Ritualised Hazing

Taken from an article written for Midwifery Matters, the magazine of the Association of Radical Midwives.

March, 2024.

I was with my usual mentor on a nightshift on the birth centre and it started off quietly… as many mad shifts do. I’d hit third year on less than 20 births - nowhere near the lowest for my cohort - so I was very excited when a woman came in labouring with her third baby, supported by her wife who bustled along with wheelie suitcases. Semi-recumbent the emergence phase progressed after several hours and her baby crowned; there was classic slow progress, ‘turtle necking’ and retraction onto the perineum. Axial traction failed, my mentor took over, also failing with axial traction and I pulled the emergency buzzer while she put the head of the bed down. Together we hyperextended then flexed the mother’s legs, and a baby girl was born in good condition just as everyone came rushing in. The mother sustained a third degree tear [still a black mark on my mental copybook] and went to theatre for repair. While I was writing up the notes - debating whether I was putting myself at risk of being accused of malpractice by accidently writing cord cut and clamped instead of clamped and cut - my mentor took over care of another woman in active labour. After an hour or so (I was still documenting) a colleague asked if I could take in a CTG as there was meconium. As I was trundling in the CTG, I watched my mentor catch the baby who had clearly been born quite quickly. The baby girl was born with the nulliparous mother on all fours on the mat and passed to her through her legs. I supported the baby whilst my mentor got synthetic oxytocin ready for an active third stage. The baby then suddenly collapsed, I saw the tone fall away and she went purple and grey. We clamped and cut the cord and took the baby over to a flat surface [I know, I’m rolling my eyes too, but you know what it is like in big high risk units]. I ran to ask a colleague to bring in the resuscitaire and whilst the colleague managed the third stage, I supported my mentor in providing inflation breaths by holding the baby’s head in a neutral position, which turned out to be good practice for my OSCEs. The baby came round very quickly and had probably just needed placental resuscitation and maintained airways but you live and learn!

We had a late ‘lunch’ after this in the staff room, with some shoddy NHS instant coffee and a good debrief of the evening’s two emergencies. The staff room itself was on delivery suite; a lovely spacious room with lots of big windows, and despite it being an intimidating unit, there were always nice supportive conversations, sometimes including the doctors who occasionally relaxed there too.

In the early hours of the morning, another woman arrived in advanced labour. She pushed out her baby boy (a long awaited boy after four girls) kneeling in the pool in a darkened birth centre room. She’d only just made it in and was quite shocked. She started to experience a brisk bleed following the delivery of her placenta, but she remained stable. However, the blood loss continued at a pace, so we administered synthetic oxytocin, assessing a minor PPH of 800mls. By this point my adrenaline was building up. I’m not frightened of emergencies; I think our national protocols are evidence-based, robust and highly effective. The teamwork at this particular hospital was often excellent, and it wasn’t uncommon to hear HCPs reflecting afterwards on how buoyant they felt after a successfully managed emergency. I completely relate to that and I think it must be something also felt within the military, A&E and paramedic services. There’s a term for it isn’t there… adrenaline junkie. In general though, I think in maternity more often than not we overdiagnose an emergency and go in heavy when actually environmental adaptations (prior to labour and birth) and holistic management are excellent preventatives.

So when it got to 0600 in the morning, and another woman arrived in active labour, I was excited but also on edge. Could I catch a third baby this shift? That would be five in 24 hours! This woman was incredible, she arrived in modest clothing but immediately got into a squat leaning over a birth ball; shed her clothes and swung her long blonde plait over her shoulder. Rocking back and forth and being really active in her birth. At 0730 my mentor left but encouraged me to stay on with the midwife who took over. This midwife was nice, but she was a core delivery suite midwife and we’d only worked together once before several years prior. The birthing woman quickly and easily gave birth to a baby boy in good condition. And then started to bleed. The blood loss was not brisk but it was significant, so we actively delivered her placenta and my supervising midwife asked if I would fetch the doctor to assess. The doctor came in, performed a perineal examination and diagnosed a cervical tear. He asked me to fetch some tranexamic acid. As it was handover time, there was no one to be found, the ward was silent with everyone huddled in their rooms. The only person I could see was the Labour Ward Co-ordinator. I usually avoided this particular midwife so I did a quick walk round to see if there was anyone else… there wasn’t. So swallowing my fear and pride, I asked her to help.

“We have a controlled PPH in room 7, the doctor is present and has assessed and has asked for tranexamic acid. Could you help me get it please?”

“Don’t you think you need some more people in there?” she replied.

I didn’t understand what she was saying, so I repeated myself.

“The doctor is already there and has asked for some tranexamic acid, but I can’t get it as I’m a student. Can you help please?”

“Don’t you think you need some more people in there?” she said again.

I was stumped, I felt I was being really clear but couldn’t work out why she kept saying the same thing. She could see I was confused; huffed, rolled her eyes and said:

“Go back in there and pull the emergency buzzer,” then she walked off to the treatment room.

I felt small and chastised and couldn’t work out why there had been such an issue. I marched back into the room, announced that Penny “has told me to pull the emergency buzzer”, went over, pulled it and tried to ignore the Reg. sitting on the bed looking incredulously at me and shaking his head in anger. I then stood by the door, announcing to the whole world that we had a PPH and needed an anaesthetist. The woman ended up being cannulated, given another dose of synthetic oxytocin IM and then an IV infusion too. A massive fuss over a 700ml PPH.

I left in tears. Elated at the number of deliveries I’d managed to get, buzzing with adrenaline at how amazing (most of) the teamwork had felt and pleased with the medically if not holistically good outcomes achieved. And also feeling completely downtrodden and confused. Why did that midwife speak to me like that? Was I really that stupid that I didn’t know the protocol of a PPH? I was sure the doctor had asked for tranexamic acid and nothing else, and I felt my explanation to the co-ordinator had been clear.

I cried the whole way home and after I’d pulled myself together I spent several hours researching tranexamic acid. I discovered that although the hospital guideline treated tranexamic acid as a last line drug of choice for a PPH, there was evidence that it could be considered a front line choice in cases of tissue trauma. In the same approach as a paramedic would use. I surmised that the Reg. had diagnosed the cause of the bleeding by excluding an atonic uterus and discovering a cervical tear, and applied an evidence based approach to his requested solution. I wondered if the Labour Ward Co-ordinator was aware of this choice of management…

That evening I went back in and I was taken aside by the midwife who had taken over from my mentor, who was now about to leave following her dayshift. She reprimanded me for what had happened and said the situation had been taken completely out of context, that we didn’t need all that fuss and that the Co-ordinator had been very critical of me after I’d left. She suggested that it would have been better if I hadn’t told the Co-ordinator that we had a PPH (although she didn’t explain how I could have justified myself in asking for a blood loss medication in the absence of a PPH).

I still don’t know why that senior midwife had such a dislike for me - and it wasn’t just me, and that wasn’t my first run-in with her. In many ways I was lucky as I always had my books up-to-date and confident mentors who weren’t swayed by seniors’ opinions of their students. I’d tried discussing similar situations with the University who downplayed the issue. When we were asked to provide feedback as a cohort, many students relayed similar experiences and the lecturer started talking about how hard it was to be a student and see emergencies and difficult things (women bleeding, babies dying) and I was just astounded, it was like they couldn’t hear us. I’d had all those emergencies on that one day and not one of them made me cry or brought me down, I was flying high as a kite after those emergencies. It was the stinging words of a sarcastic band 7 that crushed me that day.

Another midwife at another time, said “they are testing you, seeing how far you can be pushed and if you’ll fall in line.” And that’s hazing… Can you keep up? We deal with the highest risk cases here. Do you have the guidelines on the tip of your tongue? Will you prioritise the team and stick together? Come on, keep up. If you fall behind we leave you behind. We’re highly skilled and know our stuff. Do what we do, in the way we do it, or leave.

I chose to leave.

Ritualised hazing is something many students and NQMs experience. And in my experience it is often characterised by sarcasm. I think sarcasm is an incredibly dangerous and damaging form of communication, it is designed to make you feel stupid and make you want to work harder to please those who are disparaging you. It is designed to obfuscate intention and meaning, leaving the person on the receiving end to ‘work it out for themselves’. It puts women and babies in danger, hardens the compassion out of us and is incredibly unprofessional. I did continue and complete my midwifery degree, and I was lucky to be able to take advantage of an opportunity to change trust following this placement, but those feelings of inadequacy, humiliation and of not being listened to, have remained as echoes in my heart.

Names and details have been changed to protect confidentiality.