The Midwife's Special Delivery

by Carol Marinelli

  ‘Have you checked her blood pressure manually?’ Rory asked, reading through the observation chart.

  ‘Yep.’ But as Rory scanned the drug chart his expression changed.

  ‘Why hasn’t she had any painkillers? She hasn’t even had paracetamol! Did you ask if she was in any pain?’

  ‘Of course I asked,’ Ally retorted. ‘But Kathy didn’t appreciate being spoken to like a five-year-old and neither do I! I do know basic nursing care, Rory, but the simple fact is that her obs are unstable and she refuses to answer any of my questions, let alone allow me to examine her wound site or breasts.’

  ‘I’ll go and see her,’ Rinska groaned, putting down her biscuit and coffee and clearly bracing herself for another confrontation with this most difficult patient. Ally shuffled uncomfortably for a second before speaking, unsure how to say what she had to in front of so many staff.

  ‘It might be better if Rory saw her, Rinska.’

  ‘Has she refused to have me look after her?’ Rinska’s voice was strained, her cheeks flaming with embarrassment as Ally gave a slightly helpless shrug.

  ‘She did ask to be seen by someone else,’ Ally said as tactfully as she could. ‘And, given the circumstances, it’s probably for the best.’

  ‘I agree with Ally,’ Rory responded. ‘Ms Evans clearly needs a thorough examination, not, of course, that you wouldn’t give one but she’s hardly compliant at the moment.’ He gave an exasperated sigh. ‘Has anyone told this woman how lucky she is to have a healthy baby?’

  ‘She doesn’t want to hear it at the moment,’ Ally said. ‘Rory, going in there with all guns blazing isn’t going to help matters.’

  ‘I have no intention of going in with all guns blazing,’ Rory retorted sharply. ‘But clearly pussyfooting around the issue isn’t helping. The staff are all terrified to go in there in case their name’s added to Ms Evans’s long list of complaints…’

  ‘I’ve been in to see her regularly,’ Ally flared, but Rory gave an impatient shake of his head.

  ‘I’m not talking about you, so don’t take everything so personally. I don’t even want to go in there and watch her scribbling down every word I say, but the fact is we have a patient who’s clearly unhappy and not feeling at all well, combined with nurses and doctors who did everything right feeling as guilty as hell for no good reason. I think this needs to be sorted out once and for all.’

  ‘Leave it, Rory.’ Rinska shook her head. ‘I don’t need you to fight my battles—you’ll only put her off side and end up with a complaint against you as well.’

  ‘They can’t sue you for being honest.’ Rory gave a tight grimace. ‘Yet! Ally, go and tell Ms Evans that I’ll be in shortly, I just want to have another look at her notes before I see her.’ Oh, how she wanted to warn him, to tell him to leave well alone, but Rory wasn’t the intern he had been three years ago. He was a registrar now and the choice was entirely his. But maybe he saw the anxiety in her eyes, because he looked up and gave a tight smile. ‘Don’t worry, it will be fine.’

  And with that she had to be content. Taking a deep breath, Ally knocked on Kathy’s door and went in.

  ‘Dr Donovan will be along to see you shortly.’ Ally managed a smile and, mindful of Rory’s words, realising that perhaps, given Kathy’s hostile attitude, some basics might have been missed, Ally tried a fresh approach. ‘If you buzz me next time you feed Toby,’ Ally offered, ‘I can come in and show you a couple of positions that might make things a bit more comfortable for you, given that you’ve had a Caesarean. Sometimes resting the babe on a pillow—’

  ‘You don’t have children, do you?’ Kathy interrupted, glaring at Ally, who shook her head. ‘Well, I’ve been feeding Lily for three years now. I’m still feeding her at bedtime so I certainly don’t need to be shown how to feed my own child by someone who’s never even held her own baby—’

  ‘How are things?’ Rory waltzed into the room, ignoring the palpable tension, and introduced himself to Kathy. ‘I’m Dr Rory Donovan. I’m the obstetric registrar on this afternoon. Sister Jameson told me that you had a temperature and that your blood pressure’s elevated. Do you have any pain?’

  ‘Ally already asked me that,’ Kathy answered tightly.

  ‘I know,’ Rory responded. ‘And you didn’t answer her question either. I see you haven’t been taking any of the analgesia that’s been ordered for you. Are you concerned that any medication that you take will be passed on to your baby?’

  ‘Someone has to be.’

  Rory didn’t rise to the bait, but Ally saw one of his eyebrows rise an inch. ‘I’d like to examine you, Kathy. I need to have a look at your stomach wound and listen to your chest, but first I’d like to ask you a few questions.’ He ran through several diagnostic questions and each was answered with a grudging negative until Rory washed his hands and asked her to lie down.

  Ally positioned the blanket as discreetly as she could and watched as Kathy clamped her lips together and extremely reluctantly lay back. Rory gently probed her abdomen. ‘Your wound looks fine. Do you have any tenderness here?’ Gently he pushed and Kathy shook her head. ‘Or here?’Another shake of her head. ‘OK, let’s sit you up and I’ll listen to your chest.’ He held out his hand to assist her up but Kathy didn’t take it, choosing instead to use the monkey pole above her bed to raise herself. Ally watched as the woman tried to hide her obvious pain.

  ‘Some nice deep breaths, Kathy.’ Rory put on his stethoscope and listened to the back of her chest. ‘Can you just undo your nightdress for me, Kathy, so I can listen to the front?’

  ‘I’m fine,’ Kathy bristled, but when Rory stood firm she undid the front buttons of her maternity nightdress and not by a flicker did Rory’s expression give away what he was thinking. But Ally wasn’t faring so well. A frown puckered her brow as she caught sight of Kathy’s cracked, bleeding nipples. One breast was red and swollen and Ally was furious with herself that she hadn’t been more insistent with Kathy. Regular breast checks were routine on the maternity ward, but each time Kathy had been approached she had withered the staff with some cutting comment, basically refusing an examination each time. At the end of the day that was her prerogative and Ally couldn’t force her patient to be examined, but seeing how much needless pain Kathy was in was upsetting. Rory concentrated on his patient’s breathing, first moving his stethoscope across her chest before wrapping it around his neck and washing his hands again. When he came back to the bedside, Kathy closed her eyes as supremely gently he examined her painful, engorged breasts.

  ‘How long have they been sore, Kathy?’ Rory asked.

  ‘For a couple of days,’ Kathy finally answered. ‘Well, the nipples have been sore for a couple of days, but the pain in my breast only started this morning.’

  ‘Can you lift your arms a little, please?’

  More compliant now, Kathy did as she was asked, and Ally was pleased with Rory’s very low-key, matter-of-fact response to Kathy’s problem. Mastitis and sore, cracked nipples were extremely commonplace in the post-partum period, but Kathy’s case was rather extreme and the fact she had let it go on without telling the staff was worrying.

  ‘You have mastitis in your breast, Kathy and the start of an abscess.’ Rory pulled her nightdress closed as he explained the problem to Kathy. ‘Some of your glands are swollen in your axilla, you must be in a lot of pain.’

  ‘It’s not too bad.’

  ‘What about your nipples—have you tried a shield when you’re feeding?’

  ‘I can’t use them.’ Kathy’s voice was brittle again, her eyes staring fixedly ahead, refusing to look at either Rory or Ally.

  ‘I’m going to need to take some blood from you.’

  ‘Is that necessary?’

  ‘Very,’ Rory said. ‘I want to take blood cultures so we can hopefully isolate the bacterium and give you the appropriate medication. We need to get you started on some broad-spectrum antibiotics—’

  ‘No.’

  ‘Kathy, you h
ave an infection—’

  ‘I’m not taking antibiotics,’ Kathy furiously broke in. ‘I know that they pass through the milk, they’ll give Toby thrush. I’ve asked my husband to bring me in some cabbage leaves to put on my breasts—that should help.’

  ‘It will help.’ It was Ally talking now. ‘We’ve got some in the fridge on the ward. A lot of the mothers use them to ease the discomfort of engorged breasts, but as Rory has said you’ve also got mastitis and an abscess—you need antibiotics—’

  ‘I need to be left alone. If your colleague hadn’t rushed in and performed a Caesarean, I’d have been home now, instead of picking up bugs in hospital. Now you want me to take yet another drug, to clear up yet another problem you lot have created. And when my baby gets thrush, no doubt you’ll prescribe yet another drug to clear that up as well. You lot stand here dictating my treatment for my body and I’m just supposed to lie here and say thank you. Well, unlike the way I was treated in labour, I demand input, I demand to make informed choices—’

  ‘Kathy.’ Rory’s voice was quiet but firm, halting the woman’s angry tirade. ‘Let’s clear the air, shall we?’

  ‘Meaning?’

  ‘Meaning that since you had your baby, you’ve been extremely vocal in criticising the hospital and a number of my colleagues.’

  ‘I’m making a formal complaint,’ Kathy snapped.

  ‘Which is entirely your prerogative. If you feel that you have been mistreated or that the care given to you was negligent, it is right that you complain. Now you’ve refused to discuss your issues with Mr Davies or Rinska or any one of the midwives.’

  ‘I don’t want to hear their excuses.’

  ‘Fair enough. Well, the problem we face now is that you need treatment. In fact, you’ve needed treatment since yesterday, yet you don’t trust the staff enough to tell them when you’re unwell. As you’ve said, I believe on numerous occasions, you want to be fully informed—so that’s what I’m going to do. Ally, could you hand me Kathy’s medical notes, please?’

  Oh, she didn’t want to. Ally didn’t like the way this conversation was heading one single bit, but Rory held out his hand and completely ignored Ally’s slightly anguished, warning look.

  ‘I understand that you were keen to have a vaginal birth.’ Rory was reading as he spoke. ‘And it says in your antenatal notes that on several occasions you were warned that it might not be possible.’

  Kathy stared up at the ceiling, her face set as Rory pushed on.

  ‘You went into spontaneous labour at two p.m. and came into hospital around nine p.m. This was your baby’s heart tracing on arrival to the ward.’ He handed the slip of paper over to Kathy who, after a very long moment of stony silence, reluctantly took it. ‘The heart rate looks fast, but babies’ hearts beat much faster than adults, this is a completely normal tracing. The line beneath—’

  ‘Is my contractions. I’m not stupid.’

  ‘I know you’re not,’ Rory answered, and continued to explain Kathy’s labour to her in detail, as she continued with her stone wall of silence.

  ‘This is your baby’s heart rate when Rinska decided to perform an emergency Caesarean.’ He handed her the tracing but Kathy didn’t take it. ‘There are decelerations, a lot of them—that means that the baby’s heart rate was slowing down during contractions, and as the trace goes on, if you looked then you’d see that they become more and more prolonged. Toby was taking longer and longer to recover from each contraction.’ Ally noticed that he had personalised things now, was referring to Toby, not ‘the baby’, and she watched Kathy’s jaw clenching as Rory pushed on. ‘Toby was in foetal distress. He wasn’t receiving the oxygen he required. In fact, by the time you reached Theatre, Toby’s heart rate was barely picking up at all between contractions.’ He pulled out another CTG recording and this time Kathy took it, listening in silence as Rory pointed out the variances on the tracing.

  ‘She didn’t tell me this…’

  ‘She told you that the baby was becoming distressed.’

  ‘Yes.’

  ‘That it was imperative to deliver the baby?’

  ‘Yes.’ Kathy nodded. ‘But she didn’t explain all of this to me. I had no idea how serious it was.’

  ‘So you didn’t understand that if Toby wasn’t delivered immediately, he might suffer permanent brain damage or possibly die?’

  ‘She didn’t say that.’

  ‘Did you want her to?’ Rory asked.

  ‘Yes. No.’ Kathy gave a tiny sob. ‘I don’t know.’

  ‘This trace was taken at five-thirty a.m.,’ Rory said, ‘and this one was taken at five to six. Your baby was born at six a.m., Kathy. Toby had to be born, there was no choice but to perform a Caesarean. Now, if the doctor didn’t give what you consider an adequate explanation, it would have been for one of two reasons. Firstly, she didn’t want to terrify a laboring woman with the worst possible scenario when she knew that if the baby was quickly delivered it could be avoided. And, secondly, given that she had to call her consultant, and arranging theatre time would have been a factor, Rinska didn’t have time to sit at your bedside and go through all the tracings. Rinska also knew that you were extremely well versed in the risks and would have been told the reasons that might precipitate a Caesarean section. In my opinion the fact that English isn’t her first language didn’t enter the equation—the doctor was simply busy saving your son’s life.’

  ‘If she’d just let me go for a little bit longer,’ Kathy insisted, but Rory remained immovable and shook his head.

  ‘The cord was wrapped tightly around Toby’s neck…’

  ‘She could have cut it,’ Kathy said.

  ‘It was too tight for him to move down,’ Rory said, and gave her a moment for that information to sink in before continuing. ‘Maybe I’m just a guy, maybe I’m horribly insensitive to a woman’s needs, because, while I’m aware that many women want to have a natural birth, I don’t really understand it.’

  Kathy frowned, as did Ally, and Rory gave a hint of sheepish smile. ‘Like I said, I’m a guy and a doctor and I can’t really get my head around the pain part of it, but I’m happy to be educated, more than willing to listen to my patients and as far as possible give them the birth they want—’

  ‘Give them! That’s exactly my point,’ Kathy interrupted. ‘You’re a privileged spectator in a natural process—’

  ‘And one who’s not remotely politically correct,’ Rory broke in, and Ally was amazed to see the first hint of smile break on Kathy’s strained mouth. ‘What I don’t get is the “at all costs” part.’ The smile on Kathy’s face faded, and she gave a strangled sob. Tears poured down her face as Rory gently continued, ‘Hell, Kathy, you’ve got two beautiful, healthy children, you’ve done so amazingly well, you should be so proud.’

  ‘I feel such a failure,’ Kathy admitted. ‘I wanted so badly to do it naturally.’

  ‘You couldn’t!’ Rory’s words were brutally honest. ‘But it doesn’t make you any less their mother, any less a woman. Just be glad you live in these times, Kathy.’

  But Kathy shook her head, refusing to be comforted, refusing to believe it was that simple.

  ‘I’m saying all this, Kathy, not because I want to stop you from making a complaint—as I said before, that’s entirely your prerogative. I’m doing this because you need to understand what happened during your delivery, you need to get your head around those facts so that you can start to trust us again. Because if you don’t, you’ll refuse treatment, you’ll endure a massive, preventable infection that might make you seriously ill and, in my honest opinion, if you carry on with this guilt and blame, you’re going to end up with severe postnatal depression.’ As she opened her mouth to argue, Rory steamed on ahead. ‘A difficult labour, post-delivery complications, a mother with high expectations…you have some of the classic warning signs. If you won’t take antibiotics for an obvious infection, am I right in assuming that down the track you’ll be refusing anti-depressants?’

>   ‘I don’t need them,’ Kathy said through gritted teeth.

  ‘No,’ Rory agreed, ‘you don’t—yet. Right now you need to understand what happened and start enjoying your beautiful baby—and he is beautiful, Kathy. Very beautiful.’

  Kathy was crying in earnest now. Used to tears on the maternity ward, Ally recognised them for what they were—not bitter or angry, but sheer exhausting, emotive sobs that had been held in for way too long. She moved to comfort Kathy, but Rory got there first, placing one strong hand on her heaving shoulder and letting her weep for a while before speaking.

  ‘Will you take the antibiotics, Kathy?’

  ‘Can I still feed Toby?’ she gulped.

  ‘You can.’ Rory nodded. ‘But, like you said, there’s a good chance it could cause oral thrush. I see in your notes that you’ve got some expressed breast milk in the fridge. I could take the blood now and hold off starting the antibiotics till this evening, give you a chance to express some more milk. If you’re happy to do so, perhaps Toby could survive on the bottle for a few days. We’ve got teats that simulate a nipple, so he shouldn’t get too used to it. However, that’s more Ally’s department.’

  ‘He’s so young, he should go back to the breast fairly easily,’ Ally agreed. ‘And you can stay in here till you’re happy that your feeding’s established.’

  ‘But I’m supposed to be going home in a couple of days.’

  ‘Not with an infection,’ Ally said. ‘And not until you’re confident that Toby’s feeding well—which I’m sure he will be.’

  ‘I’ve actually got some more breast milk in the freezer at home.’ Kathy looked over at Rory. ‘If I ring my husband and tell him to bring it in…’

  ‘You’ve got some stored at home?’ Rory asked, and Ally held her breath, hoping that Rory wouldn’t blow things now. ‘How come?’

  ‘Kathy is still breastfeeding her daughter, Lily. I guess she wanted to be prepared.’

  Rory could have given a wide-eyed look that she was feeding her three-year-old, could have said any number of things to upset Kathy in this rather labile mood, but, instead of making things worse, his face spilt into a wide grin of admiration and he made things suddenly a whole lot better.