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Posts Tagged ‘staffing levels’

Tomorrow, 13th October 2014, is an historic date in the history of midwifery, for tomorrow midwives are striking for the first time since the profession became regulated. Shock horror, women will be left unattended in labour; babies will die, just a couple of scare-mongering comments I have read in response to articles discussing the industrial action. Wrong. Midwives are ‘striking’ from 7am until 11am on Monday. The strike action may affect elective caesarean sections and routine appointments, other services i.e labour wards, birth centres and the on-call provision for homebirths will be unaffected. For the rest of the week midwives will be working to rule, in other words they will take meal breaks and finish work on time.

Well, how much of this will happen? The usual level of staffing for births will happen, as for the rest………it is unlikely that there will be an adherence to the work to rule.

Why are Midwives joining in the action? The pay review body recommended a 1% pay rise, the government decided not to take this advice. At the same time as this has happened the cost to remain registered as a midwife (or nurse) has increased by 31.6%, with a further 20% rise in the pipeline. The pensions contributions have risen from 6.8% to 9.5%. Those are just a couple of the financial reasons but for me, why would I take action*?

I’m sick, tired and fed-up with the way the maternity services rely upon ‘good will’. A joint staff-side survey in 2012 discovered that two-thirds of midwives work more than 2 hours extra each week and, of those responding, only 2.9% have recompense for the overtime. Many Trusts now operate a 12-hour shift system. Staff working these should expect to have a break, in my experience this doesn’t occur, midwives work through, constantly on their feet and making life or death decisions in frequently stressful situations. The community scenario is often equally debilitating. A community midwife can expect to work all day and then, if on call, may find herself continuing to work through to the following morning. This is not necessarily due to a homebirth happening, s/he can be called in to cover a birth unit or the labour ward. A working day approaching 24 hours is not unusual and this is totally due to ‘a lack of NHS funding and a national shortage of 2,300 midwives‘. This is why I support the action. Yes, I would enjoy a pay rise but far more than that I am calling for an increase in staffing levels. I want the maternity services to be safe for women, babies and care providers.

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Midwife Muse’s roll call of causative factors so far –

  • PCT’s for with-holding government monies
  • Groups who place the majority of their emphasis on THE BIRTH, and lobby accordingly, putting antenatal and postnatal care on the back burner
  • Trusts for employing too many managers

Fittingly the midwives come last, that’s the usual position we appear to occupy in any planning, so why alter the status quo? Why are we to blame then? Well we will do what we always do when change is foist upon us, we will grumble, get stressed, some of us will even rant, in private but ultimately we will comply. When I used to work in the unit the obstetricians, generally the registrars, would keep coming out with jokes which were always based upon how bolshie midwives are, ‘What’s the difference between a rottweiler and a midwife? A rottweiler eventually lets go.’ That may be true in the one-on-one clinical situation, when we are being an individual woman’s advocate, but as a group, when change is being imposed, our contracts being re-written or some other attack on our ability to provide the care we KNOW that we should provide we capitulate and fail to work together to resist or modify the changes.

My crystal ball is showing me that once again we will moan and have a brief, vaguely supportive interaction with our union, incidentally that won’t get us anywhere (prediction), a couple of us will leave, another couple will retire, half of us will apply for other jobs, perhaps midwifery related but the majority of us will just end up going along with a change we are intensely unhappy with.

Midwives are their own worse enemies. We are already working above our capacities, both within the maternity units and in the community but we don’t ‘work to rule’, we can’t, but we should. The managers are not ignorant of the ridiculous workload and the number of extra, unpaid hours the staff put in, in fact I do believe that the managers join in sometimes, so we are all colluding in the farce which will allow these changes to go through, these changes which will definitely affect the coal-face midwives, the women and babies.

For a profession whose members are portrayed as fierce we are badly misrepresented, we are actually shrinking violets.

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I’ve been musing, and I’ve come to an earth-shattering decision, early discharge from hospital after giving birth should not be encouraged. I can sense much sharp in-taking of breath, I know, it’s pretty radical stuff, now I’m going to explain myself.

Recently I made a day 5 visit, that’s the day we reweigh baby and take the neonatal blood screening test (aka heel prick; guthrie; PKU). This was the couple’s first baby, born by emergency CS, 2 day hospital stay, second visit by a community midwife. They had phoned before I left the office to ask what time a midwife would be visiting  as they had seen some ‘blood’ in baby’s nappy and were worried, I told them that I would make them my first visit and asked them to save the nappy. Mum and Dad had been to NCT classes so, when having looked at the nappy, I told them that it was normal and was urates from his urine they then produced an A4 handout they had been given, which showed photos of what they may see in early nappies! Having addressed the blood in the nappy worry I had a look at her notes, useless, the hospital had kept her inpatient notes so I had no idea how things had gone for either of them whilst in hospital. The midwife who had visited before me had recorded that Mum as recovering well, her scar was clean and dry, baby was breastfeeding, passing urine and meconium. I glanced at baby and saw a ‘worried’ looking baby. Worried. This is my description of an underfed baby, they do all seem to have this little sad expression, a furrowed brow, very difficult to describe but when I see it it makes me worried. I decided to examine his Mummy first and remove her suture  before I had a good look at, and weighed him, I had a feeling that she may be somewhat agitated after I had examined her little baby. I should say more agitated as she was extremely anxious about having her suture removed, but my incessant talking worked it’s usual magic and the stitch was out before I could finish my life history. As I undressed baby I asked her about feeding, she was breastfeeding, basically when she thought that he should feed, this was equalling about three times a day. I gave them my usual spiel “It’s normal for babies to have lost up to 10% of their birthweight ……..we plan what happens next on how baby is, what the nappies are like etc. might just come back in 48 hours if all seems well and re-weigh then to make sure that baby is putting on weight but we might ask them to go into hospital to have baby checked by a paediatrician”. Baby’s mouth was very dry, his skin was like an old persons, there was no elasticity, his poo was sticky and green. He really wasn’t bothered about me undressing him, a floppy little boy. As I put him on the scales he showed his startle reflex, little arms and legs shot out star-like, his eyes opened wide, even those seemed dull, and his cry sounded as if he had been screaming for hours, it was hoarse. The results of the weighing were not good, he had lost nearly 20% of his birthweight. I explained to the concerned parents that I would be happiest if he were seen by a paediatrician but, first things first, get some nourishment into him. He was awake and trying to latch onto my arm so I asked Mum to get comfy and we would put him to the breast, once he was feeding I could then contact the hospital he was born in, not one I work for. Basically the attempt at feeding was not a success, Mum obviously had no idea how to breastfeed and it really didn’t help that baby was so malnourished that even hunger was not going to keep him awake. I showed her how to hand-express into a sterile syringe and I went through the long process of referring him to the hospital. I nearly lost the will to live at one point, I considered hanging up on the officious, series of people I was put through to and just send them to the hospital I work for. In the end I resorted to the unspoken threat,’ Since you can’t seem to help, can you put me through to the head of midwifery?’ Works a treat, I was told that baby would be seen on SCBU.  On admission he was found to be severely dehydrated with dangerously high sodium levels; he was immediately put on an IV and a tube was passed into his tummy so that he could be fed easily. He remained in hospital for 8 days.

Following their second discharge from hospital I visited again. By this time baby was still not back to his birthweight, but was a different little man, alert, bright-eyed and peachy skin. His Mum was still anxious, and no wonder, she had spent over a week in a Special Care Baby Unit watching her newborn be jabbed, infused, and tube fed.

That’s the background to my desire to encourage women to stay in hospital for longer after giving birth. My concerns about this ‘early discharge’ culture has been growing gradually over the years, every week I come across examples of where a longer stay would have been beneficial but this latest one has been the most extreme. The couple involved were educated, one was medically qualified. They had attended NCT classes, hospital antenatal classes and breastfeeding ‘workshops’  but none of this theory had adequately prepared them to successfully nurture their first baby. The ward the woman was cared for on was safely staffed but this does not necessarily mean that there was time for staff to ensure that baby was feeding well, or time to reassure anxious first-time parents. The short stay meant that it was not evident prior to discharge that baby wasn’t breastfeeding successfully. WHO wish to promote exclusive breastfeeding, to be successful some women require more support than ‘workshops’ during the antenatal period, they would benefit most from a slightly longer stay in an establishment where there are enough staff to provide assistance and reassurance.

Guess what it is that has caused the early discharge culture? It’s staffing levels, the closure of smaller maternity units and the resultant loss of ‘beds’. What causes all this? Cutbacks. It’s a false economy though, I’m not talking the small cost here of re-admissions, like my example above, I’ll just reproduce the opening paragraph from WHO’s ‘Promoting proper feeding for infants and young children’ and it’s easy to see that a cutback in the maternity services has lifelong health implications.

‘Nutrition and nurturing during the first three years are both crucial for lifelong health and well-being. In infancy, no gift is more precious than breastfeeding; yet barely one in three infants is exclusively breastfed during the first four months of life’. (World Health Organisation)

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“Unscheduled closures should only occur in very exceptional circumstances when to keep a unit open would be unsafe.” so said the NCT. What caused this statement? The news today that 50% of maternity units had to turn away women because they were full and 10% also had to close because of shortage of staff or facilities.  Thanks to the Conservative party this is now public knowledge and they are using the figures to show that  smaller maternity units shouldn’t close as they have fewer closures. I applaud their effort but do worry about their rationale for the link. Larger units, on the whole, provide care to ‘higher’ risk women as they have more specialist obstetric services, facilities and a higher level of special care units for premature or poorly babies. On this basis they are in higher demand and so more likely to experience having to turn women away if the woman, or baby is need of specialist services. I do agree though that the current policy of closing smaller units is unfortunate. They are there to serve a local community, whereas the ‘new’ larger units require women to travel 15 plus miles which has two effects. The first is that some women will go to the hospital earlier than they need to as they are aware they have some distance to go, frequently involving problems with traffic congestion, and once there are reluctant to return home until labour is established, and who can blame them? However, this has the effect of the unit becoming ‘clogged up’ with women who really do not need to be there. The other problem this can cause is that the labour is more likely to be subject to intervention, either early use of epidural or augmentation in an effort to speed up transit through the labour ward and so requiring increased vigilance as this is no longer ‘normal’ labour. As a result the staff are more pressurised, safety on the unit, due to staffing levels, becomes a concern and so the unit temporarily closes it’s doors. One of the reasons that smaller units are closing, and I’m not talking about ‘stand alone’ birth units here, is that because of the reduced hours of junior doctors smaller units are not able to sustain adequate medical cover, particularly paediatric, the solution is to consolidate services in one location. I’ve mentioned the stand alone birthing centres, these are midwife-led and have no medical cover so the shortage of medics cannot be used as the excuse as to why these are opening to great fanfare and then, all too often, closing after a couple of years. No, these close due to midwife staffing problems at the obstetric unit they are linked to. In the end, as usual, it’s all down to the finances as, if staffing levels, doctors and midwives, were not kept at minimal possible numbers, frequently below those recommended by Birthrate Plus, the units would not find themselves having to turn women away.

“It is difficult to precisely predict when a mother will go into labour and sometimes, at times of peak demand, maternity units do temporarily divert women to nearby facilities,” said a spokesperson for the DOH.

“True, this is something that will happen occasionally, but improving the numbers of Doctors and Midwives and keeping smaller units and birth centres open should make it less likely that this or this tragedywill be repeated.” said Midwifemuse.

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