the second shoulder to be delivered at birth. A posterior placenta is implanted on the back of the lining of the uterus.
Postpartum haemorrhage (PPH): Excessive blood loss after birth; usually accepted as anything over 500 millilitres. This can be caused or exacerbated by a number of things, including trauma to the genital tract, failure of the uterus to contract properly after delivery, or a shortage of essential clotting factors in the bloodstream.
Pre-eclampsia: A condition of pregnancy which is usually characterised by high blood pressure, swelling and protein in the urine. Left untreated or poorly controlled, pre-eclampsia can be fatal for both mother and fetus.