It’s Spring of 1969, and brand new midwifery students are joining the crew at Nonnatus House! My midwifery practice at Henry Ford Health has been expanding over the past year and our midwifery team has doubled in size, so I understand the excitement and adjustment that comes with bringing new midwives on board. Whether someone is switching practices as an experienced midwife or has just graduated from their midwifery program, joining a new practice always has unique challenges and learning experiences.

Pupil midwives Joyce, Rosalind, Kathy, and Norelle have come to Nonnatus House after starting their training in the hospital setting. I can imagine that the learning curve from hospital birth to home birth is a big one, but these student midwives seem ready to take on the challenge. Even within the first episode of the season, we see some tremendous growth in these student midwives. Joyce quickly learns that assessing someone’s mental well-being can take priority over carrying out the physical tasks necessary to complete their appointment. Rosalind is first up on-call with Trixie and attends a rather complicated birth with Iris Melia. Not only do they have to deal with a violent outburst from her husband Les, but Iris also has a difficult time coping with the pain during her long and difficult labor. Rosalind and Trixie are working hard to provide labor support to Iris since the gas-and-air machine they have brought is not working. After the successful birth of her baby girl, who did need a little bit of resuscitation initially, Iris started hemorrhaging.

Postpartum hemorrhages are the leading cause of maternal mortality worldwide. Nurse midwives are equipped with both the knowledge and the tools to manage a postpartum hemorrhage, but sometimes surgical intervention is required. Trixie and Rosalind administer ergometrine, which is a medication that helps the uterus contract down to try to stop the bleeding. Part of midwifery training is also knowing when to call for help, and the midwives wanted to get Iris and her baby to the hospital for a higher level of care but were initially blocked by her Les, who was in a standoff with the police and had barricaded them all inside the apartment.

Afterward, Rosalind is debriefing the situation with her midwifery student colleagues. She highlights that postpartum hemorrhage in the hospital seemed like such a routine procedure; there were plenty of staff available to help, and then the housekeepers would quickly clean up as if nothing had happened. However, after Iris’s hemorrhage at home, Rosalind was left with the messy reality of a complicated birth in the home setting. Blood soaked into the mattress and the carpet, and tracked through the house. It was much less “medicalized” and sterile-feeling and the gravity of the situation was frightening. Looking back on this situation, I think it’s actually a really good thing that this experience happened for Rosalind during her schooling while under the guidance of an experienced midwife like Trixie. There will come a day when Rosalind may be the primary or only midwife at a birth and she will need to stay calm, call on her previous experiences, and use her knowledge to manage an emergent situation on her own.

I would be remiss if I didn’t mention Doreen Challis, a young woman with cerebral palsy who is expecting a baby with her boyfriend, Graham. Doreen has been closely cared for by her mother, Ada, and her older sister. Doreen and her sister hid the pregnancy from their mother, worried that she would be angry. Ada is quite upset when they tell her about the pregnancy, especially since Doreen is just weeks away from giving birth. Ada quickly realizes that Doreen and Graham are in a loving relationship and he plans to offer support and help Doreen raise the baby.

While Dr. Turner knows that Doreen has cerebral palsy, she didn’t start receiving care in the district until she was around eight years old. They had to do some hunting into her previous medical records to see if there was any pertinent information about Ada’s birth with Doreen that might impact Doreen’s upcoming birth. Ms. Higgins and Dr. Turner then discover that Doreen was delivered by Sister Julienne. The documentation shows that the birth must have been traumatic, with Doreen sustaining a broken clavicle. She was not diagnosed with cerebral palsy until she was 14 months old.

When Sister Julienne discovers that she was the midwife attending Ada’s birth, she feels an immense sense of guilt and responsibility. She also feels awful that she cannot recall any details about Ada, Doreen, or the birth. Given that the documentation shows a traumatic birth, Sister Julienne feels she should remember this. After talking through the situation with Sister Monica Joan, Sister Julienne decides to meet with Ada and Doreen. They can not only discuss Doreen’s health history but also discuss what might be necessary for Doreen’s upcoming birth.

I can easily imagine what Sister Julienne was feeling walking into that meeting. I have been a midwife now for 12 years, and have been in situations that had an unexpected outcome. Even if you provided the absolute best standard of care, you cannot help but feel a sense of responsibility for that outcome. It is very difficult to know that you played a part in someone’s trauma, even if it was just happenstance that you were the midwife working on the day when the trauma occurred. I feel this every time I diagnose a miscarriage or have delivered a stillborn baby.

One thing that stuck with me after this episode was how Ada did not blame Sister Julienne. In fact, she remembered Sister Julienne’s unwavering support, and how her quick thinking during a birth emergency actually saved Doreen’s life. Sister Julienne was calm, knowledgeable, and skilled during one of the scariest birth emergencies, a shoulder dystocia. This occurs when the baby’s head is born but the shoulder becomes stuck behind the pubic bone. The baby is deprived of oxygen until their body is fully born, so we try to work quickly to get the baby out, sometimes resulting in a broken clavicle like Doreen experienced. I have found that honest and calm communication with families both during and after an emergency is very important for reducing trauma. I have taken care of many women who report that their trauma stems from not being informed about what was going on during an emergency, and being worried that they or their baby would die. In many of those cases, the staff is visibly worried and rushing around, but no one has stopped to take the time to explain what is happening. I am very cognizant in my practice that there is always time to give an explanation about what is occurring and what to expect next. It is also very important to stay calm externally, even if it is very hard to feel calm.

I am always learning and growing in my midwifery practice, but with more than a decade of experience behind me, I do feel confident in my ability to manage many complications. Also, I am grateful that our backup physicians are always in the hospital with us should we need them. I’ve often been told by the nursing staff after an emergency that since I stayed calm, they could stay calm, and I think that’s an amazing compliment. I promise you that inside my head, sometimes I feel the furthest thing from calm! But I do know that panicking is not going to help anyone and that I do have the knowledge and skills to manage the situation. I am looking forward to watching the same evolution and growth of the student midwives this season on Call the Midwife!