Australian Midwives

by Paula Heelan

  ‘Six hours later we returned to base with healthy twins in one humidicrib. The babies needed a small amount of oxygen to assist their breathing and were kept under observation during the flight.’ A fatigued but very relieved mother was on the rear stretcher under the close eye of her midwife, Genevieve.

  The second eldest of four children, Genevieve was named after a Catholic nun. She worked hard at school and from an early age wanted to do something with her life that would make a difference. ‘I was fourteen when my father died and knew I needed to do something to support myself through my entire life,’ she says. ‘Mum didn’t have a career and we kids had to take all sorts of jobs to help stay afloat. When a good friend said she was going to do nursing and wanted to be a midwife – I instinctively knew, yes, that’s what I’ll do as well.’

  In the early 1980s, when nursing registration was required before midwifery training, Genevieve, who was only seventeen, and her friend started nursing together with fierce determination to succeed. ‘We trained at the Royal Adelaide Hospital for three years and then completed a graduate year to finish,’ Genevieve says. ‘If they liked your work during training, they employed you for a graduate year. I worked in the ophthalmology, high-dependency and vascular units and stayed on to work in high-dependency after my graduate year.’

  Just before her graduate year Genevieve married Andrew, a diesel mechanic she had met in Adelaide. When Andrew was offered a position in Broken Hill to start a branch for the company he worked for, Genevieve said she wouldn’t move unless she could get a job. But she was a nurse, and nurses and teachers could apply for work in Broken Hill and were indeed sought after. Other vocations were kept for locals, which was the government’s way of keeping young people in town.

  Not having lived in the country before, let alone the outback, it was a culture shock on multiple levels for Genevieve. Located in far western New South Wales, Broken Hill’s landscape is known for its post-apocalyptic appearance. Locals say depending on the season, the vast, largely flat landscape flecked with mulga trees is either dying or thriving. But the hauntingly beautiful desert-fringed, semi-arid country with intense blue skies lures painters, photographers and filmmakers from around the world.

  Genevieve worked in the hospital’s intensive care unit and theatre suite for the first eight months she was there. And though the townspeople were warm and welcoming, it did take some time for her and Andrew to build friendships. ‘We did make some lovely friends, but it wasn’t easy,’ she says. ‘It was very quiet and the locals were guarded about making friends with new people in town. They knew most people coming in were transient workers and would move on. I adapted quite well and learned a great deal about myself.’

  To socialise, Genevieve and Andrew would often go to the Silverton Hotel on weekends, about 30 kilometres out of town. This is the site where Mad Max was made, and it looked exactly like it did in the film. ‘It’s a pretty barren place but really interesting. Broken Hill was an interesting place to live and a great place to build and gather new skills and strengths – both in work and character.’

  A little of everything came through the hospital door and Genevieve observed a number of caesarian sections. ‘I also made a connection with the RFDS at Broken Hill as at the hospital we flew people in and out,’ she says. Night shift began at midnight and finished at 8 am. ‘That was foreign to me and a little hard to get used to,’ she admits. ‘I applied to do a twelve-month theatre course through the Royal Adelaide while we were in Broken Hill and had to go back to Adelaide to complete it. Andrew stayed working at Broken Hill – so with a three-and-a-half-hour drive to Adelaide, there was a lot of commuting going on.’ Once the course was completed Genevieve returned to Broken Hill and landed the position in charge of the theatre suite.

  In 1990 Andrew changed jobs and the couple moved again – this time to Alice Springs. He was appointed branch manager of an earth-moving company. When she arrived at the Alice Springs Hospital, having worked in charge of the theatre suite in Broken Hill, Genevieve went straight to work in theatre. She was also asked to coordinate flights for patients on commercial planes to Adelaide and Darwin. The ICU could only hold intubated, ventilated patients for 24 hours and didn’t have the resources or staff to look after them for longer periods. ‘If the RFDS was too busy or couldn’t arrange to transfer patients, the transfers were organised with the commercial airlines, in particular, Ansett Australia,’ Genevieve says. ‘That marked the beginning of my interest in a flight career. I often flew with the patients and sometimes returned with those that had gone down for treatment. The patients we took down were usually intubated and ventilated and accompanied by an anaesthetist and nurse – more often than not, me. I also worked in the ICU, which was a fantastic place to work as far as teamwork goes. We were making a difference and you could see your work was needed and appreciated.’

  While in Alice Springs Genevieve decided to become a midwife. ‘Even though I had to drop from a senior registered nurse’s salary to a training midwife’s salary, at least we were paid,’ she says, laughing. ‘We were given all the good oil, including domiciliary midwifery training. We looked after women and could stay on after the shift finished if a birth was imminent.’

  Sadly, Genevieve saw a lot of intrauterine growth restriction (IUGR) babies. ‘This is when the baby is smaller than it should be because it’s not growing at a normal rate inside the womb. Delayed growth puts the baby at risk of certain health problems during pregnancy, birth and after birth.’

  One memorable day Genevieve looked after a young, reasonably fit woman at 39 weeks who had a terrible obstetric history. Six previous pregnancies had given her four live children, one miscarriage and one neonatal death. She had experienced a postpartum haemorrhage (PPH), two premature labours and one premature rupture of membranes. ‘With this pregnancy she had already been through premature labour at 28 weeks and again at 32 weeks, but both had been stopped,’ Genevieve says. And with this pregnancy she had also experienced leaking fore waters (the amniotic fluid cushioning the baby’s head from the pressure of labour) for five weeks, so both the woman and her baby were at risk of infection.

  ‘The two of us had time to build a good rapport as this was the mum’s sixth baby and the labour progressed smoothly,’ says Genevieve. ‘Usually, the speed of labour increases with more children, but when you are “grand multipara” [a woman who has had six or more pregnancies that resulted in viable births], labour slows down again.’

  Genevieve was acutely aware the woman was at very high risk of another PPH. ‘But after six hours, she birthed a beautiful, ten-pound two-ounce [4.6-kilogram] healthy baby girl. The placenta and membranes delivered soon after and we actively managed this stage to prevent the possible PPH. As the midwife you’re there to monitor and support, but essentially the mother does all the work – which is what happened this day.’

  To both the mother’s surprise and Genevieve’s, given the baby’s weight, the mother’s perineum was sore but intact. ‘There were no tears, no episiotomy needed and no PPH. We were both delighted with the outcome when the odds were not really stacked in her favour.’ Genevieve was even more delighted when the mum revealed the little girl would be named after her.

  Genevieve loved working with the Indigenous mothers and their babies. ‘The women were usually supported by their grandmothers or aunties, rather than their mothers,’ she says. ‘They gave clear and wise direction to the mothers and to us and their support and knowledge was really beneficial. It really helped improve my practice. If the grandmothers and or aunties thought you were at one with them, they would give you tips on how to improve and a mark for how you managed their granddaughter’s labour. They taught and supported women to feed while lying in bed to try to help manage the fatigue. They also stressed the importance of staying upright during labour, rather than being pinned to a bed, because gravity helps the progress.’

  Genevieve says Alice Springs was a wonderful place to learn midwifery. It was a very supp
ortive environment and best outcomes for women and babies were always a priority. ‘Interestingly, we found the most trying mothers to be the Americans and teachers,’ she says, smiling. ‘There were many Americans living in Alice Springs due to the military base there. The labouring mothers would come in with a long, fully prepared birth plan and husbands fully equipped with the video camera ready to take very close-up shots. They’d read up on everything and knew exactly what they wanted and how the birth should go,’ she says. ‘Of course, the births often didn’t go to plan.’

  Halfway through Genevieve’s midwifery course, Andrew was offered a position with an underground mining equipment firm in Kalgoorlie, Western Australia. Located 579 kilometres east of Perth, it’s Australia’s largest inland city and centre of the Goldfields. Andrew went ahead while Genevieve finished her midwifery. ‘I didn’t particularly want to go,’ she says. ‘Career-wise it was sad to leave Alice Springs at that time as I loved working in the midwifery area and possibly would have moved more into the special-care nursery. High-dependency/intensive care work has always tended to be my focus, along with looking after critical-care midwifery patients. Moreover there were only a small number of us with midwifery qualifications, so there was a bit of an expectation you’d stay and be part of the staff. But it helped that I was going to Kalgoorlie,’ she says. ‘At the time people in the remote areas looked out for each other’s community.’

  Genevieve and Andrew packed up their furniture for removal and drove to Adelaide before continuing on the long road trip to Kalgoorlie with their dog. They moved into a company house at Boulder – close to the massive Super Pit goldmine. ‘Every day, when they let off a blast, the whole house would shake and everything got coated in dust,’ Genevieve recalls. ‘It was quite an experience. The old house wasn’t quite what I was used to after our really nice home in Alice Springs – with a swimming pool. It was just as hot in Kalgoorlie, so we did miss the pool.’ At the time, Kalgoorlie and Boulder were two separate towns – they’ve merged into one now. The town’s grand historic colonial architecture is testimony to its booming gold-rush days and importance to Australia’s goldmining industry.

  When Genevieve and Andrew arrived in the early nineties, living expenses were high and ordinary houses came with big rents. ‘We were lucky to have a company house and eventually we were upgraded to a better one.’ In a twist of fate that would become one of the highlights of Genevieve’s career at that point in time, the RFDS Goldfields base in Kalgoorlie was urgently looking for casual flight nurses. Genevieve knew some of the senior flight crew and because they were aware that she was a registered midwife and experienced in critical care they contacted her. ‘I was planning to have a couple of months’ break,’ she says. ‘But I started flying on a casual basis two weeks after arriving in town from Alice Springs and I absolutely loved it.’ Eight months later Genevieve, at 27, moved into a full-time position with the RFDS only to discover she was pregnant with her first child. ‘I had Jonathan in 1994 and Courtney was born in 1996.’

  There were strict rules for pregnant flight nurses and Genevieve couldn’t stay on full-time when she fell pregnant with Jonathan, but she was able work on a casual basis with the RFDS Eastern Goldfields section. ‘I managed to get the rules bent a little and flew until I was eight months pregnant. Our doctors signed me off as “well” every week and as I was working with medical staff everyone knew I was in good hands. Amusingly the senior flight nurse suggested I hide from the chief medical person when I was at the Jandakot base, south of Perth. She said, Don’t be seen when you’re down there – he doesn’t believe in flight nurses working after 22 weeks. So I’d stay in the hangar and not venture into the offices until it was time to fly out again.’

  Late one afternoon Genevieve and a pilot were at the base waiting for an elderly patient who was to be returned to his hometown when they received notification of a woman in her fourth pregnancy who had gone into premature labour at 33 weeks. ‘She had been at the local hospital we were about to fly to for three hours. Her contractions had increased and her membranes remained intact. She was on the CTG [cardiotocography] machine and the baby’s heart rate was regular with good variability. The baby was cephalic presentation – head down, back anterior, and the mum had been given the first dose of Celestone [to mature the baby’s lungs] and another drug to slow or stop the contractions. Her observations were satisfactory, so the decision was made to go ahead with the return of our elderly patient to his home and then to bring the labouring woman back with us for more advanced care. As usual, there wasn’t a doctor on the flight.’

  The midwife from the local hospital accompanied the woman to the airstrip to meet the RFDS crew. ‘Our elderly gentleman was off-loaded from the aircraft and the woman loaded as quickly as possible. Her labour had increased in intensity, even though a further drug dose had been administered.’

  To complicate matters and as the pilot had predicted, the weather deteriorated significantly. After handover of both patients, the pilot and Genevieve quickly closed the aircraft doors to block out the pelting rain. ‘Dealing with rainwater in the aircraft is difficult without a mop; and wet linen and clothing on both the patient and the nurse is less than ideal,’ Genevieve says.

  On flight departure, it is policy for the ambulance officers to wait for the aircraft to leave in case the flight nurse decides the patient needs to return to the hospital or needs help with anything. ‘I conducted a quick assessment of our labouring woman. With everything okay, the pilot started the engine and we took off. Once in the air, I checked on the woman again. Due to the bad weather and turbulence, I had to stay seated with the seatbelt fastened, which limited my ability to conduct a full assessment. But it was clear the woman’s labour was progressing. Mid-flight she said she felt she needed to push. I thought, Oh no this is not a good situation. I really don’t want to be alone up here with a woman in active labour who could have a postpartum haemorrhage (PPH) and then a premature baby that might need resuscitation.’

  Genevieve also knew that blood and amniotic fluid could corrode the aircraft airframes and interfere with the avionics under the aircraft floor. ‘So I encouraged her to breathe deeply and to blow out to help avoid pushing. Although I hadn’t done a vaginal examination, this was her fourth baby, so I estimated she was probably about eight centimetres, not yet fully dilated – another reason not to push. As we neared the airport she said again that she really wanted to push. I encouraged her to keep blowing and I explained to her that if the baby birthed I’d have two patients to care for. I said, It would be difficult to decide which of you to care for first if we have a worst-case scenario. There’s no one else on board to help and we certainly don’t want the pilot over here to assist!’ With sheer inner strength and mind over matter, the courageous woman made the determined decision to keep blowing to avoid pushing.

  ‘Power of the mind prevailed (and maybe the medication finally started to work) and the baby wasn’t birthed for another twenty-four hours.’

  Genevieve regularly flew into rural and remote areas to retrieve women for their sit-down, those who had started labouring prematurely, or those with high blood pressure and/or premature ruptured membranes. ‘We attended the full gamut of emergencies, from mining accidents, snakebites, road accidents, cattle-station accidents, farm accidents and fractured bones to women in early labour where there is no midwife available. I’ve stabilised people in hotel rooms, front bars and station lounge rooms. I’ve sat in the back of a ute with a stretcher and bags and bumped along to the station manager’s house to treat someone on the floor. I’ve been taken to a clinic in a remote community in the back of a paddy wagon to stabilise a patient – now that was interesting! I had never been in a paddy wagon before this. Hurtling along dry, dusty, rutted roads at a rapid rate is quite an experience. In those areas the SES and ambulance crews are all volunteers, and along with the police, they keep it all going. Sometimes we had to land on the road, and they would get in and organise the safety of th
at. If the pilot couldn’t put down at a designated airstrip the police would go along and take out the side posts so the plane could land on the road without hitting the posts with the wings. The road would be blocked off and we could see the endless trucks lining the road as we approached for landing. Even though the pilot tries to park off the road, if there’s a major accident across it, everyone’s held up anyway. Every experience topped up my knowledge so I’d know what to do better next time and how to improve my care of people.’

  Often nurses working in remote communities are the only nurse on call 24 hours a day, seven days a week, and working on their own for six-week blocks. These nurses usually contacted the RFDS doctors for support and advice over the phone when needed. When called in to assist, the RFDS crew would deliver milk, bread, papers, pillows and blankets, medications and other resources to the nurses – anything they thought might be appreciated. ‘Often the communities had to wait a fortnight or more for a pharmacy order to be flown in, so we’d take in medications to replace whatever were used on the ground. We all pulled together as part of a big team and we had a great system in place.’