Sunday 28 July 2019

Obstetrical days at the Rotunda.

Come along with me,
Down the river Liffey..........,
To the Rotunda, the oldest continuously functioning Maternity Hospital in the world.
Established March 1745.

We were sitting in Mooney's pub, right across from the Rotunda Maternity Hospital, where they maintained a phone line specially for the students, residents and doctors on call who could have a cozy meal and a beer, while they were waiting to be called to assist in the delivery of a new addition to the human race. Sometimes the wait was long.
In those days, before anesthesia and Caesarian Section was the rule, observation and patience were paramount and CS was reserved for emergency situations. So patience was a major part of the game.
"Team B report to District Maternity Gate 2 to go on home delivery immediately."
Team B was me, and a rather older rather aristocratic English guy, whose surname was 'English' (appropriately) and a midwife neither of us knew. We didn't drink very much mainly because even if we wanted to most of us couldn't have afforded it, so there was no problem in the fact that our waiting area was a pub, rather than the squalid cells that the Rotunda assigned to us as our living quarters.
We gathered at gate 2. We introduced ourselves to the midwife and we hustled into the ambulance. Five minutes later we were at a crumbling tenement and the midwife said to the driver, "you hold on for a few minutes while I assess the situation and decide whether I am staying here or going back to the hospital with you."
"Okay Mam."
A rather motley crew Anthony English, the upper class Englishman, the Midwife, Moira O'Connell and Smith, the Irish Jew disembarked from the ambulance.
"Wait here," ordered Moira, authoritatively.
The driver could see that she was middle-aged (over forty only by a bit, mind you) and was obviously in charge.
We entered a large, old dilapidated Georgian house that had obviously once been the magnificent home of some wealthy aristocrat, but was now a crumbling tenement, housing God knows how many families. Families with four and more kids often lived in one or two rooms, peeling wall paper, with filthy floor covering that might once have been linoleum. A fireplace was the only heating, an alcove with a stove for cooking was the only source of hot water, so bathing was rare and when the large man-sized corrugated metal basin that was used for bathing was eventually filled with hot water, once every week or two it had to be boiled by the kettleful. It was too precious to waste, so Mam and Dad bathed in it first and then the children in order of seniority. Hot or even luke warm water was precious. Thus it was in Sean McDermot Street and many more areas in the heart of down town Dublin, where the once magnificient mansions of the wealthy were then dirty slums.
We walked into the shabby two roomed apartment. It was noisy, with several yelling kids with snotty noses were racing around while an older sister of about nine was trying to control them. The husband was sitting by the fire reading the newspaper. His wife, Mary, was sitting in an armchair at the right side of the fireplace, puffing on a cigarette and in no obvious discomfort yet. They both greeted us warmly, and the husband stood up to welcome us.but before he had a chance to say a word his wife chipped in.
"I told him he shouldn't be calling the hospital so early. I only just started having a few pains an hour or two ago and nothing much at that. (We called labour pains just that - it was before the time when politically correct terminology called for everything to be seen in a euphemistic and unrealistic light. After all they were contractions, not pains. After a few hundred deliveries I still think of them as pains.)
"We'll do an examination now to see whats what," said the Midwife.
We went into the other room and after getting our stethoscopes out of our bag, examined the patient's abdomen to determine the position of the baby and listen to the fetal heartbeat. She questioned us at each step, "What's the baby's position? Is the head engaged? "
Then came the really difficult embarrassing part.
"Now it's time to do the pelvic examination." The expectant mother was completely unfazed by the proceedings. She'd been this route several times before and was chatting away affably as all this was going on.
We put our gloves on, only slightly used that were kept soaking in a huge basin of disinfectant, from which we recovered them, patting them dry before we left the hospital. Both of us went through the process of examining the woman under the expert guidance of the Midwife.
"Can you feel the cervix?"
"Where is it?"
"Er, I don't understand."
"It's very posterior, isn't it." she prompted.
"Yes." I agreed.
"Just starting to dilate, don't you think."
"Yes." I agreed eagerly.
"Oh, I knew it was going to be quite a while," said the patient. "The pains are just starting to get a bit regular but still a long time apart. It mightn't be until tomorrow.
At the end of all this the midwife decided that it was going to be quite a while before this lady delivered.
"I want you lads to get the bed ready. I want you to time the contractions and keep a log and I want you to check the fetal heart regularly. I'll be back in a couple of hours to see how things are going."
She placed a mysterious large black bag she had been carrying in front of us.
"You'll find all the stuff you need for preparing the bed right there in the bag. You've both done your required three deliveries in the hospital and observed many, so if she comes along much more rapidly than we expect, you'll know what to do."
We were getting more and more anxious by the minute and she succeeded in topping off our fears.
"If you were getting really worried that things are going wrong there is a public phone half a block from here. You can phone the hospital and have the 'Flying Squad' out in five minutes. Anyway, I'll be back in a couple of hours and from what I can see now it's unlikely we'll be much further along."
With those reassuring words, she took her leave and left it to Tony English and me to carry on. We started to unload the black bag. With each item, kept in place by an elastic band, we looked at each other, trying to figure out just what was what.
Mary, no fool and a veteran at this game, smiled at us, pulled out a Woodbine - a cheap cigarette that came in a paper package, (the good ones, like Players came in a cardboard pack).  
"Would you lads like a cigarette?" she asked considerately.
"Have one of mine," said Tony, pulling out his packet of luxury brand fags."
She took one gratefully and so did I. We all lit up, sucked on the cigarette and inhaled deeply.
Mary said, "That first little package you unloaded is a rubber sheet, you put that over the mattress, so all the blood and stuff doesn't destroy it. The second package there is a bunch of old newspapers."  
She was interrupted by her husband: "Mary, I just have to go down and pick up a few groceries and a bottle of milk for the kids breakfast in the morning."
Mary smiled wearily. "Okay, don't be too long."
She looked knowingly at us as he left, "He's just going down to Murphy's for a couple of pints. This is all very hard on him, being out of a job and all."
She eyed us unbundling the rubber sheet that was to waterproof the mattress. On top of that, to mop up the blood and fluid that would soak through the sheet we carefully placed layers of old newspaper and anothre sheet on top.
"Yes, that's right." she said approvingly. "Now how would you like a nice cup of tea? Oh I'm just gettng a contraction," she added, holding her back.
"We better have you lie down so we can check your abdomen and the baby's heartbeat."
"Ah there is nothing much happening yet, just finish up making the bed and then we'll have a nice cuppa and then youse can examine me."
She called her eldest daughter Una, the nine or ten year old who was obviousy taking over from her until this inconvenience was over. " Make the boys here a nice cup of tea."
That's exactly what she did and although the immaculate Tony looked at his not too immaculate, chipped cup anxiously, he had the good grace to take a few sips.
In an attempt to divert attention from his poorly disguised disdain I enthusiastically exclaimed,
"A really great cup of tea, just the way I like it! " I shoved a broken biscuit into my mouth and chewed noisily.
The eldest girl came into the room again. "Is the tea alright, doctors?" she asked anxiously.
Delighted at being mistaken for doctors, even by a nine year old, we assured her it was delicious!.
"Mammy, I told the kids that they have to stay in the other room because you are going to have baby soon, but they don't do what I tell them. You'll have to talk to them." said Una.
"Bring them in here," said Mary.
Nine year old Una herded three snotty-nosed kids and carried a one year old in her arms.
"Now you all do what Una tells you," she said sternly. "She's in charge until i have the new baby. Don't make me tell your father on you. Okay, now you can go out in the street and play." 
In those days it was safe for the kids to play in the street. Una shuffled the three yelling kids out of the door and still carrying the little one said. "Don't worry Mammy, I'll keep an eye on them." as she followed them out of the room.

Wednesday 10 July 2019

Ancient Obstetrics!

Obstetrics-the state of the art 70 years ago!

   When I started learning how to deliver babies there was no ultrasound, there were no fetal monitors, x rays were considered dangerous and not very precise. Epidural anesthesia was unheard of. Most deliveries that were considered to be uncomplicated took place at home.
   I recall coming into my office one Monday morning to find an X-ray pelvimetry report on my desk that stated, "There is gross disproportion between the baby's head and the pelvic inlet. This delivery will require a Caesarian section."
   In fact I was called at three o'clock on Saturday morning and barely got there in time for the delivery which proceeded without difficulty.
   Medical students in the world famous Rotunda Hospital got rigorous hands-on training, much of it in the slums of Dublin, 'on the district' as home deliveries were called. The 'delivery suite' might be half of a one room apartment with a sheet divider crudely hanging so as to divide the room in two. The pregnant woman and the 'delivery team were on one side of the sheet, while the husband and the kids (often several) were on the other side.
   Behind the screen was the bed, often sagging and dirty and cleaning that up and preparing it for the forthcoming event was one of the duties of the medical students - usually under the watchful eye of the midwife, who ruled us with an iron fist. The bed needed to be stripped and a rubber sheet placed on top of the mattress and well tucked in so that the mattress, which may have to last a long time would not be destroyed with blood and amniotic fluid. To stop the fluids overflowing , on top of the rubber sheeting several layers of newspaper to sop up the excessive fluids. Over this was placed a single sheet on which the pregnant woman would lie and eventually give birth.
   In those days, Caesarian Section carried a substantial risk and women often laboured for a long time. It was before the philosophy of "Never let the sun set twice on a contracting uterus" and it was not unusual for a woman to be in labour for two or three days or more, with all the attendant risks.
   Once contractions started the husband or one of the kids would jump on their bicycle and race to the hospital. None of these patients had telephones.
   "My wife (or Mammy) is going to have the baby. Send the doctor right away."
   What they got was a midwife and a couple of students. The midwife was in charge and we were there to evaluate the situation. Was the woman actually in labour? Was the baby's head engaged (down into the birth canal)? What position was the baby in?
   She taught us how to do the initial evaluation, how to do a proper pelvic examination, how to talk avoiding embarrassment for oneself and the patient. If the woman was not in well established labour the midwife would go on her way with a comment that she would be back in an hour or two after she called on some other patients in the vicinity who had recently given birth to see how they were feeling.
   "I don't think she'll be doing much for a while but if the is any problem there is a public phone just half a block away and you can call the hospital for help. ".
   This was long before the day of the cell phone and none of the patients had telephones. So two or three of us terrified students were left in charge barely aware of which orifice the baby might pop out of.
   The midwife made sure we were instructed in the patient's medical history
particularly her obstetrical history. She would instruct and supervise each of us (2 or 3 students) in doing a pelvic examination emphasizing the need to assess cervical dilation and the necessity to determine the fetal position.
   "She's not very dilated, is she?" inquired the Midwife. I had no idea.
   "Er. I don't think so,". I tried to sound as though I at least had some idea of what I was doing.
      "What about position?"
      "Er. I'm not sure." I said stupidly.
      She told me what I should looking for.
      And so it went. We students learning all about the dramatic high forceps maneuvers in rare complicated cases that we would never be called upon to do, by high powered hospital Actor-specialists and learning the vital common everyday obstetrical skills which we would need as GPs from the midwife.
    We also learned a great deal about life in the slums of Dublin and the influence of the Roman Catholic church that caused the poor and unfortunate to become even more poor and unfortunate. Ten, eleven, twelve and even thirteen children was not uncommon. I once delivered a woman of her seventeenth child and more than once I cared for a woman and daughter about to give birth at approximately the same time.

Come back in a couple of weeks and I'll take you with me on one of those adventures!