Week in the Life of a midwife in Quebec

Monday

I am back on call at 8:30am, after a weekend off. At 8am I received a phone call from Christine, my practice partner, who gave me the news about our clients.

She attended Julie’s birth on Saturday morning at the birth centre, then visited Mom and baby again on Sunday. Everything was going well. Annie had a caesarean section on Friday for a breech presentation and will probably go home from the hospital today. Christine also told me about some telephone calls she received but don’t require any follow-up. She is now off call for 24 hours from 8:30am so I change the voicemail message on my pager to let clients know that I am available.

9am I arrive at the birth center for a day of pre- and postnatal visits.

The first is with Marie who is 24 weeks pregnant. We talk about her working conditions and how she might be able to rest during her breaks. She says she feels guilty about her impatience towards her children, and the lack of time she has to devote to this pregnancy. We talk about possible family support now and after the birth, and about paternity leave that her husband Jacques might be able to take. I give her information about gestational diabetes so that she can make a decision regarding the screening test offered. Her physical exam and health are normal. She will return in one month, and knows how to get hold of me if she needs me. After her departure, I record the key information from the visit in her file.

At 10am I meet Jessica and her partner for their first appointment at 12 weeks gestation. I have allotted one and a half hours to this visit because there is a lot to cover and they will probably have lots of questions. I take her medical, family, and social history; I explain the tests offered; I take blood, urine, and gynecological samples; and I do a general physical exam. Having explained the various screening tests available I give Jessica a prescription for an 18 week ultrasound in case they decide, after our visit, that it is something they want in this pregnancy. I end the visit by giving them some information about early pregnancy, about the community services available to them, and about how their midwifery team works, including the telephone numbers with which they can get hold of me.

At 11:30am I meet Mireille, along with her 12 year old daughter who hopes to attend the birth. Now at 37 weeks, Mireille comes every week, alternating visits between myself and Christine, to ensure that she knows the midwife who will attend her birth. Everything is going well for her today.

My first client of the afternoon arrives about 30 minutes late for her 2 weeks postpartum visit. She tells me that her baby was crying from hunger and she couldn’t leave the house on time. When she tells me she is having feeding difficulties I realise I can’t shorten her appointment and so ask my secretary to delay the next appointments. Finally we succeed in getting the baby to latch well to the breast, and because he had regained his birth weight, mother and baby left my office contented, with instructions to call if any further difficulties arise.

The rest of the day passes without complications but, before leaving, I have to return 4 telephone calls, finish my charting, and file lab results received during the day. Finally, I call one of my clients whose haemoglobin is at 103 g, to advise her to take an iron supplement and we review her nutritional intake to ensure good sources of iron and how to aid its absorption.

I leave the birth centre at 6:30pm and go home for the evening. I go to bed at 10:30pm. My alarm clock is set for 7am and I have put my pager, telephone, some paper and a pen beside my bed.

Tuesday

4:30am â€œBeep, beep. Beep, beep.â€� wakes me up. I call the number on my pager and reach my colleague Marie-Claude, who is at the home of a second time mom at 38 weeks who is starting to feel the need to push. I jump into my clothes, ensure that I have the directions I need to get there, and leave my apartment as fast as I can. I have to scrape the ice off the car windows before I go, hoping that I will make it on time.

5:05am I arrive at the woman’s home and find that all is ready. Her first child is in the living room with his grandparents and the couple is on their big bed. Marie-Claude is by their side talking to them calmly. I check that the emergency equipment is working and that warm blankets are close at hand. I take over checking the fetal heartrate and do the charting in her file.

After several contractions a little boy is gently born, welcomed by his Dad who puts him on his mother’s belly. He breaths spontaneously, I clean him gently, and cover him with two warm blankets and a bonnet on his head, then leave him in peace with his parents, while keeping an eye on him from time to time.

Marie-Claude hands the father scissors to cut the umbilical cord, once the pulsing has stopped, and the placenta is expelled spontaneously 12 minutes after the birth. Marie-Claude checks the mother’s genital area, using a portable lamp, and determines that no suturing is necessary.

After ensuring that the mother’s uterus is contracted and her bleeding normal, we give the family some time alone to get to know their baby, while we complete the charting and necessary documents at the kitchen table. A short visit now and again to the bedroom allows us to ensure that mother and baby are doing well and that nursing has started nicely.

At 6:20am I leave, while Marie-Claude remains with the family to continue monitoring the immediate postpartum, and to do the newborn physical exam.

I go home, take a shower, have some breakfast and call Christine at 8:15am to give her the news. We agree that, since she has appointments booked all day at the birth centre, I will do the planned home visits.

At 8:40am I set off to do my postnatal home visits, the first to Julie and Paul whose third son was born on Saturday. The second visit is with Annie who left hospital yesterday after her Friday C-section.

At Julie’s everything is going well, I take a blood sample from the baby’s heel for the PKU test, and after examining Mom and baby, I respond to the couple’s questions. I let them know that Christine will visit them on Thursday if there are no problems before then.

At Annie’s, I find her up and dressed, and in the process of sterilizing bottles “just in caseâ€�. She tells me, with tears in her eyes, that her baby does not seem satisfied with her breastmilk. Her partner, Luc, has gone to the pharmacy to buy formula. I spend the next two hours at their house. I have to give them a lot of information, reassurance, and practical assistance in bringing the baby to the breast. I stress the importance of rest and support, as well as the baby’s needs which can often be perturbed after a caesarean. By the time I leave, the baby has nursed well, the parents are calmer, and Luc says that he will call his mother to come and help with the meals. They know that I will come again if they need me, and how to reach me if they do.

At 2pm, I go home for lunch and a rest. I don’t receive any calls.

At 7pm, I call Annie to find out how things are going. Luc’s mother tells me that all three are resting and that the baby fed well for an hour, that they could hear him swallowing and that Annie seemed reassured.

I go to bed at 9pm, hoping for a good sleep.

Wednesday

9am I start my morning with prenatal visits, 45 minutes being dedicated to each one, except in the case of Jeanne who is 38 weeks, knows me well, and has no questions. I have allotted her 30 minutes in order to check her health status and to allow us to have a short discussion on the signs of labour and her preparations.

After having finished my charting, I sort my mail, check and file lab results, return a phone call about a second trimester question, and have lunch in the kitchen at the birth centre with a few colleagues.

The team meeting takes place from 1:15pm to 4:30pm. All the midwives, plus three student midwives, are present.

The agenda:

• A review of specific clinical cases. Generally this can be to obtain an opinion from colleagues, to report on complications or transfers of care, or to share information gathered from research for a clinical case and that might be of general interest.
• Decisions needed on team organization
• Preparation of a communication for stakeholders in the local health services network.
• Discussion on the results of a study on vaginal birth after caesarean

After the meeting I return a call from Annie who tells me that everything is going well but needs advice on breast engorgement. This done, I record it in her file, and go back home, stopping at the grocery store on the way.

Thursday

I have prenatal and postnatal visits from 9am to 2pm at the birth centre. Then I collect a pack of materials for a homebirth and take it with me to Marianne’s house. She is 36 weeks pregnant with her first baby. As required by Quebec regulations, she has been informed of the advantages and disadvantages of the different possible birthplaces, and she has chosen a homebirth. I am, therefore, doing this prenatal home visit and will give her advice regarding her preparations. I also take advantage of this visit to bring her some items of our birth kit so that I don’t have to carry everything around with me.

I include the usual physical observations in this visit along with a discussion about her well-being at the end of pregnancy and a verification of the home in view of the birth, its accessibility, exits, etc. as well as the materials that we asked her to supply. Next week her appointment will be with Christine at the birth centre.

My day ends at 5pm with a call to Christine before turning off my pager and changing the message, alerting the clients that I will be off for the next 24 hours.

Friday

I go back on call at 5pm, after finding out about Christine’s clients since she will be off for the next three days.

In the evening I don’t get any calls and am able to go out to a movie with friends.

Saturday

A call a 7:10am from Marianne wakes me up. She thinks she has lost some amniotic fluid but on questioning her, it is evident that it is a mucous discharge. She isn’t having contractions so I give her the usual advice, reassure her, and get ready for my day.

I don’t have any visits booked for the day, but know that there is a good chance that one of my colleagues will ask me to assist  her at a birth. So, a morning of housework while waiting to be called seems the thing to do.

At about 10am, Annie calls me to ask if it is normal that her baby, who fed very well during the night, and again at 4am, isn’t waking up this morning. After asking questions to confirm that he is doing well, I reassure her. At the end of our conversation she tells me that he has started to wake up. She will make an appointment for a visit at the birth centre at 10 days postpartum, but she can always call me again if she is worried.

At 2:25pm Isabelle, a colleague, telephones me. She is at the birth centre with Jennifer, a primip at term who is at 9cm dilatation, and Isabelle believes that the baby will be born soon. I go to the birth centre, let Isabelle know I am there, and 30 minutes later she calls me to the birth room. The head is now visible during pushes, and the baby is born after 25 minutes of contractions. He is doing well but the mother bleeds a bit more than average after the placenta delivers. While massaging the uterus, Isabelle asks me to give an injection of Oxytocin. That done, the bleeding becomes normal, the uterus is well contracted and the blood loss is estimated at 500ml. All goes well after that, and Jennifer doesn’t require any other intervention, expect for a few sutures of a small 2^nd degree perineal tear. Isabelle sees to that while I complete the chart and legal paperwork. The centre’s birth assistant brings Jennifer some juice and a plate of fruit and cheese. A birth assistant will remain at the birth centre to support the family after Isabelle, who will monitor the first three hours postpartum, has left. They may remain up to 24 hours after the birth.

I leave the birth centre about 5:30pm and go home to get ready to join my children at a cousin’s birthday party.

While I am getting ready for bed at 11pm, I receive a call from Marianne who reports mild contractions every 5 minutes since 9:30pm. She has no other signs of labour, is feeling good fetal movements, and says that she is tolerating the contractions well. Her partner, Sean, is there and she tells me that he is very busy preparing everything for the birth. She feels confident and calmer than him, she says!

Since her labour is only just beginning and might even stop again, I give her some coping strategies and suggest that she try to get some sleep, explaining to Sean that it might just be “false labourâ€�. She knows that she can call me at any time.

I manage to fall asleep after 20 minutes of reading.

Sunday

A call from Sean wakes me up at 4:10am letting me know that Marianne slept for two hours and has been having painful contractions every 3 to 4 minutes for the last hour. I talk with Marianne to confirm her labour and to let her know that I will be there in about half-hour.

I call Caroline, a student midwife in her first practicum, whom Marianne has already met with Christine and agreed to have at her birth. I prepare to spend several hours away from home.

At Marianne’s house, she is sitting in the living room with a heating pad on her lower back. I do an assessment to find that she is beginning her active labour, at 3.5 cm dilated, with a soft, thin cervix and intact membranes. The head of the baby is at station 0 and the fetal heartrate is normal. All other indicators are also normal.

Marianne, having chosen to be tested for groupe B Streptoccocus and having had a positive result, will receive antibiotics during labour, so I review and demonstrate to Caroline the technique for inserting an intravenous catheter. Marianne has painful contractions and the care and support I give her are a good example for Caroline who, at present, has only attended two rapid births.

Labour progresses well but slowly and Sean offers us breakfast at 8am, that we willingly accept even though I have brought nuts and fruit to snack on.

In order for Marie-Claude to be able to plan her time, I contact her at 2pm to let her know that I am with a woman in labour at her home and that I will call her later for assistance. She already has in hand the directions on how to get to the home.

Marianne takes regular baths and alternates with periods of walking around the house, squatting or leaning forwards during contractions. We encourage her to drink and to eat a little. Sean is a good support for her and we leave him to be that support person for Marianne unless she asks us for help.

At 3pm Marianne is 8cm dilated and the head is at +2. At 3:40pm she feels pressure on her rectum, and during a strong contraction loses a good quantity of clear amniotic fluid. We confirm that the fetal heartrate is normal and after several contractions Marianne is having strong urges to push.

Marie-Claude is on the way and Caroline and I get the last preparations ready for the birth.

Marianne pushes for 50 minutes before giving birth to Aurelie, who takes several seconds before letting out her first cry, but then shows us that she is in good form with an Apgar of 10. The delivery of the placenta is spontaneous and blood loss is normal, the uterus is well contracted, and the baby is searching for the breast already. So we help Marianne to get comfortable and encourage her to let the baby find her rhythm. This being successful, and everything being under control, we busy ourselves with paperwork in another room in order to respect the privacy of the couple.

After inspection Marianne’s genital area, I see that there is only a first degree laceration that does not require repair.

Marie-Claude leaves to meet a woman who has just called to say that she has had a loss of fluid at term. Caroline attends during the newborn examination and we leave three hours after the birth, having given the usual information and advice.

When I go to bed at 10pm, I have to read a bit before I can fall asleep. No-one calls me in the night.

Monday

I start another week with a day of visits . . .