Should Midwives Be Nurses First?

When I first heard this “recommendation” from the Okenden report. My initial response was to roll my eyes. I felt defensive. I also felt totally unseen. My own journey into midwifery did not involve “nurse training” so naturally I felt annoyed by this assumption that carried with it a really unhelpful “in my day” energy.

I watched social media as the popular birth accounts started posting responses. All quick witted, and getting straight to the point, putting words to my thoughts with images, memes, and articulating much of what I was thinking.

I wanted to respond too.  Despite “not having a very big following”  (something a popular birth account remarked about me when I asked if they would be interested in having me on their podcast), I had a lot of thoughts I wanted to share too.

The Okenden recommendation seemed to say in so many words  “Back in my day this was how we were trained, and it worked well, and it’s because we don’t do x, y, z, anymore that these terrible tragedies are happening”

I appreciate it is human nature to look back on your own experience and view it as superior. Yet the reality is that maternity care, obstetrics, and the NHS are not what they were 20-30 years ago.  So to superimpose exactly what “worked” then, onto the current situation is unrealistic, unhelpful, and feels out of touch.

When I finally had time to try and create my own response, I realised that so much of what I wanted to say has already been said.

I have decided instead to share my story.

To reflect on my path into midwifery, rather than defend.

My journey into midwifery is probably the furthest you can get from “starting out as a nurse”. My grandmother was as nurse for 40 years, so maybe it’s somewhere in my DNA, but honestly it is not a profession I ever seriously considered entering.

I lived a very different life up until the age of 37.

There are “mature” students, and there are 37 year old newly divorced single mums who can count on one hand the times they have stepped foot in a hospital.

I was the latter.

I had absolutely no clinical experience, and I had a lifelong history of feeling nervous around and judged by medical professionals.

On my first delivery suite placement, everyone wore the same exact scrubs. So because I looked so much older, it was not obvious I was a student. until you took a closer look and clocked the wide eyed pensive look on my face, constantly on the edge of profound embarrassment.

I inwardly cringe as I remember:

The first time I tried to take someone’s blood pressure with an electronic machine  and put the cuff on the wrong way around and it just blew up like a balloon.

The time I I was asked to grab some equipment for canulation and did not even really know what a canula was exactly let alone where the various “bits” lived or what they looked like.

The first time in theatre, when a registrar freshly scrubbed for surgery whipped around and angrily snapped “did you just touch me?”

The emergency transfer to theatre when I was handed a ream of CTG paper and the doctor asked to see it and I dropped it on the floor and it unravelled everywhere like a giant accordion.

The first attempt at scribing during an emergency and the midwife slapping the paperwork down saying “this would never hold up in court”.

Functioning in a clinical environment and getting used to performing basic clinical tasks, documenting, and communicating in a multi disciplinary team is a massive learning curve for anyone. Some take to it like a duck to water. Others (like me) take a bit longer.

I will never forget how intimidated I was to take blood. I think I was the last student on my cohort to learn.  My first few fumbled attempts  left me in tears. One of my midwife mentors gave up and just refused to teach me and told me I would have to learn in another placement.  A rather rude and dismissive midwifery support worker told me I should go back and “practice on the dummies”. But by the end of my first year, I ended up perfecting the skill during a heat wave where I had to take blood from women who had been fasting all night in preparation for their gestational diabetes test.

In addition to being  older, with no clinical experience, I had a long history of never feeling comfortable around medical professionals.

Growing up, my mother would try every “natural remedy” when I was sick as a child, and I have memories of kitchen cupboards overflowing with supplements, herbs, and mysterious tinctures and very few memories of engaging with the medical profession.

Having to “go ask the doctor x, y, z” filled me with absolute terror. I will never forget entering a handover room where the doctors were gathered. The midwife I was working with must have wanted me to tell them something, and I distinctly remember the feeling of them literally looking straight through me as I spoke, the colour draining from my face.

I was also completely unfamiliar with the hierarchy and varied roles of medical professionals ie who was who, SHO’s, ST3’s. consultants, baby doctors, advanced nurse practitioners, anaesthetists, ODP’s.

So that was me, the extremely “mature” student midwife, awkwardly fumbling around certain aspects of her first placement, but, fortunately, not all aspects.

My very first day on delivery suite as a student, I was assigned to a room where a woman was in the throes of a complex induction of labour.  This experience is common for student midwives training today. We are meant to spend the first year learning all about normal birth, but the reality of practice makes this impossible.

Most student midwives’ first exposure to care in labour in in a high risk setting. 

The midwife assigned to this woman was kind, capable, and experienced. She  graciously took me under her wing, introduced me to the paperwork and gave me simple tasks I could do straight away with supervision, such as recording observations, and documenting the fetal heart on the partogram every fifteen minutes (my very first introduction to reading a CTG). She also helped me take the woman’s blood sugar and I observed closely while she adjusted the woman’s insulin requirements. I was in no way responsible for any aspect of her care, but I certainly learned a lot that day.

Without disclosing too many details, in addition to the complex clinical care, the family required quite a lot of support emotionally. As I was getting to grips with the paperwork and recording observations, I found that providing emotional support was something I could do without really even trying. It felt natural and effortless.  (unlike figuring out how to put a blood pressure cuff on).

At the end of the shift, the midwife and I stepped outside the unt together after handing over, and the midwife burst into tears. She was exhausted, drained and discouraged. We talked about the situation and I confessed that I felt out of my depth with regards to the clinical side of things. She looked up at me and said “but you were amazing at supporting her emotionally,  and that can’t be taught. All that other stuff?? You will learn it. We can teach you that, and you will get plenty of practice,  but what you did in there today on your first day? The way you supported her? That is midwifery, the rest of it will come in time.”

It was an incredible compliment to receive on my first day, and it certainly helped me get through the course, on those days when my confidence was low, or when I would be crying at the end of a shift thinking “I don’t know if I can do this”.

Three years and hundreds of practice hours later, despite my total lack of clinical experience, I learned.

I am coming up to six years qualified as I write this. I surprise myself some nights when I leave a room and report to the coordinator that I managed to “canulate and get bloods” off a woman in advanced labour, a skill that I still find challenging but have come a long way with.

I do not recognise myself when I hear myself over the phone to the on call senior obgyn,   knowing I have just woken them up, firmly asking them to come and review a woman for me.

I have always viewed my time within midwifery as an exercise in personal growth, so the learning is ongoing. Some aspects come naturally, other aspects I am still learning.

 I do not expect to be perfect at everything, and I know I will always benefit from good leadership, support, and help.

So did not doing my nurse training first put me at a great disadvantage?

Maybe? Sometimes when a doctor asks me a question about a complicated case I have just taken handover for, and I don’t immediately know the answer, my brain descends into a fog and I battle feelings of incompetence.

Sometimes I am I situations where I feel out of my depth, if here is something I am struggling with, I ask for help. I know that my ability to carry out the role of the midwife is not defined by getting a grey canula into a tiny vein, or some of the more complex elements of delivery suite care.

When I reflect on my overall education, what has contributed to moments in my practice where I was out of my depth? Moments where things nearly went very wrong, but thankfully didn’t?

What was lacking was not “nurse training”. In reality , I spent hundreds of hours in clinical environments getting to grips with the basics of physiological observations, paperwork, escalation pathways, clinical language, medicines management, and clinical skills.

Like most of the midwives trained in recent years, my practices hours more than prepared me for the role of an obstetric nurse.

On reflection though, I can identify one obvious gap in my training.

A lack of solid consistent mentoring from seasoned midwives who could really spend the time teaching and modelling the intrapartum care. Midwives who knew when to sit on their hands, and when to act. Skills that are learned and perfected over time, from those with years of experience supporting physiological birth.

When the induction rate is so high and less than 10% of births are occurring nationally in a midwife led environment, it is understandable why this sort of mentoring is not happening for students as well as newly qualified preceptor midwives.

The clinical guidelines and parameters for accessing midwifery led care in labour are narrowing all the time making it ever more difficult.

I did of course work with some wonderfully supportive and skilled midwives of all ages as a student.

But sadly, one of the first midwives I worked with on delivery suite was recovering at the time from having been to coroner’s court. The nightmare of every midwife. It was only my third or fourth day on placement when she broke down in tears telling me about it after a doctor had approached her asking her how it all went. She said “that was the first time he’s spoken to me since it happened”. She is no longer a midwife.

Rather than learning how to be calm and competent, I learned how to be afraid.

There is an erroneous narrative in the media perpetuating this myth of young newly qualified midwives being “overwhelmed” or not at all prepared for the level of care required of them to deliver. This could not be further from the truth in my experience.

Once I qualified, I found the support was fully in place for learning and growing and excelling in a high risk setting. The whole team is there. Experienced midwives, the senior midwife coordinator, your fellow peers, and even the doctors are often more than happy to support and teach.  You are in the deep end, but there are life jackets everywhere. You are not alone. The stress is real, and fear is tangible, and many times there are not enough of us, but, we are not totally alone.

Perhaps I was fortunate enough to be in a workplace where I was not afraid to ask for help. Or maybe it was my maturity that recognised it was better to look incompetent asking for help, than not ask for help and then something go wrong.

I would argue that today’s midwives are more “nurse trained’ than they were several years ago. The role of the midwife more closely resembles that of an obstetric nurse. With a 50% C-section rate, and a 60% rate of induction of labour and most hospitals only reporting 6-10% of births happening on a midwifery led unit, and less than 1% of births happening at home, this would suggest that student midwives today are getting far more exposure to obstetric practice and care than they ever did and far less exposure to normal physiological birth.

When midwives qualify,  they can scrub for theatre, take blood, canulate, catharise, take observations, interpret CTG’s, safely move  immobile patients, and can confidently communicate with doctors and other senior medical staff. They also have extensive experience caring for women in the community and will have seen many women begin their pregnancies as midwifery led, and over the course of nine months be transferred to obstetric led care for any number of reasons.

By the time they do their first shift as a qualified midwife, they have likely been exposed to more obstetric emergencies and assisted in more instrumental deliveries than their “nurse trained” counterparts did 30 years ago.

One slight caveat to my reflection is that perhaps those who have done their nurse training have more exposure to true pathology, due to the nature of their work, they are exposed primarily to those who are unwell. One of my midwifery colleagues did a masters course  in critical care and her reflections afterwards were not what I expected. I imagined a midwife doing this course would come away much more risk averse, and nervous about midwifery led care, having studied in depth just how critically unwell women can become in pregnancy and as a result of complications in birth. Instead she experienced the opposite. She said that really learning  in depth about pathology, and what it actually looks like when a woman is critically unwell made her much more confident looking after well women in spontaneous physiological labour.

The way midwives have entered the profession certainly has changed over the years, and the education of midwives does need consideration, but to blame the tragic stories and failings that have been exposed in recent investigations all down to this ONE aspect is extremely short sighted and gives off  “in my day…..” energy, not to mention historical scapegoating.

It disregards how maternity care, especially standard midwifery practice is essentially unrecognisable to what it was five years ago, let alone twenty or thirty years ago.

Midwifery education in the UK has changed, but so has midwifery care, obstetrics, and the NHS right alongside it, and at an alarming pace in just the last five years.

Nurses who converted to midwifery training thirty years ago would not have been expected to manage several high risk inductions at once. A process that inherently poses risks to both the mother and baby, can be highly unpredictable, and requires frequent close monitoring. They would not have been looking after the sheer number of mothers and babies on a post natal ward, recovering from surgery, or being treated for suspected sepsis.

However what they would be doing, is attending more home births, and caring for more women in spontaneous labour.

So to put is simply, twenty  to thirty years ago, midwives who first trained as nurses worked in a far less medicalised environment, caring for mostly well women having  mostly normal births. Today, direct entry midwives are gaining far more experience resembling obstetric nurse training, and have far less experience looking after normal physiological labour.

The way it’s being communicated is that there are all these fresh faced midwives who are fumbling around delivery suite not sure of what they are doing because all they know about is normal birth. It just isn’t the case. There just isn’t enough normal birth happening for them to have that kind of experience.

Back to my own story. How would nurse training had benefited me?  I certainly would have avoided some of the more awkward cringe moments as a 1st year student midwife. I would have been more comfortable in a clinical environment, and probably less intimidated by doctors. Having not done nurse training definitely hurt my pride at times, damaged my ego, and caused flushes of embarrassment, but it certainly did not put any woman or baby in danger.

Over time, I learned what I needed to learn in order to practice midwifery which is fundamentally different to nursing. Holding space for a woman giving birth, which at times involves medical understanding and clinical care is not the same as looking after someone who is unwell or injured.