by Leah Hazard
Fast-forward to that sodden Wednesday a few years later, by which time I had learned these, and many other, valuable lessons. Having left the labour ward, the opportunities to catheterise Triage patients were few and far between, so I picked up bed four’s notes and read them with interest. Hawa was a twenty-one-year-old Somali woman who had recently been granted leave to remain in the UK, and was forty weeks and two days pregnant with her first child. Rifling through her paperwork, it seemed that Hawa’s pregnancy had been fairly unremarkable: a bit of early nausea, then a scare with a small bleed at twenty weeks, then routine antenatal appointments and a plan for induction of labour at forty-two weeks. No history of urinary issues, and the call sheet clipped to the front of the case notes read simply, Abdo pain, patient unsure when she last passed urine, query labour.
I pulled back the curtain around bed four. A woman in a long purple nightie was on all fours on the bed, bottom raised towards me, head down, a thousand tight black braids spilling out onto the starched white pillow. A hijab had been neatly folded over the chair by the bedside; like many of the devout women I had encountered, Hawa had swapped a degree of modesty for comfort as soon as she was safely ensconced in the female sanctuary of Triage.
‘Hawa?’ I asked, and the woman whipped her braids back and smiled at me over her shoulder. She was beautiful, with flawless amber skin stretched over the highest, most regal cheekbones, and a long, graceful neck.
‘Sorry, sorry,’ she said as she turned round to face me. ‘I was trying to get comfortable. The pain is very bad.’ Although her smile didn’t waver, I heard the coarse crack in her voice. ‘It has been worse since this morning.’
‘Is the pain there all the time, or does it come and go in waves?’ I asked, thinking that at this point in her baby’s gestation, Hawa was most likely to be experiencing the crampy tightenings of early labour.
‘It’s there all the time,’ she said, ‘all across here,’ and she moved her hands over her belly, long fingers tracing the pain.
‘And when did you last pass urine?’
‘This is the thing. I’m not sure. I – I can’t remember. My husband thinks maybe last night. He wanted to come here but I said don’t be silly, it’s nothing, go to work. His boss, he is very strict, he does not like lateness.’ She smiled again, but her fingers grasped a little tighter at the purple fabric of her gown.
Moving to the bedside, I asked Hawa if she would mind drawing up her nightie so that I could have a feel of her abdomen. Palpation is the first step in many antenatal examinations, as it tells the midwife so much: how large the uterus is, whether the baby is well grown, which way the baby is facing, and whether the muscles are soft and relaxed, or taut with contractions, or rigid with a hidden bleed. I reached for a sheet to cover Hawa’s legs – we do try to preserve patients’ modesty, in spite of the commonly accepted notion that pregnancy requires women to ‘check your dignity at the door’ – but as Hawa lifted her gown, cold panic glued me to the spot. Instead of being smooth and round, Hawa’s bump looked like a water balloon that had been cinched in the middle with a tight belt.
My face must have betrayed my surprise as my hands traced the indentation across Hawa’s midline. ‘Is everything all right?’ she asked, eyes widening.
Bandl’s ring, I thought. It’s unmistakeable. A rarely seen sign of a dangerously obstructed labour, this invisible drawstring around a woman’s abdomen was something I had only read about, but here was one in real life. Maybe Hawa had been contracting for days without realising it, and for whatever reason the baby’s passage through the pelvis had been blocked, and this fibrous ring had begun its deadly constriction who knows how many hours ago.
‘I just need to have more of a feel,’ I stalled, and my hands moved lower down Hawa’s abdomen. As I felt the telltale bulge of a grossly distended bladder, I began to second-guess myself. Could this be the true cause of Hawa’s bizarre shape? I strapped the fetal monitor to her belly and the baby’s heartbeat ticked loud and steady. Fetal heart 140 beats per minute, I thought, planning my notes as the monitor drummed on. Accelerations present, no decelerations. Beyond the curtain, five other babies’ heartbeats chugged away in interweaving rhythm. The room was busying up – Stephanie’s voice was somewhere to my left, advising a woman to ‘breathe, don’t push, just breathe breathe breathe’ followed by the squeal of wheels against linoleum as another bed was dragged towards the door.
‘I think your baby sounds fine,’ I said to Hawa as the monitor continued its steady beat, ‘but I’m not sure what to think about the shape of your bump. Do you really think that maybe you haven’t peed since yesterday?’
Hawa rubbed her belly. ‘I think yes, this may be true. I have been up since very early this morning, and yes – maybe – perhaps it was the afternoon when I last passed water.’
I studied the trace of the baby’s heartbeat, which still looked completely normal, with no sign of the potentially fatal distress that a Bandl’s ring would cause. Cool your jets, I said to myself. You could page the doctor for an emergency that isn’t really there, or you could catheterise and see if a good, long pee makes this bulge disappear. As the thunderous chorus of heartbeats all around me seemed to grow louder, my decision was made for me. Just get on with it, I thought. If she does have a ring, then you freak out, page the medics, and stand back while the faeces hits the fan. But not before.
Hawa wasn’t wild about the idea of being catheterised (because really, who is? It’s a bit of a niche interest), but the pain in her abdomen was becoming so intense that the possibility of swift relief was too attractive to refuse. As soon as she consented, my panic receded. I was back on familiar ground, retrieving the necessary pack from the bedside trolley, pulling the corners open with care as if it were the most wonderful Christmas present, each component nestled in the crisp white paper, a neat-freak midwife’s dream. I splashed some sterile water into a little tub, pulled my gloves on with a satisfying smack, and prepared myself for a nifty bit of catheterisation while Hawa drew her legs up.
And there it was. Another shockwave that made my heart turn over in my chest, but this time, the shock was tempered with sadness as I realised what I was seeing, and the true cause of Hawa’s pain revealed itself.
While every woman’s genitalia are different, with variations in size, texture and proportion, we all share a basic structure, and there is actually a comforting truth to the cliché that once you’ve seen one vulva, you’ve seen them all. However, what Hawa was showing me was not what nature had gifted her: even an untrained eye could have seen that this was something that had been cut, reshaped and sewn back together, most probably many years ago, most likely in a faraway place. Where I expected to see soft, fleshy folds, there was a smooth surface, like the sexless Barbie dolls I used to collect as a child. The edges of Hawa’s skin had been brought together to create a small, crudely fashioned opening, and even with my sharply angled torch, I could only just see where my catheter needed to go. As I probed gently with gloved fingers, I confirmed that Hawa was one of the increasing number of women we’d been seeing who had been cut as a child. Most of these women were from countries where the practice of cutting young women and girls in various intimate ways was a centuries-old tradition. While this mutilation and desexualisation are undoubtedly horrific, it’s difficult for midwives, politicians or anyone responsible for women’s safety to know how best to approach the issue with sensitivity: the practice of Female Genital Mutilation (FGM) may be rooted in only the most tenuous religious doctrine, but many parents and elders perform FGM in the mistaken belief that it will preserve their daughters’ virtue and, by extension, the family’s honour. What is criminal in one country can be seen as sacred in another, no matter how brutal the act.
Swallowing down my anger at whatever long-ago auntie or neighbour had done this to Hawa, I continued my work, passing the slender tube where it needed to go and watching with relief as urine began to rush out. The collection bag at the end of the tube began to fil
l, and it wasn’t long until there was almost a litre of fluid inside it. Clearly, the pressure of a fully grown baby had been too much for Hawa’s altered anatomy to handle, and her bladder had simply backed up. It was possible, even likely, that Hawa had endured years of urinary and sexual dysfunction, but like so many women in her situation, shame had stopped her from disclosing her history. Living with this secret, she had not sought any kind of medical treatment until today’s pain required her to do so.
I looked up to Hawa’s belly. As the catheter bag filled, I could actually see the bulge in her lower abdomen disappear and, as it did so, her bump evened out as I watched, settling into the smooth, round shape it should have had from the start.
I must have been too quiet for a little too long. Hawa looked down the bed questioningly, but my usual midwife patter failed me. For the second time that morning, I was lost for words. Where to begin? What was the right ‘word medicine’ for this beautiful woman who had crossed continents to end up on this bed, wholly reliant on me at that moment to keep her and her baby safe? Now that I knew Hawa had been cut, I was obliged by law and hospital protocol to ask her how, and when, and where, and to get her reviewed by the doctor, and to link her in to a gynaecological follow-up plan that might slowly reverse the pain and dysfunction she had probably been suffering for years. If her baby was a girl, Hawa would face fresh questioning and surveillance to ensure that her child wouldn’t fall victim to the same fate, but there was no guarantee that the cycle would stop. The law is strong, but sometimes the pull of tradition is stronger.
‘Is it OK?’ Hawa asked, nervously pulling at the rumpled purple fabric of her gown.
So I did what midwives do. I took a deep breath, and I smiled. Gently, I lifted the catheter bag off the bed, cradling it in my arms. It had the warm, soft heft of a newborn, and I lifted it so Hawa could see. ‘Congratulations,’ I replied, grinning. ‘We’ve delivered your pee baby. Now we just have to deliver the one in here,’ I said, nodding to Hawa’s belly.
She looked at me, then she looked at the sloshing, golden bundle in my arms, and she laughed. Slender neck thrown back, eyes closed, braids dancing around her head, she laughed until she shook, and I laughed with her. And we sat there laughing together, while her baby’s heartbeat drummed steadily around us, until we stilled and gasped for breath.
Notes on Getting It Wrong
Mistakes will be made.
Children will write their name backwards. Cashiers will hand back the wrong change. Drivers will run red lights. And midwives will get stuff wrong, along with doctors, nurses, dentists, firefighters, teachers, police officers and pretty much everyone else who gets paid by the public to get stuff right.
It’s a design flaw; people are prone to glitches – neurons firing gaily in the wrong direction, lighting up the brain like a pinball machine gone haywire – especially in times of extreme physical or emotional stress. Unfortunately, I slept through my alarm on the day when my midwifery tutor gave the lecture on How Not to Be Human; consequently, I am prone to all of the same foibles as the rest of the population. Most of the time, these errors have zero impact on my patients: I spell ‘intravenous’ wrong, I spill my coffee, I get halfway through my shift before clutching my unusually soft, free-flapping breasts in horror and realising that I forgot to put my bra on that morning.
Sometimes, though, my innate human knack for howling self-sabotage really comes to the fore, and I just plain get stuff wrong. There was the time when I misjudged the speed of a patient’s labour. She was a first-time mother who sauntered quite casually up to the Triage desk, barely flinched at a vaginal examination which revealed her to be six centimetres dilated, and then proceeded to push out a baby in the middle of a busy corridor as I oh-so-casually walked her along to the labour ward lifts, believing, until the moment I saw that telltale, baby-shaped bulge in her sweatpants, that we had all the time in the world. There was also that other time when, to the great and lasting hilarity of my colleagues, I spent twenty minutes on the phone talking a woman through what seemed to be the throes of advanced labour, only to be told by the paramedics who grudgingly brought her to hospital that the patient was, in fact, only five months pregnant, and felt so much better after doing a giant poo. As a student, these kinds of mistakes are mortifying, especially when they’re broadcast to the rest of the shift’s staff with great embellishment. Time, age and experience eventually smooth the edges of that piercing shame and as long as no significant harm is done, the canny midwife knows to suck up these glitches, learn from them and even accept them as an inevitable part of the job.
Fortunately (or not, depending on how you look at it), I’m not the only clinician ever to have made an error of judgement; the long hours, the scant resources, the constant emotional strain and the notoriously unpredictable workings of the body might have something to do with the prevalence of human error in the health services. Sometimes the mistakes midwives make actually have very little to do with birth, and more to do with the myriad of medical conditions that can be triggered or exacerbated by pregnancy. This is the real ‘meat’ of Triage. Yes, our patients have uteruses (uteri? I’ve never been comfortable with that pompous plural), but they also have all of the other organs that non-pregnant people possess – the soft, fleshy baggage that makes us all human. These organs, from liver to lungs, from kidneys to colon, can backfire in spectacular fashion, leading to confusion, consternation and yes, mistakes.
As midwives, we develop an intricate understanding of pregnant physiology and all of its potential problems, but when complex medical conditions intersect with obstetrics, our partnership with doctors comes into its own. We may slate the young ones for their wide-eyed enthusiasm, bemoan the sneaky ones who demonstrate selective deafness when their pagers go off, and formulate personal lists of the ones we’d never, ever let near our sisters and daughters, but the good ones – the ones who listen, who collaborate, who learn and teach in equal measure, who possess that perfect combination of knowledge and creativity – these are the ones we want by the bedside when a pregnant woman gets really, really sick. We love these doctors. We bring them tea and biscuits when they’re on the verge of collapse after five straight hours in theatre. We nod sympathetically when they tell us they can’t remember the last time they saw their children in daylight. And we may or may not cut their hair in the middle of Triage on a rare quiet night shift.
I had a high-school biology teacher with a syrupy Southern accent and a wry sense of humour who enjoyed strolling among the lab benches as his hapless students struggled over dissections and diagrams. ‘Weeeell,’ he would drawl as he stopped by one particularly flummoxed pair of lab partners, ‘two halfwits make a whole-wit.’
I often hear Mr Combs’s voice in my head amid the din of Triage, especially when presenting a doctor with a case history that’s got me stumped. With years of training but often precious few hours of sleep between us, we discuss, debate, and finally we hatch a plan. Sometimes one or both of us gets it wrong, and mistakes will be made, but every now and then our two half-baked halfwits come together, and eventually, blessedly, just-in-the-nick-of-time-edly, we get it right.
Tina: Flu Season and Fear
‘Did you bring a sample?’
‘Yes, it’s just here.’
She reached into her bag, withdrew the red-capped vial of golden liquid, and passed it to me with a smile.
This is the ritual of the antenatal clinic: the Patient, knowing she will be called upon to present a urine sample, gives the hallowed jar to the Oracle. The Oracle, in return, plunges her sacred, divining dipstick into the fluid – once, twice, three times in solemn succession – reads the colours blooming in tiny squares now along the length of the stick, and pronounces her wisdom.
‘You have protein in your urine.’
‘You’ve got an infection brewing.’
‘There’s glucose here,’ she may say gravely. ‘Is there any family history of diabetes?’
‘No,’ the patient replies.
‘But I did have two bowls of Frosties, a chocolate chip muffin and a cappuccino with three sugars before I came here today.’
And thus it was spoken on that Monday morning in December, when I had been ‘pulled’ from my usual home in Triage to help out in the antenatal clinic along the corridor. Staff from every ward had been shuffled and redistributed across the hospital like a pack of cornflower-blue cards, and instead of answering the day’s first phone calls about leaky vaginas and babies who won’t move, I had been hustled into a small, unfamiliar room, armed only with a blood-pressure cuff, a Sonicaid and a drawer full of leaflets about pelvic pain. The unit had been short-staffed overnight, I was told, and apparently it was to be short-staffed again for that day, and the next, and the next. ‘Flu season,’ the night staff had groaned by way of explanation before flapping out the door in hastily donned winter coats and scarves, hurrying off to scrape their icy windscreens before heading for home and bed.
In addition to the ever-exciting game of ‘Musical Chairs for Midwives’, flu season brings with it a raft of delights including the Peer Vaccination Programme (a cheery diversion which requires the dutiful midwife to spend her lunch break seeking out a colleague willing to inject her with that season’s flu vaccine in the cosy confines of the drugs cupboard), and also the famous Flu-Like Symptoms (a fantastically vague, catch-all term that can refer to sniffles, sneezes, sore throats, feeling hot, feeling cold, nausea, diarrhoea, aches, generalised malaise, and pretty much every other condition that might affect the average human on any given morning in the middle of winter).
