Obstetrician's distress

Charlotte and Arthur had been married for seven years when they attended my clinic because Charlotte was still virgo intacta. I have given them Bronte pseudonyms but in Yorkshire sexual medicine is much the same as elsewhere in Britain. Few clients live up to the strong, silent stereotype: “You're frowning, Heathcliff. Would you like to share your anger with us?”

Treatment began with “sensate focus.” According to the standard texts, this involves the couple going home, getting naked, and relaxing together. They are advised to touch in a non-genital way and verbalise their feelings. I suspect this works better in California than in the Pennines. The British may have acquired central heating but they still retain their sense of humour.

Back in the clinic I suggested that Arthur put his finger on to his wife's hymen. He gamely did so, turned pale, and had to sit down. I wrote to their general practitioner that I thought treatment would take some time. I predicted that it would be successful “over about four or five months.”

Two years later Charlotte became pregnant. After many visits and some imaginative counselling we had a good rapport and although she lived near her local hospital she asked to attend my antenatal clinic. I felt embarrassed by her making unnecessary journeys but it seemed churlish to refuse.

This was a low risk pregnancy and the clinic visits involved us beaming at each other and chatting. Then, a month from term, Charlotte telephoned to say the baby wasn't moving much. She came straight to hospital. The monitor showed a normal fetal heart rate but the trace was “suboptimal.” The registrar decided that labour should be induced next morning: was this all right with me?

It is a cliche in our specialty that we can cope with fetal distress and maternal distress but by far the most dangerous condition is obstetrician's distress. I told myself that there is no such thing as a “precious pregnancy” and that I was too close to this patient to be objective. Looking back it is hard to say why I decided on immediate caesarean section but I think any consultant obstetrician would have done the same.

Baby Jane was delivered almost dead, with a pH of 7.01 and a haemoglobin of 4.9 g/litre. There had been a massive fetomaternal haemorrhage. Jane made what the neonatal senior house officer's discharge summary described as “an exceptionally good recovery.” Charlotte wrote a nice letter and I never saw her again.

The point of this little anecdote is its political incorrectness. Our sexual medicine clinic is now at the bottom of our cash strapped purchaser's list of priorities. Consultant involvement in routine antenatal care is currently as unfashionable as plus fours (though I sense the pendulum starting its swing again). Routine fetal movement counting is on the list of interventions that “appear promising but require further evaluation.” Rising caesarean section rates are causing national concern. And obstetricians are no longer practising anecdote based medicine. Or if we are we certainly aren't writing about it.—JAMES OWEN DRIFE, professor of obstetrics and gynaecology, Leeds