The outbreak of COVID-19 has meant that midwifery around the world is currently set against an ever-present backdrop of disease. Although pregnancy and childbirth are most often a healthy and normal part of a woman's life, medical conditions and disease can also feature in the midwifery care that is needed. Throughout the pandemic, the world's midwives have continued to care for women becoming mothers and continue, in turn, to be shaped by their midwifery experiences. In a midwifery career, COVID-19 and other medical complications in a pregnancy can present steep learning curves for midwives and even sometimes refocus or change practice entirely. This narrative article explores two midwives' recollections of medical conditions in pregnancy that changed their practice and considers the conditions that played a role. These are their stories.
Importance of routine maternity care
In the Spring of 2019, I was running my usual weekly antenatal midwife clinic based in a community children's centre. A ‘low-risk’ woman and her partner attended whom I had met before. She was 28 weeks pregnant with her first child. She was an otherwise fit and healthy woman with no pre-existing medical conditions. Her pregnancy had so far been straightforward and under the sole care of the community midwives and her local GP.
On assessment, the woman appeared particularly oedematous and reported that this was of a sudden onset—her whole body, including her face, was noticeably swollen. Upon urinalysis, the sample stick became quickly glowing with the green of proteinuria—the darkest green I had ever seen. Her blood pressure, previously normotensive, was now hypertensive. On palpation, the fetal heart rate via sonic-aid was tachycardic and the symphysis-fundal measurement was below the 10th centile for estimated fetal weight.
As expected, I urgently referred this woman into the maternity assessment unit at the booking hospital of Queen Charlotte's and Chelsea—calling ahead to inform my colleagues of the situation. She was reviewed quickly by the senior house officer where she developed a sudden severe headache and was sent directly to labour ward with admission to the High Dependency Unit. She was soon diagnosed with severe pre-eclampsia, requiring pre-eclampsia protocol and the insertion of an arterial line with multi-disciplinary involvement. A scan showed that the fetus was severely growth restricted. The woman's protein-creatinine ratio was >900. That evening, she experienced an eclamptic seizure and a decision for emergency delivery was soon made.
A healthy, albeit premature, baby girl was born via emergency caesarean section less than 48 hours after the woman's attendance at my community clinic. The woman was discharged around 10 days later with outpatient hepatic follow-ups related to suspected liver disease. Her daughter remained on the neonatal intensive care unit.
I visited the woman at home following her discharge. She was unrecognisable in comparison to the woman I had reviewed a few weeks ago—slim, pale, non-pregnant and stunned. It was an emotional visit, the absence of her daughter, and the heavy atmosphere of such an acute obstetric complication hung in the air. The woman told me that she saw me as the saviour of her and her daughter's life.
While assessing for pre-eclampsia is engrained into the minds of both midwives and obstetricians, it was rare to experience such an abrupt and life-threatening case. Urinalysis and blood pressure is the bread and butter of an antenatal appointment, and yet so critically important. The significance of midwifery care – the routine and the regular – was made strikingly clear to me. I was being thanked and congratulated for the care I had given which of course was the care any of my colleagues would also have provided too.
So, while my everyday practice has gone unchanged – blood pressure, urinalysis, conversation, palpation, repeat – my perspective of midwifery and maternity care had. It is incredibly important for women to receive routine, consistent care (Chappell et al, 2019b; MBRRACE-UK, 2019)-however repetitive and simple this may appear. Equally important is the specialism of each professional and their quick-thinking ability to detect the acute in amongst the daily and often healthy presentations and questions of the pregnant women that filter in and out of our care (National Institute for Health and Care Excellence, 2019b).
A normal day for a midwife or obstetrician is the extraordinary day of an unwell woman. While this level of service seems obvious, it remains the case that many pregnant women in the world receive little to no maternity care (Hillan, 2017). I feel my voice for maternity services and my commitment to safeguard women and their families has deepened as a result of this experience. How essential, for example, is a manual sphygmomanometer, a trained professional and an attentive ear. These traditional, core skills are the making of every midwife and obstetrician, and yet so critical to women's health and experiences (Homer et al, 2014).
Our vocation is important; let us remember and be proud of that.
Written by Anna Merrick, community and research midwife at Imperial College Healthcare NHS Trust and Imperial College, London.
Table 1. Definition of key terms
| Key term | Definition |
|---|---|
| Severe pre-eclampsia | Pre-eclampsia with severe hypertension that does not respond to treatment or is associated with ongoing or recurring severe headaches, visual scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension, as well as progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal Doppler findings |
Table 2. Incidence and outcomes of severe pre-eclampsia
| Incidence of severe pre-eclampsia | Develops in 1%−2% of pregnancies in the UK |
| Maternal outcomes |
|
| Neonatal outcomes |
|
Betty's baby and the medical problem of poverty
It was 33 degrees under the mango tree. I was sitting in a circle with 10 Ugandan midwives who wanted to know more about how research could elevate their midwifery practice. We were on the grounds of a government maternity health centre on the edge of Kampala. I had come from London, supported by a Royal College of Midwives twinning project, to develop research capacity among Ugandan midwives. No small task to deliver, on the spot, without much in the way of resource or planning. I had, however, risen to the challenge and set up a four-day workshop on the role of research in midwifery.
On this particular day, we were at the health centre to undertake our pilot study of a survey designed to better understand the role of men in childbirth. Over the morning, we had engaged with men and women about their views. We were settling in to reflect on some of the main themes around this topic when someone came to tell me that my British colleague was asking for me on the ‘labour ward’, a separate building behind us a little bit off to the side and up the hill. My colleague from Norfolk's brief for our time in Uganda was to look at improving ways of working in the clinical setting with our Ugandan colleagues.
In this moment, an extra pair of hands was needed, so I excused myself hastily and headed for the labour ward. The so-called ‘labour ward’ was more like a depository. Women didn't go there to labour. They went there to give birth. The real ‘labour ward’ was outside the building where are all the partners, family, and other labouring women were pacing in varying stages and states of labour. My friend had brought a few birth balls from England and one had been adopted with good effect by a couple in the corridor. A labouring woman was rolling gently back and forth on the ball supported by her husband. He looked relieved to have a job to do.
I made my way past, into the delivery room, to a two-bedded concrete bay where Betty was about to have her first baby. Betty was thought to be about 34 weeks pregnant. My NHS-accustomed hands felt clumsy in the context but I soon ditched my layers of protocol and expectation, and got down to the simple task of catching her baby while the on-duty midwife made her way over. There would be almost zero documentation, no policies and, in this context, bare-bones midwifery seemed better than nothing.
What was about to happen was that Betty would give birth to her baby normally and swiftly, needing little from the shell of maternity service that surrounded her. In fact, my ‘nothing’ seemed better than something. The standard here was that midwives hurried women along in labour, sometimes slapping their legs or telling the woman to be quiet and to lie down. I saw the glass top of a syntometrine ampoule used to perform an amniotomy. In the midst of all this, there was almost always a financial transaction at the bedside. Scruffy bank notes were commonly passed across women in the throes of labour for a pair of gloves, a bag of fluids or a medication. The midwife also acted as the broker of equipment amidst a deeply broken infrastructure. In this context, my steady and respectful ‘nothing’ seemed a good enough match for Betty's brisk birth. The poverty of the place was the most complicated of diseases.
The fact of prematurity in this context has high likelihood of manifesting in some of the common disease complications of prematurity for baby, including necrotising enterocolitis, infection, feeding problems or retinopathy of prematurity, as well as possible longer-term cognitive, motor and behavioural consequences (RCOG, 2017). For the woman, prematurity is also a disease. The fact that absent antenatal care meant that medical conditions such as hypertension, pre-eclampsia, diabetes or infection that were possible causes of prematurity would never really be known or pursued (Tommy's Charity, 2017; World Health Organization [WHO], 2018).
In Uganda, the maternal mortality rate is 343 per 100 000 births. Antenatal care is increasing understood to be key to reducing poor outcomes yet antenatal care attendance for the recommended four visits is less than 50% (WHO, 2019; UNICEF, 2020). Barriers to this are complex and there are many. Luckily for Betty's baby, her breasts dripped with colostrum, her baby suckled spontaneously and there were no overt signs of infection or complications. Of course, that was just the beginning for Betty and her baby, and we won't really know the story from there.
Back in the NHS, I had all the feelings of a typical returnee from a low resource sub-Saharan setting and was fundamentally changed as a midwife for the better. Betty's birth and the context of Uganda gave me a calm and immovable focus on the woman herself in the moment of birth. Birth is socio-economically constructed and diagnosis and treatment of medical conditions will wax and wane dependently. Being born is like rolling the dice for much of the world and poverty is the biggest of diseases. Yet, in the fleeting moment of birth, most else momentarily melt away and, with a midwife, the woman can always be at the centre of her stage.
Key points
- Midwives are in a unique position to experience both normal physiology of pregnancy and the complex medical conditions that can accompany it
- The routine tasks of a midwife's daily practice are essential in identifying potentially life-threatening conditions
- Prematurity has different outcomes dependent upon socio-economic context
- Poverty complicates pregnancy and childbirth in complex ways
CPD reflective questions
- What medical condition of pregnancy has influenced your practice and in what way did it change your practice?
- How do you think your experience as a midwife during COVID-19 might enhance your practice?
- Who is responsible for the prevention, detection and treatment of disease in pregnant and postnatal women?
- How can midwives raise the profile of the significance of routine care?