In the Realm of Hysteria IV

After surviving a mind-numbing weekend full of post-delivery "mum checks" - those repeated enquiries about bowels movements, pain, bleeding and contraceptive choice - it was with a sigh of relief that I returned to an afterhours floating shift following the directions of a more senior doc in confronting what comes through the door in any moment.

"They almost always throw up..."

We were scrubbed in, doing an emergency Caesearean section on a young indigenous woman obstructed in labour. The woman is awake with an epidural in her back, and she had told me with a fresh open face earlier whilst I held onto her hands during the epidural insertion that she already has three sons, one in her brother's care and two at home. She smiles shyly with liquid brown eyes and tells me she hoped this would be a girl, and that having a Caesearean was a new experience for her.

Her labour had progressed unexpectedly slow, especially for someone whose uterus was well trained in delivering babies, and the decision was made to proceed to a C-section because the tracing of the baby's heart rate was beginning to show signs of distress.

I played first assistant to the friendly senior doctor, and we were going well until she began to frown and remarked: "This is a really thick lower segment (of uterus)..." and asked for the more senior O&G trainee (scrubbed and sitting in the background) to step in. The next few moments saw him take hold of scissors, snipping away at the sides of the thick, pregnant uterus, adjacent to the yet-unborn baby's face, in order to make more room. And then with both gloved hands he reached in deep within the uterus.

I've always cringed at this part of the ordeal. Guts and gore I can generally tolerate, but fishing slightly (normally) blue looking babies out of a small hole in an internal organ, with the various twists and angles to assist in maneuvering its exit, is another matter altogether.

Somehow, the baby's head was stuck and not without difficulty and a lot of force for what seemed like frozen moments in time, the head was finally disimpacted and delivered, and the rest of the body slurped out of the uterus, as if nothing had ever happened. I had the honours of cutting the umbilical cord, relieved that the baby was safe, for now.

That was the cue for the anaesthetist, who gave the uterus-contracting medication, an intervention that has saved the lives of many women from the Grim Reaper's post-partum haemorrhage, a phenomenon that claimed numerous lives throughout history. Next the cauliflower-like placenta was delivered, uneventfully.

"...when the uterus comes out."

The senior doc swiftly dug his hands again deep inside the woman's body, and brought out with him, the now contracted down uterus which he placed on top of her abdomen. Fully one-inch thick in each wall, the strongest muscle of a woman's body now appeared like the body of a huge, firm octopus. Now my job was to hold it in position whilst they repaired the ragged bleeding edges. It was clear to see how good the blood supply to the uterus is, as more and more blood came from nowhere and oozed and filled the pelvis, frequently blocking the view for suturing.

And then she started vomiting on the other side of the curtain. Her belly heaved and heaved beneath the green coverings of the surgical drapes, the same long coverings that disguised her as an anonymous pregnant uterus that contained a baby that needed to be rescued, and took away her humanity, an individual with feelings, a past and a future.

My hand rode up and down with her uterus beneath a sterile cloth, and more blood spurt forth with each vomit. I feel uneasy and snuck a peek at the suction bottle, and it now contained a litre of blood lost. If she does not stop bleeding soon despite the medication and the suturing, we would be running out of options. My mind drifts admist the senior doctor's efforts, only to find my own discomfort at knowing that things weren't going well, that I felt helpless and unhelpful, and that the patient was awake and could hear exactly what was going on and our discouraging conversation. I could feel my objectivity slipping, and in its place the suffering of distress... perhaps my own, perhaps the patient's, perhaps the senior doctors'. It didn't even cross my mind that she could be in this moment rejoicing about the arrival of her wish-fulfilling daughter.

Luckily, things took a turn for the better. Eventually she stopped vomiting, and the blood loss was much lessened. The nightmare has abated, for now. A tube was put in, just in case, to drain any further bleeding in the area and the muscle and skin closed. From the outside, you could not tell what had happened or what sort of healing will take place deep inside her in the time to come. She would not be able to strain or undertake forceful activities for six weeks, not even able to drive, and that certainly should she have more children in the future, her uterus will be too scarred to withstand a normal vaginal delivery; a C-section will be the only way.

As I said earlier, I am frightened by Obstetrics. A place where the margin between life and death seems so unnervingly narrow, not just for one, but for two.

In the Realm of Hysteria III

Another shift started as per usual. Wandering aimlessly into Birth Suite and seen and ignored loudly by the nameless midwives. As if they were able to sus out who would be useful to them in a glance. To them I'm a nameless young medico with questionable aptitude.

I do not want to be like the med student, also wandering and being actively ignored. I do not want to elicit the same distaste she conjures up by overcompensating with aggressiveness and requests being involved in patient care.

I think, like nursing staff elsewhere, you have to prove your worth or willingness to listen to experience by sticking around, by being polite, by cooperation. Midwives are just a little more territorial, that's all, being more independent than other nursing specialities, and have strong beliefs about the whole childbirth experience.

I was asked by one of the bosses today how I'm doing whilst in the above state. I responded honestly: "Lost," I said. He seemed surprised and probably took pity and invited me to participate in theatre time. Instead of "providing entertainment" as he had planned, my suturing skills, though shaky, were better than he had expected. He seemed pleasantly surprised at my one-hand tying technique that we learnt a couple of weeks ago, on (defrosted) chicken rumps.

Despite more involvement, I just still don't "get" Obstetrics. Not only that each Casearian section I see scares me, and the heavy smell of blood and gore linger in my nostrils. I hold my breath and pray during each baby delivery (I think that's an euphemism for "extraction," as akin to "dental extraction"). I just keep on missing a puzzle piece of the whole complicated system. It's just a whole different world to everywhere else.

However, as I retire to bed, only to rise to a weekend of more work, I thank goodness for bored clinicians who occasionally remember that what bores them is still uncharted learning territory for others.

In the Realm of Hysteria II

There is something that frightens me about Obstetrics.

It is almost expectant in the course of life that women somehow naturally go through childbirth. Perhaps a rite of passage into womanhood. Perhaps the joy and responsibility that accompany bring a new life to earth. But from what I've seen, I would describe it as a trial by fire, through tempting and dancing with fate and death.

And almost certainly, we are talking about two lives simultaneously, mother and child. No one can predict the exact outcome.

At my first afterhours shift, the Birth Suite is ghostly quiet.

"Oh I don't like the feel," says more than one midwife and doctor, "it's like the calm before the storm."

"Let's not worry about later, here," I proffered chocolate that has become public property lying about on the station desk, "have an easter egg."

As we munch on the generosity of perhaps the hospital, perhaps some staff member, perhaps some patient, sure enough we catch wind of a lady coming in with preterm labour. The new senior doctor responds to my naiive questioning and looks up clinical protocols and guidelines on the computer.

Within ten minutes, the ambos arrive with a stretcher bearing a woman in emotional distress. Always dramatic, always effective. Not always delivers, though. You can never tell the severity of a problem when people arrive via ambulance. Well, perhaps if they had someone jumping on their chest, yes, that would be barn-door. Yet that almost never happens.

The woman is in her mid-thirties, with a wild look in her eyes. She pants and grimaces, and occasionally a cry erupts. By dates she is only half-way through her pregnancy, bearing twins through in-vitro fertilisation. She is angry at the situation and wants to keep her babies desperately. We reassure her we will try to stop the labour by giving her medications, but we may not be able to stop it, and she will deliver two extremely premature babies. Babies, unfortunately, have a very low survival rate at 24 weeks, and hers are only 22 weeks old.

The next half hour saw me fail a cannulation amongst her agitated continual questioning of "is there a chance...?" "what if...?" and negotiations of private versus public care. In the meantime, the medications have failed to stop the contractions, and the first examination revealed bulging membranes and outline of the first twin's hair and scalp, even I could see it standing in the back of the room. The babies were coming, despite our efforts, despite our hopes, despite their grim survival.

The boss on call arrived, and attempted a conversation to the woman's unlistening ears. Her husband held onto her hand, hovered in the background, with pain in his eyes and a flushed face. The paediatricians arrived and waited patiently in the corridor with the warmed resusitation cubicles. The private obstetrician arrived, knowing the inevitable, and reinstated what we already said.

"Noooo!" She yelled, "Wait! Don't come now!" Holding her legs and buttocks tight. She was doing everything to fight the contractions. "Nooo!" She yelled with every tightening. There was now a small crowd that gathered in the corridor beyond her door.

"But there is a 5% chance of them surviving, right?" She pleaded to the air in between grunts and yells now, the contractions were becoming closer and closer.

I admired the senior doctor, a general practitioner, in his gentle yet firm manner as he continued to guide her during delivery. The membranes were ruptured, and pale yellow amniotic fluid gushed onto the bed, mostly caught by the midwife's skilled placement of a kidney-shaped dish and slight turn of the face to avoid splash injury. "I'm sorry, I'm sorry, I'm sorry," she said to her partner, who holds her head and shoulders and turns his head away in visible tears.

Eventually, the first baby was delivered. Size of a small kitten, skin so thin and tightly stretched that it appeared a deep pink, tiny configured features, waving his arms and legs in the air in the unfamiliar environment. The cord was cut and baby quickly swathed in warm towels and shipped outside to the waiting clinicians.

And so the second baby came, also a boy, this time feet first. Breathing, animate, just like his brother as he emerged. And then the injection for the uterus to contract down again and the placenta delivered uneventfully. A warm, fleshy, bloodied mass, not unlike soft coral.

By now, the new mother has relented, and asks only that we try everything for the babies to survive. We nod and say they are in good hands, but that she does not keep her hopes too high.

I depart from the room, to look for her blood type on the computer, and lingered to listen in on corridor conversations from the bosses. The event is now over for the obstetric side, it is now a fight on the paediatric side. And perhaps a lifetime, for these two eager parents.

I take my leave as it was now at the end of my shift, having done little aside from feeling overwhelmed by the whole episode. I tried to reflect and cannot conjure up a better solution or communication effort for the night's events. I go to the adjacent ward, where the paediatric special care unit is, and assist the doctor there in placing miniature lines into the baby's umbilical cord, until I was truly tired, and long overdue for rest.

It's a difficult world, and one difficult to navigate in, emotionally and clinically. I used to think that transparency was the only patient communication that was needed. But now it appears so cruel, that we do not allow a shred of hope, even though the reality is a tough one.

Is Hope the only medicine? If so, what are we hoping for?

In the Realm of Hysteria I

Hysteria: \his-ˈter-ē-ə\ noun

From the Greek notion that hysteria was peculiar to women and caused by disturbances of the uterus 1 : a psychoneurosis marked by emotional excitability and disturbances of the psychic, sensory, vasomotor, and visceral functions 2 : behavior exhibiting overwhelming or unmanageable fear or emotional excess


The tribe of women gather in the mornings. Discussing other women who are in the process of giving birth, the various obstacles, or suffer from a pregnancy related illness. The elder's responsibility is rotated on a daily basis, but always present at the meetings: guiding, teaching, challenging decisions made for the sake of self-reflection. The men are token attendees in the secret business of women.

We disperse and go forth in the day's activities. Waiting for us in the ward are two women. Commonly these women were sent in by their family doctor for definitive management of their miscarriages. Starved and thirsty from midnight the night before, their anxiety and emotional fears simmer just beneath the surface.

I went to review one of these young women, holding at bay my own insecurities and palpable sense of lack. I only hoped I did not appear as ghostly white as the woman in front of me. With her pale long blonde hair and lacklustre eyes, she was an apparition, linked vaguely to earth by her partner holding her hand.

We had had several phone conversations on the previous day. She wanted to delay her review as she could not get someone to replace her at work. The only information I had was her doctor's urgent referral letter for a more serious condition and adviced her it would best to come in at the arranged time. Then she told me her doctor had called her and said it was just a miscarriage, and nothing more serious. I told her I had no records but I will chase it up and ask for senior advice. Then she called again and said she wanted to come in on the arranged day, but in the afternoon. By then I had sufficient information available to me and I adviced her it would not be more advantageous, and that it was easier the next day, as she had desired in the first place. But of course, I added, if she was feeling feverish, unwell and bleeding a lot that she should present herself to Emergency. Oh, she added, but if she were to have a procedure done, would she be able to go to her daughter's dance performance that night. Yes, I reassured her, it is a straightforward day procedure.

And so the following day, she presented at the original time, apparently after waiting for four hours at the Emergency department overnight, when she was obviously not an emergency, and left to go home. Apparently our circuitous discussion had not worked out as I had planned. And here she was, driven mad by anxiety and fears. Nevertheless she was here, and I went on to prepare her for the procedure.

It's hard to get away with being in hospital without at least a blood test. And especially with pregnant women, the risk of bleeding copiously is always there. She mentioned her needle-phobia, amongst various other random thoughts that I had ceased to pay attention to and I grit my teeth internally.

So there we were, alone sitting in the waiting room, glass panes and all, her partner holding her in a tight embrace while I tried to utter soothing sounds as I first inserted a cannula into her vein. And when the blood did not flow freely, due to her much starved and dehydrated state for too many hours, I regrettably informed her that another needle was needed. Only to be met by further hysterical tears and cries. And I felt hardened in my heart in that moment, doing what was necessary, in an imperfect world.

That was my first taste of hysteria.