After three years of training, Gayle Smith has been a registered midwife at UHNT for three years.
She came to midwifery later than most, starting her working life with the post office: “managing different kinds of deliveries!” Gayle was inspired by the midwives who helped her give birth to her own three children and, following a three year stint in NHS administration, decided it was something she wanted to do.
The day begins at 7.15am with handover, where Gayle is allocated Sarah (not her real name) to look after today. Sarah is in for induction of labour for her sixth child, as baby is small for her weeks of pregnancy. She’s very worried about the prospect of caring for six children and is understandably emotional. Midwife Polly hands over care to Gayle and they agree an appropriate pathway of care to ensure the wellbeing of both mum and baby.
Gayle introduces herself to a clearly upset Sarah, and attempts to reassure her and build an early trusting relationship. She takes a blood sample to check iron levels while she gently asks about her home life and support networks, checking her family history. Gayle needs to ask many questions; any pain when you pass urine, are you opening your bowels normally, are you eating well, any nausea or vomiting, pains, headaches, spots in front of your eyes? Do you know what you’re having? A boy? How lovely! Any allergies? No. Are you happy for baby to have a vitamin K injection when he’s born? Feeding choices are discussed and Sarah knows the benefits of breastfeeding but prefers to feed formula milk.
While she’s sending the bloods to the laboratory through the pod system, the delivery suite phone rings and Gayle picks it up. The caller thinks she’s in labour. During the conversation, the woman doesn’t have any contractions, so Gayle advises a warm bath and paracetemol for now, and documents a plan in the triage paperwork to review when the woman rings back.
Sarah’s asked whether she’d like to be involved in the unit’s OASI trial. Usual birthing practice is at the discretion of the midwife to either have “hands on” or “hands off” the perineum, but OASI is testing the effectiveness of all midwives guarding the perineum with their hands during birth to reduce the risk of tearing. Sarah agrees to be part of the trial, when the time comes.
Gayle listens to baby’s heartbeat, first using the doptone (this reassures Sarah who remains anxious) and then again using a Pinnard stethoscope (pictured) which is a traditional method of listening to baby’s heart rate.
Then Gayle prepares Sarah for induction, attaching a CTG machine to Sarah’s tummy to monitor any contractions and baby’s heartbeat, and completing routine observations along with an internal “membrane sweep”, before inserting a hormone pessary which will help to encourage labour. She’s talking to Sarah about her plans for the birth; does she want skin to skin? What pain relief? Who’s going to cut the cord? Gayle uses humour to help ease Sarah’s fears and anxieties throughout, helping Sarah relax and developing the mother-midwife relationship further.
Back in the break room, a kind colleague has prepared a plate of hot buttered toast and a huge pot of tea for their break, which the midwives fall on ravenously. Gayle is interrupted by shift lead, Kim. A patient has self-referred to the day unit after her waters broke, and she’s in room 18.
Erin has arrived wearing soggy pyjama bottoms; she is with her partner. She’s five days past her due date with baby number five. She’s classed as a high risk mum as she’s very slight (also known as low BMI) and has had two previous caesarean sections. Gayle checks her history and performs a quick but thorough examination.
Meanwhile, Sarah’s partner and mum have arrived. Gayle updates her notes: “I like this pen” she comments. Clearly, pens are very important to midwives, who write a lot.
Suddenly, an alarm buzzes and Gayle drops her pen and runs from the room. One of the mums in another room is having post-partum haemorrhage, which is when some women bleed more than normal after delivery, and all the midwives rush to help.
As she runs past the nurses’ station (so this is why they wear trainers!), Gayle calls to the ward clerk to bleep the registrar. It’s a hive of activity, with the team calling instructions and responses and mum clearly in distress, but as the bleeding slows, her blood pressure improves, the noise subsides and the normal calm environment returns. It’s 10.40am.
At the nurse’s station, a past patient is waiting with her husband and new baby. She’s bearing flowers, chocolates and biscuits to say thank you to Gayle, who hugs her and coos over the baby: “I’m really touched to know I’ve made a difference. I don’t do this job for the babies; I do it for the mums” she says. Any gifts or letters of thanks are recorded on the Compliments chart in the staff room, and Gayle adds hers to the list.
Gayle’s keeping a watchful eye on Erin, who is hoping for a vaginal delivery after having two previous caesarean sections. She is now bouncing gently on a birthing ball to try and speed things along. Baby’s heartbeat dropped slightly with one of her contractions, which means a CTG stays on for now to continue monitoring in case baby starts to show signs of distress. Moving between the two rooms, Gayle checks regularly on her charges, updating notes, helping with pain relief and calling Kim into both rooms to check the CTG readouts. This is called “fresh eyes”, and is a protocol to make sure each CTG monitoring gets a second opinion on its interpretation and classification.
The nurse’s station is a haven in this busy unit – everything has its place and forms, reports and specialist equipment are all neatly stacked on their own shelf. There’s an air of calm efficiency as the midwives check their screens while absent-mindedly comparing the dryness of their hands from the frequent washing and application of antiseptic gel.
Sarah buzzes, she thinks labour is starting. Once a woman is in established labour, she must have dedicated, 1:1 midwife care so Gayle askes Kim to take over with Erin while she picks up a prescribed loading dose of antibiotic Benzylpenicillin from the electronic drugs cupboard, known as the Omnicell; this antibiotic will help protect Sarah’s newborn from Group B-strep. Gayle then goes and locates a drip stand.
Sarah’s contractions are getting stronger; she’s definitely in established labour. It’s 2.24pm. Gayle breaks Sarah’s waters and offers her some diamorphine to help with the pain, as she appears to be uncomfortable despite using gas and air. She asks Sarah to rate her pain out of ten… she’s at eight or nine.
Gayle continues to monitor Sarah who is getting more uncomfortable, all the while quietly checking her charts and updating notes. Is it pain or pressure? Both. Kim calls in to “fresh eyes” Sarah’s CTG monitoring and Gayle consults her on the new NICE guidelines for fetal monitoring in labour which have just been introduced to the unit this week and they update the notes together. It’s 3.24pm.
Suddenly Sarah needs to push, and in ten minutes, baby’s head is out and the rest of him quickly follows. Gayle helps Dad cut the umbilical cord, gives Sarah a quick injection in her thigh to help with delivery of the placenta then goes back to her notes, to update on the birth.
Sarah is peaceful, holding her newborn. Dad’s facetiming the family and they’re all thrilled with their new brother, squealing with congratulations and exclaiming how much he looks like one of his elder siblings.
Sarah hasn’t delivered her placenta, so Gayle and Kim help out, massaging Sarah’s toes – it’s a pressure point and can help release it. Once the placenta is delivered it is checked carefully to make sure it’s complete, as any bits left behind could cause a nasty infection or a postpartum haemorrhage – but everything’s fine. Gayle inspects for any tears and carries out basic observations again, and Sarah is given time to bond with her baby in skin to skin.
Sarah has forgotten to bring in her own bottles of formula milk so Gayle brings in some baby milk, so Sarah can give her baby his first feed, and leaves with instructions that he must feed at least 15-20ml.
At 4.30pm. Gayle finally cuts into the enormous lemon cake she brought for her colleagues this morning and inhales a huge slice with her second cup of tea of the day.
Baby is weighed and measured and he’s managed 25ml of milk. Mum has been taking dihydracoedine during her pregnancy which means he needs to be monitored for withdrawal. With Sarah’s permission, Gayle pops a red wooly hat on his head so he can be easily identified as needing a bit of extra looking after.
Baby’s delivery is recorded on the trust’s electronic patient record system, Trakcare which will generate his NHS number, and his birth must be logged on the Grow app, which is a tool used to identify clinically small babies who may need extra care. GROW flatly refuses to function on two computers, but works like a charm at the third machine. It doesn’t take long, there’s one page for baby and another for the placenta.
It’s ten past six. New patient Julie has been brought in for induction after she was unsure if her waters had broken over a week ago and a scan showed low levels of fluid (liquor) in her amniotic sac. She’s 37 and a half weeks pregnant. Gayle palpates her tummy and she can feel baby’s head like a cricket ball in her lower torso. She launches into the now familiar long list of questions and explains how induction will work.
Back at the nurse’s station, Gayle registers Julie on the system and begins writing up notes before a quick round of her charges – Sarah’s fine and baby’s feeding, Erin’s gone for a walk to try and move things along.
Finally, it’s 7.25 and time to hand over to the night shift – suddenly there’s a commotion at the end of the corridor. There’s a shout from a room where a woman has just come in: “The baby’s here!!!” and the midwives rush to help.
Afterwards, Gayle stays behind to finish up her notes from the day. As we’re saying goodbye, we check the status update for the most recent birth. The new mum was 2cm dilated when she was examined an hour ago. Gayle grins: “If you’re going to have a baby, that’s the way to do it!”