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Career profile: Community midwife

Community midwife
NAME: Fiona Coker

OCCUPATION: Community midwife

What is your job? Describe your main duties and responsibilities

I’m a community midwife and have been since 1993. For the last five years I have also managed the community midwifery service locally. But my strengths are as a clinician, not as a manager. I consider myself very experienced but not an expert. As a community midwife, my job is to see women who are newly pregnant and take a detailed health assessment. This includes any previous pregnancies they may have had and we consider mental, physical and social health. This appointment may be in a surgery or in the clients’ home. Antenatal screening is a large part of the choice agenda in the antenatal period so women have a lot of information to absorb at this time. Once the assessment is completed, I’m responsible for making an assessment of risk to the client and her baby. In conjunction with the client, we then decide which pregnancy care pathway would be most suitable for her as an individual.

I give antenatal care to women in clinics, which tend to be routine appointments, and sometimes at home if a problem has been identified. All community midwives in this area offer a birth-planning meeting to women, which is generally conducted in the home environment. Intrapartum care is given to 6-7% of women in this area in their own home and so as a community midwife I’m on call for women in one particular area. On average I will do two to three nights a week on call and will work one-in-four weekends. There are women that are very keen to know the midwife that will be delivering their baby and there are times when the consultant unit is short of staff, so I may give intrapartum care to women in the hospital setting. The community teams work in pairs and so I will be first on call for women in one area and I am also second on call for a neighbouring team. This is because it is recommended that there are two midwives present at a birth. Community midwives give postnatal support to mothers and babies at home and have a huge agenda around public health; so screening, smoke cessation and encouragement of breastfeeding are large parts of this.

What is your favourite aspect of your job? 

As a community midwife, I work autonomously so there are daily challenges on balancing efficiency with quality and working within the sphere of midwifery practice. You have to think quickly, act quickly and often have to be creative about how you prioritise work. For example, women that are in need of care do not always have that perception and so do not ask for help. Then there are those that are very capable and do not need care but want it and so they shout the loudest! I think what I enjoy mostly about the job is that it stretches me without usually stressing me and that every day is entirely different.

What are the challenges you face in your job?
Working within the NHS is challenging. In all areas of the NHS there are never enough resources and politics are influential from the top to the bottom of the organisation. In lots of ways the NHS is a victim of its own success. As new techniques are discovered and new innovations are introduced the organisation has to endure more cost, which brings further financial pressure to bear. The greatest challenge I feel is to work within these constraints and yet feel positive about the job on a daily basis. I manage this by ensuring I have some awareness of the machinations of the organisation as a whole and trying to focus on the balance between quality and efficiency, as well as supporting people to become parents.

Please give me a real-life scenario of an easy aspect of your job

Today I conducted a booking interview with a woman and her partner that have had 16 years of infertility. This was a very rewarding experience as this couple have finally achieved a pregnancy and was so thrilled to be meeting a midwife. The fact that midwives are so welcomed into homes and families makes life very easy.

Please give a difficult aspect of the job

Last week I was called on a Sunday evening just as I was putting dinner together for my family. The labour ward was calling and they asked me to attend a woman that had felt ‘the urge to push’ an hour ago. That sensation had dissipated but now she felt the urge to push again. Other than being told this was the woman’s third baby and that she was in the 39th week of pregnancy, I had no other information. Each time I go out on call I get a frisson of anticipation, as I never really know what I am going to encounter when I get to an acute situation. No matter how tired I am I need to switch on my brain and work within the parameters of guidelines and policies that ensure safe practice. On arriving at the home, the woman was writhing on the floor of her lounge holding her lower abdomen and moaning ‘my scar, my scar’. Two of her children were in the room looking quite terrified and her partner was in a blind panic. I asked him to call an ambulance as I could see, from her abdomen that she had previously given birth to at least one of her children by caesarean section and in subsequent births there is a 1-2% risk that the scar will dehisce in labour. Next I administered some Entonox as pain relief and ascertained that she had had a straightforward first pregnancy and her first child was born vaginally, but the second was in a breech position and delivered at 39 weeks by caesarean section. She had been experiencing mild abdominal pain for most of the afternoon, but this had intensified over the last hour. The woman’s pulse was a little high and I could not auscultate the fetal heart. On looking at her abdomen, there was a large swelling over her scar. This could have been the baby’s head herniating through the scar or it could have been a pronounced bladder and her husband could not tell me when she last emptied her bladder. The ambulance had yet to arrive and I was worried that I could not hear the baby’s heartbeat. I decided to examine her vaginally; just before doing so I popped a catheter into her bladder and emptied 500mls of urine. The swelling dissipated and she then began to push to expel the baby. On examination I found her cervix to be fully dilated and the baby was advancing headfirst. I could then auscultate the baby’s heart rate and as the ambulance arrived she pushed a 7lb baby boy into the world. To say I was relieved was an understatement.

Why did you choose to become a community midwife?

I became a community midwife quite by accident, not choice. I had been qualified for 18 months and had been doing some preparation for childbirth classes for the team nearest to my home. A situation arose where the team needed someone to relieve for holidays and I was asked whether I wanted to do this. I was keen to increase my experience and knowledge base, and so agreed. Within two months I was hooked.

What route did you take to become a community midwife?

I trained as a nurse before becoming a midwife. I had not considered midwifery until I did a small stint during nurse training and it was very obvious to me that midwives worked in a different way to nurses and they were very autonomous in the way that they practiced. I appreciated that the work was very acute and that midwives worked predominately with well mothers and babies. This was different from the sick and dying patients I worked with as a nurse. After qualifying as a nurse, I worked in a paediatric unit that was very acute and very dangerous because of very poor staffing and the amount of very sick children on it. After two years I decided I needed progression and considered and applied for midwifery. It’s a decision I have never regretted.

Three words to describe yourself:

Kind, motivated, positive.

What advice would you give to a student midwife wanting to become a community midwife?

If a student midwife wants community midwifery I would advise them to pursue this ambition. Community midwifery is hard work but very rewarding and you learn to think differently as a lone-working midwife. It is more than a job, it is a lifestyle and it is important that midwives and their families understand this. There are interruptions to family life with calls from colleagues and the on-calls are challenging. A caseload is with you 24 hours a day. The real positives are that community midwives understand normality and strive to maintain this, but they need to be careful that they do not try and make the abnormal, normal. I think being a midwife in the community is a privilege. It has its frustrations as any career does. It takes commitment, and midwives need to be supported to practice in this way. It is also fundamental to be a team player because although community midwives are lone workers they are always in a team and that team is a resource to be used. Community midwives must be excellent communicators as there is a lot of information to be imparted and gleaned in a short space of time. Knowing how to communicate with women and their families, from all walks of life, is a skill and kindness costs nothing.