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Wednesday, July 6, 2016

Making of a Child Psychiatrist: (42) Down to Work Sort of… (1)

The month at Plymouth was memorable, if not a small turning point in my career. The work consisted of routine antenatal clinics under the eyes of a registrar, or occasionally a consultant. This felt very similar to working at King’s where we had been expected, appropriately, to have every step checked. But as a third year student, and having had some obstetric training at King’s there was an expectation in Plymouth of taking just that bit more responsibility. So after the first week, people began to trust judgment and clinical reports, and allow you to complete some outpatient visits alone. I was anxious but honoured, and grateful for the excellence of the training I had already gained.
A long term consultant in gynaecology at King’s College Hospital was the eminent Sir John Peel, who had been head of department, and during my time was the Director of Clinical Studies for the school. We came to know him well, and his advice was highly prized given he was an examiner at other universities. As surgeon-gynaecologist to Queen Elizabeth II, he had attended a large number of royal births in the extended family, so there was a certain reverence when others referred to his work. In some of that work, Sir John had been assisted by Michael Brudenell who was an active obstetrician at King’s. More than that he had published a book simply called ‘Obstetrics’ (Staples Press, 1964). With an eye to our futures many of us purchased this one because we had studied with him, but also because he might be an examiner for our finals. For me, the book was to be priceless; relatively short, simply written and with easy to digest (and memorable) diagrams. It served me well at the time, but also later when doing a formal six month training in Obstetrics, and then in general practice.
In Plymouth on a one month rotation, we were on call for Devonport Maternity, which prior to 1957 had been a Military Families’ Hospital on the site of Raglan Barracks – long low single storey buildings, now long demolished. Devonport was popular and, if you were on call, it was possible to attend up to three births in one night.
‘Attending’ meant scrubbing and getting gowned and masked, introducing yourself to a preoccupied patient who had no interest in who you were, and then standing back and letting the very competent midwives get on with the job. But then, watching how they managed a variety of people and reactions so carefully, was learning; and I soaked it up. Subsequently, after the production of a living breathing red to purple coloured snuffly infant, we all waited patiently for the afterbirth, usually with the babe at the breast amidst combined tears of relief. An assessment of residual bleeding, and any possible vulval damage was then made.
It has always amazed me how a rather large object like a head can stretch the perineum so much as to pass through usually with almost no damage at all. But so many women, even those having babies for the first time, seem to get away with it. Of course, you have to trust nature. In addition, I came to learn that the midwives were careful to slow the process sufficiently, and the mother’s breathing, to provide sufficient stretch time. They had a way of holding the almost born infant at the point of exit, supporting the perineum just for a short time to ensure no tearing. Such skills and patience were to be admired. In addition there was the bonus of a relieved mother not needing sutures.
If there was a tear, then there was work for us ‘doctors’. If there was a registrar available then they assessed the situation. In the first week, I was shown precisely how to clean up the environment, close the layers from inside out, choose the right type of suture material, and ensure closure. Then there were a couple of times when a registrar (and on one occasion a GP obstetrician) leant over my shoulder watching as I worked. For the next few weeks, I was on my own unless it all looked too complex or severe, in which case we called in a consultant. Of course we med student ‘doctors’ all knew that experienced midwives could do the job even better than we could. They usually hovered, and I am sure on some occasions took over, or on busy nights did the job themselves.
So, here I was with a plastic mac and a gown, fully masked and anonymous, sitting between a pair of thighs, injecting local anaesthetic before repairing damaged flesh. The mother and I chatted about her new baby, and her child at home, her husband and his job, and how she thought this might be her last baby. I checked whether she was in pain as I slipped in another suture; she was not. But otherwise the conversation was as if we were having afternoon tea. She thought nothing of her position in life at that moment, and I was there simply to do the best job I could and ensure she healed well with no problems into the future from her scarring. At the end, she said simply: “Thank you doctor. I hope the rest of your career goes well.” And I went on to another new mother who needed my sewing skills, such as they were.
On reflection, it was one of those moments that made me feel worthwhile. I was not just clerking a patient and then presenting at a ward round so that the consultant or registrar could take over the practical care. I had actually done something useful. I just prayed I had done the job well enough. Equally I had this nagging thought that even if I had not, and something went wrong, I would simply become that ‘nameless young doctor who messed up my sex life’. All very odd!
One evening near the end of our intensive month, a group of us were celebrating at a Plymouth pub known to have the very best ‘sherry on wood’ (that is, in a barrel). I was second on call, and had thought it would be a quiet night with no calls, so I felt able to celebrate my time. As we neared closing time, we were happy and noisy, and I knew I was slightly drunk after several sherries. My pager went off, and when I phoned through to Devonport, I was told they had several jobs on the go, and needed my time urgently. I talked it through with my tipsy colleagues, but got no more than I deserved; raucous laughter.
We piled into my friend Peter’s minivan. There were about seven of us, and I am not sure to this day how we all got in. I was last in to the back, and it was squashy. It was impossible to close the rear doors. So as we drove off with a very tipsy driver, two of us holding the back doors to; the best we could do. The jokes were flying thick and fast, and two students broke into raucous song. Subsequently, I could never work out how we survived a slightly nightmarish journey, but eventually we drew up briefly at the front doors of the hospital. The minivan rear doors were pushed open, and I was literally rolled out onto the tarmac. I sat for several moments listening to the minivan roar off amid raucous laughter. I checked myself and my clothes for damage, wondering why I was there, and whether I would be able to do whatever was expected of me. I was half hoping someone would recognise the state I was in, stop me at the door, and send off a report to King’s about my disreputable behaviour.
I am not sure how I pulled myself together. But inside, I found I could walk, and was immediately bound up in the ongoing panic. There were four births happening at the same time, and three midwives were already taken up with three of them, along with the junior nurses. I was shown into a single room with a young woman about to have her first child. She was clearly in labour, with contractions coming every three minutes. She appeared to be managing well, perhaps due to the effect of breathing Entonox for pain relief. A nurse came back with a delivery pack, and said she would return later if she could: “Would I be alright?” I muttered some response, wondering what had hit me as I took off my jacket and shoes and donned a mac and boots. I opened the pack, donned a gown and began to lay out instruments and prepare.
My patient was on a single bed against a wall rather than a delivery table. So I sat on the side, took her blood pressure and pulse, then watched a firm contraction and when that was over listened to the foetal heart. The baby was head down, and the heart rate fine. We introduced our selves, and I found out this was to be her first baby. I guess that was why I had been left in charge. The nursing staff thought she was going to take some time, as is often the case with first babies; they could deliver the others and return in time.
We went on talking about her pregnancy, her family and what names she had chosen. She smiled, giving some alternatives, not knowing the gender of her baby (as was common in those days before ultrasounds). There was another contraction, and she reached for the Entonox. That over, I once again checked her baby; the head appeared to be engaged in the pelvis, the heart beat regular and fine. We both thought there was plenty of time for the nursing staff to return, so we talked on. She wanted to know whether I was married, and I told her a couple of funny stories from the honeymoon. She appeared very relaxed, but again reached for the Entonox as the next contraction came only a couple of minutes since the previous one. It lasted quite a time, and my patient smiled as she told me she had felt like pushing. I checked her baby again. All good. This was not supposed to be happening this quickly. I could not leave my patient to find a nurse. I decided it would be stupid to shout out my rising panic. So I smiled, arranged an extra pillow to help my patient to be half sitting, and we continued to make small talk.
Contractions became stronger and more frequent, and within what appeared to be no time at all, my patient was needing to push. With a calmness I did not feel (even in my own slightly anaesthetised state), I used the language I had now heard the midwives use time and again. The baby’s head crowned, and we managed to slow down the pushing with panting breaths. Within minutes we had a perfectly formed baby girl messing up the bed sheets in between my patient’s thighs. Seconds later she voiced her rage at coming into the world. I clipped the umbilical cord as I had seen the midwives do, and passed the baby up to my patient, providing a blanket for covering. The tears flowed as the baby snuffled and settled, and they did not all belong to my patient. I retrieved a kidney dish, and several minutes later filled it with the placenta. Our nurse returned at that point, and began fussing over mother and child. So I returned to my role of checking for vulval tears with a view to practising my sewing. There was nothing. I wiped away residual blood from the removed placenta, and could see little damage at all. I was bemused; this young primiparous mum was having her first baby and had delivered her with little fuss, no drama, and no perceivable damage. How did that happen? Had I added to her Entonoxed state with fumes from sherry on the wood? Did she even need me in the first place?

As I have noted, life is full of lessons, and this case has remained in my memory because it was so unusual. And yet it was how a birth should be; that was how the equipment was built. The major lesson for me, I think, was that I was there for my patient if she had needed my help. As doctors we are present, provide support and if necessary help lives to get back on track. But if intervention is not needed, we are simply privileged to be present at small miracles.

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