What did you expect?

We have become obligate avoiders, dwellers in the middle of the field well away from boundaries –the just-right-baby-bears of the Goldilocks tale. We seek to protect ourselves from edges, no matter how pervasive, how common, how important they may be. It was for a very good reason that the American folk hero, John Wayne, felt he had to remind us that ‘Courage is being scared to death… and saddling up anyway.’

Most of us seek to insulate ourselves from every extreme: we read about our lives from the safety of a middle page while dreaming of the youth in early chapters –as if there were no beginning or conclusion to the book. I suppose it reads as well in the center as at either end, but that misses the point; the book is a story –our story- and to ignore the epilogue or, for that matter, the introduction is to miss the context in which it is written -the gestalt.

The end of life, is an example –until recent times, most people in Western civilizations died where they lived: in their own homes. Family and friends were usually there to provide comfort and support; it was not treated as an event that necessitated separation, but rather as a communal passage –something that invited witness and provided solace for all involved.  Dying, especially of advanced age, was not something to be hidden away or delegated to strangers, however skilled. Death was visible and inevitable; death was a known, if unwelcome guest in each home.

Birth, the beginning of the story, has also had a somewhat chequered history. It, too, was once relegated to the home, but with sometimes unfavourable results for both mother and baby. This led to it being assigned to areas –or assistants- with more training and facilities in case unexpected -or anticipated- problems arose. And while, as an obstetrician, I feel more comfortable in an institutional setting, there is no reason why a well-trained midwife should not be able to pick and choose the appropriate venue for the birth depending upon her assessment of the risk involved. And there is no reason, either, why family or friends should not be able to witness and support the event.

I was surprised, therefore, to come across an article in the BBC news that treated as, well, unusual, the idea of a mother’s children being present to witness the birth: http://www.bbc.com/news/uk-37020059

Clearly, some vetting might be required in terms of the children’s age and behaviour, but as long as they are prepared beforehand, and there is someone else in the room who could supervise and help them understand what is happening, I think it could be a positive experience. Birth and Death should be presented as they are: natural events –not secrets whispered behind closed doors.

*

I kind of suspected birth was no secret to Loretta’s kids. A third-time mother of six and  nine-year-old daughters, she brought them to every antenatal visit. I asked her one day while her older daughter played doctor with my stethoscope, how she managed to get them out of school each time.

She pointed to her watch. “Ever notice that I always book my appointments around noon?”

I nodded. We’d often joked about our stomachs rumbling each time we met. “But they don’t mind leaving their friends to come here?”

“McDonald’s,” she said and then shrugged. “It’s their reward for agreeing to come with me.” She was silent for a moment and then stared at me, her eyes twinkling. “Don’t look at me like that, doctor. Remember Bill Clinton?”

I nodded, puzzled by the non sequitur.

“I never inhale,” she whispered conspiratorially.

The girls were always on their best behaviour in the examining room –full of questions and wanting to try my equipment on themselves. I suspect that the visits sometimes even cut into McDonald time, but they seldom complained –they were much too curious about the growing baby. They never seemed to tire of asking me how much it weighed, and whether it could hear them through their mother’s tummy –apparently they would sing to it at home. The moment they both waited for, however, was when I would place the Doppler device on the uterine wall so they could hear the heart. Janice, the older one, would even time it with her watch to make sure my device was counting correctly. They were both as involved in the pregnancy as their mother.

One day, towards the end of the pregnancy, Loretta phoned me. “I’ve been thinking of letting my girls see the birth,” she said. I could hear a little hesitancy in her words as she spoke. “Will the hospital allow that? My mother will make sure they don’t get in the way,” she added, almost too quickly.

I smiled into the phone –I’d been expecting her to ask. “As long as they know what to expect Loretta. There’s sometimes a lot of… well, yelling as you push… and a lot of blood –especially when the placenta comes out.” I paused for a second. “They have to be told that none of that means there is anything wrong. I wouldn’t want them to become scared.”

She chuckled into her phone. “They watch deliveries all the time now on YouTube, doctor –complicated ones, scary ones, and even ones that end up in Caesarian Sections. I think they’ll be all right.”

“Then it’s fine with me.” I reminded her that I may not be on call when she delivered, but she merely laughed.

“You didn’t make it for the first two either…”

*

Obstetrical practice nowadays is a hectic melange of joy and crisis, each delivery unique and exhilarating to be sure, and yet strangely merged into the one a few minutes before and blended into the one a few minutes later when on call at the hospital. So I have to admit that I was pleasantly surprised one evening as I was rushing to yet another delivery further down the hall when a nurse informed me that Loretta had just been admitted in labour.

“She’s almost fully dilated and it’s her third baby; she won’t be long…” she yelled as I ran past her to the accompaniment of screams from the room where I was originally heading.

Obstetrics is sometimes an exercise in ad hoc triage, and the screams were becoming louder and more compelling from that room, so I had little choice in the matter. I arrived just in time to exchange the mother’s for the baby’s screams, and allow a placenta to jump suddenly into my lap while she snuggled her precious baby against her abdomen.

In the warmth of smiles and congratulations that followed, I almost forgot about Loretta until the nurse’s face appeared in the door. “They want you in Room 8, doctor,” she said, almost casually.

I removed the placenta from my lap and stood up ready to run from the room.

The nurse shook her head sternly. “Better not show up like that,” she said, pointing to my gown. “You’ll scare the girls…”

I grinned sheepishly from behind my mask. I’d forgotten about the girls.

Loretta’s room was strangely calm when I arrived. Everybody was smiling, the baby already snuggled skin to skin on Loretta’s abdomen, and the girls were standing beside their mother enthralled and staring wide-eyed at the crying baby.

Maria, another nurse, who’d been with Loretta since her admission, was just removing her gloves after making sure the newly-delivered placenta was in its little metal bowl. Even though trained as midwives, the obstetrical nurses rarely get a chance to exhibit their skills except at times like this, and she was smiling from ear to ear. Things had obviously gone well.

“Congratulations, Loretta,” I said and immediately blushed. “Looks like I missed number three as well. I’m sorry…”

“Don’t be sorry, doctor. Maria did a fabulous job.”

Maria glanced at Janice who hadn’t even noticed that I’d finally come into the room then focussed her attention on me. “Actually, I was a bit rusty,” she said with a mischievous smile and winked at me. “Janice kept reminding me what to do next…”

Janice turned her head and stared at me. “Maria did a good job,” she said approvingly, “But she dropped the placenta,” she added, her face turning serious like a teacher unwilling to overlook a mistake. “I told her it’d be slippery…”

 

Placentaphilia

Finally! Somebody has had the courage to think the unthinkable and say what most of us have been too shocked to verbalize, too nauseated to contemplate: that eating your baby’s placenta is not a plus. My risen gorge has been vindicated.

An article in the BBC news http://www.bbc.com/news/health-33006384 reports on a review article on placentaphagy (the practice of eating placentas) from Northwestern University http://link.springer.com/article/10.1007/s00737-015-0538-8#page-1 (published in the Archives of Women’s Mental Health) that suggests that there are no proven benefits and no research on the potential risks.

Uhmm… Well, okay, no blinding epiphany there. I mean even if you saute it and hide it under a leaf of lettuce between two slices of toast, you would think it would still lack that magic je ne sais quoi. But, alas, you would be wrong. There has long been a fascination with the placenta and its powers, no doubt rooted in its dual role in both sustenance and connection. It is, after all, neither baby nor mother, and yet an essential workshop serving the two worlds. A mythological creature, its function does not cease with the accident of birth.

Name the culture, and there’s probably a tradition. Some of the aboriginal peoples of the Pacific Northwest of Canada, for example, have the belief that if the placenta is placed in a tree and then carried off by a raven, the child will travel. The New Zealand Maori suggest that the placenta has a link with the earth and should be returned to it when it is no longer needed. There are even those who believe it was alive and functioned as a companion for the baby but then sacrificed itself so the child could be born –I like that one.

My point, I suppose, is that given the magic surrounding the placenta, it should not come as a total surprise that some might feel that the power it wielded might be transferrable if it were consumed. Or, perhaps, that some of its constituents may be beneficial. But I wonder if it’s the same kind of logic that Macbeth’s three witches used. It’s certainly a stretch to suggest that the placenta offers something that isn’t more readily and efficiently available in some other more acceptable format. The fact that it came from within the body and has served as a treatment plant in utero does little to recommend it in my opinion.

But I am more than a little disappointed with my own Medical culture’s lack of imagination. Its lack of narrrative. We are a society of stories –it’s not only how we impart information, its how we value it. Evaluate it. Surely we could have made something up as well… Tradition wrapped in metaphor is far more meaningful than facts trapped in lists. Sometimes facts must wear scratchy and uncomfortable clothes to attract attention. Gather adherents.

Once upon a time when I was young and still wore a stethoscope around my neck, I found myself in the midst of nothing less than an epidemic of placenta-eaters. Wave after wave of them swept into the case room, teeth sharpened, and bread sliced. They couldn’t wait to enter the Kingdom of the Enriched –some even partaking before they left the delivery suite. Usually they were discreet and waited until we had left them alone in the room to bond; sometimes they seemed in a rush.

I’m not certain what started the practice –it was, as I recall, before the days of social media- but start it did. Suddenly, and with an enthusiasm I had never witnessed, it was upon us. But until I saw my first bite, it was a horror that lived in legend alone.

*

The hospital nurse assigned to the couple was an English-trained midwife and she shooed us out of the room as soon as we doctors had congratulated them and put away our instruments. I should have known something was up when I was even led away from the little window in their door.

“They need some privacy, doctor,” the nurse informed me as she grabbed my elbow and steered me away. “This is a really important time for them,” she added, winking at me cheekily and then hobbling into the lounge to get a coffee.

I wandered over to the ward desk and pulled out the chart to enter the usual description of the delivery and write some orders when I discovered I didn’t have a pen. I checked the counter and even riffled through some drawers, but to no avail. It was around two-thirty in the morning, and no one else was around. I decided I must have left mine in the delivery room, so I walked down the corridor to their room and pushed open the door.

Mistake. The father was lying on the narrow bed beside his wife who was holding the swaddled baby on her chest. Three things struck me: the baby was preternaturally quiet; the parents both had silly, embarrassed smiles on their faces; and he looked like he had been practicing with bright red lipstick. He’d even got it on his teeth.

I quickly looked away so I wouldn’t embarrass them in their intimacy. “Sorry to disturb you like this,” I said, a bit uncomfortable that I had maybe caught them in flagrante delicto as it were. “I left my pen in here,” I mumbled and searched around on the floor for it. It was then I noticed the umbilical cord suspended from the edge of a blood-tinged sheet on the bed. I was horrified; I thought perhaps the placenta had somehow gotten mixed up with the blankets after the delivery.

I stood up suddenly beside the bed. “I’m so sorry,” I said, in my most apologetic voice. “Did we forget to clean up your bed after everything?”

He looked up at me sheepishly, still holding a fragment of placenta in one hand. “I’m afraid it was us…” His voiced trailed off as his wife looked at him with hooded eyes. A profound silence blanketed the room suddenly. No one spoke; the baby snortled; and I could hear all four of us breathing. Labouriously. Expectantly.

The husband broke the tryst. “Not what I expected, actually,” he mumbled cryptically. I could see his wife giving him a poke under the covers. “Wouldn’t recommend it to anybody, that’s for sure…” She sighed loudly and glared at him over their still sleeping baby.

I thought it was unusual for the baby to be so quiet –they usually cry a fair amount after delivery to fully open their lungs and adapt to life outside the womb. I reached over and vigorously rubbed its back through the blankets he’d been swaddled in –at that time the parents weren’t taught the importance of skin-to-skin contact for mom and baby like they are nowadays, so it would have been difficult to spot breathing problems in the infant through all of the layers.

The baby made a weak attempt to cry while mother sat up immediately and demanded to know why I had attacked her baby. She pushed the bell for the nurse at the same time. By the time the midwife had arrived with angry eyes, I had transferred it to the bassinet and was fiddling with a suction tube preparing to suction out the baby’s mouth.

When the nurse heard the grunting of the infant and saw what I was attempting she smiled at me and took over.

The mother, in the meantime, was distraught. “Why did he wake my baby up?” she screamed. “We were having a little quiet time when he barged in here and grabbed my baby.”

The nurse handed a screaming infant back to the mother and touched her gently on the arm. “You should be glad that Doctor came in, Emily. Your baby was having trouble breathing with all that mucous in its mouth.”

The husband looked embarrassed. “I think we were too focussed on that weird placenta stuff,” he said and smiled at Emily to sooth things over. She blushed and cast a loving glance at her screaming baby.

“It wasn’t very tasty was it, honey?” she whispered. “Not at all like that book promised…” She reached over and kissed him warmly on his cheek.

He returned the blush. “I… I spit mine out into this,” he admitted and pulled out a little plastic K basin he’d hidden under his pillow. “Couldn’t swallow it,” he said and shrugged. “How about you, sweetheart?”

“Terrible heartburn, dear…” She glanced at the midwife, in case she had transgressed on some sort of midwiffic tradition. “But maybe it just needed more salt, or something,” she added quickly to try to make the best of a bad situation.

The room filled with the cries of the baby. “Maybe it just needed to stay in the metal bowl where the doctor put it,” he said in a brief lull as the baby sucked in a lungful of air and he returned his wife’s kiss.

The midwife was all smiles. “I couldn’t eat mine, either,”she said, winked, and cast a knowing shrug towards them. Then she walked slowly over to a sink in the room, picked up a couple of towels and, ever the nurse, dampened one edge of each.  “Anybody want to clean up a little?”

A Placental Tale

Her light brown hair was long and tied in a little pile on the top of her head like a haystack about to topple. Her cheeks were rosy, her eyes were bright, and her face was lit with the jubilation that only the young experience at the start of a journey. She was happy –her whole body trembled with the joy of a recently discovered pregnancy. Her smile was so infectious and irresistable that my mood changed the moment I saw her in the waiting room. It’s one of the many benefits of my profession –like a gratuity, almost- to experience her exhilaration vicariously.

She could hardly sit in the chair in my office she was so excited. I congratulated her on her first pregnancy and after taking her history and filling in the antenatal forms, sat back in my chair to chat less formally. It’s an opportunity for both of us to get to know each other, and for her to ask me questions: management questions, fear questions, rumour questions… Even silly questions she would have been afraid to ask at the beginning. “You know,” she started hesitantly, but obviously more comfortable talking to me, “You know, when I first thought about it, I really assumed we’d strayed too far from our roots…”

I smiled encouragingly. “What do you mean?”

She stared at the ceiling for a moment before continuing. “I mean, nothing’s natural anymore.” She let her eyes fall on my face for an instant to check my reaction before letting them wander again. “Pregnancy’s sort of, you know, compartmentalized .”

An interesting observation. I hadn’t thought about pregnancy in compartments before. But I didn’t say anything; I didn’t want to break into her stream of thoughts.

“You know… First there’s the Missed Period stage and then the Discovery stage…the Nausea stage, then the Feel Better for a while part, the Big and Clumsy part…  And each part is framed by some test or other.”

“You’ve been reading, Marilyn…”

She shrugged noncommittally and sighed. “But you know, I’ve come to like the idea of compartments. It’s a more interesting and useful way of dividing up pregnancy… I mean, rather than into the more traditional trimesters.”

“I think that doctors tend to medicalize things too much; it’s an unfortunate byproduct of our profession.”

She smiled, but warily. She was testing the waters. “I’ve been thinking about documenting the stages online. You know: feelings, physical symptoms, test results –that kind of thing.”

I nodded encouragingly.

“I thought I’d try a video blog…” She let her eyes sit firmly on mine and left them there. “I might see how it goes and then edit them all into a short documentary for YouTube.” She searched my face for a reaction.

My expression obviously suggested I was digesting the idea, but I suspect she saw some suspicion of the whole process, because her smile widened to engulf her face. Her enthusiasm was captivating.

“No, I don’t want to film all our visits, or anything…” She hesitated and then her eyes twinkled mischievously. “Just some of them. It’d be too boring and time-consuming to do them all.”

I am usually up for adventuresome projects, but I admit I couldn’t keep the doubt off my face. The question of privacy, and physician/patient confidentiality ran through my mind, to say nothing of the medico-legal implications. “Well, I…”

She giggled and her whole body seemed to relish the sound. “Just testing,” she said, almost shaking with her delightful laughter. “We’ll just do one visit; you can choose…” She stared at me with a merry expression. Then a change: not more serious perhaps, but more cautious. Uncertain.

“Actually, this has all been done before,” she said with a sigh. “So there has to be a point to my documentary -a twist: a different view of the process of pregnancy and delivery…” She looked down at her lap for a moment, as if summoning the courage to explain. “I’ve always been fascinated with the idea of the placenta as an intermediary. A facilitator. A gatekeeper. I want to document the pregnancy from the placenta’s point of view… You know -give it a name, sort of. Time on the pedestal…” She made eye contact briefly then withdrew her eyes for a moment. “Does that sound crazy?” She shrugged her shoulders and then studied my reaction hopefully.

“That sounds absolutely fascinating!” I said, honestly enthusiastic. “The placenta is something that has always interested me as well. It’s an active and important organ, not just a passive filter.”

“Exactly,” she said as her face lit up. “I’d like to film parts of the labour and delivery for the documentary if that’s okay with you… Especially the  Delivery.”

I cocked my head and looked at her. “The Delivery? I don’t…”

She shook her head in mock exasperation. “The placental delivery! And ,” –she really emphasized the ‘and’- “I’d like to keep the placenta as well. Will they let me?”

I nodded. “And” –I thought I’d try my own emphasis- “you get to keep the baby, too.”

She chuckled and her face pixied. “Oh yeah. I forgot about the baby…” She looked at me mischievously. “What about the filming?

I looked at her for a moment, wondering how to respond. “Well, if it’s okay with the staff in the room. You’d have to get their permission… And don’t forget we’re on a call schedule, so it might not be me who’s there for the delivery… But we’re a pretty liberal group. I’ll bet they’ll be as fascinated as me.”

Her smile never waivered, but her eyes did roll upwards a bit when she shook her head as if she were confronted with a particularly slow student. “I know all that, doctor. Don’t you think I’ve looked up you and your colleagues online already?”

                                                   *

The days, as usual, unfurled thickly but rapidly after that, and the quotidian details, written so densely on each hour, meant that I inevitably forgot about Marilyn’s plan. Even when she returned with her partner for the scheduled antepartum visits they blended into the background of a crowded waiting room and the endless round of weights, blood pressure measurements and fetal heart rate checks that fill each day to overflowing: Samsara.

I don’t mean to suggest that I forgot Marilyn; she was just too enthusiastic and happy to overlook. But I did forget about her video blog. I did forget about her placenta.

I did not forget about her compartments, though –she wouldn’t let me. And one day, during the Big and Clumsy division, she arrived with a little video camera and asked if her partner could film the visit. I glanced at her otherwise unremarkable chart, saw how completely normal her pregnancy had been up until then and shrugged. Why not?

He filmed her getting weighed, and even her sample of urine being tested with the little dipsticks we use to measure protein and sugar. A little embarrassed smile ran briefly across his face when her back was turned and he saw me peeking around the corner at the production. I didn’t mean to stare, but I have to admit I was curious.

The problem began when I measured her abdomen to gauge the size of the baby –all captured on the camera, of course- and I had to explain to them why it didn’t seem to have increased in length from the last visit. There can be many reasons the measurement can vary from expectations, actually: position of baby for one, and minor discrepancies with measuring technique from visit to visit for another. Of course we always worry about a decreasing amount of fluid around the baby or lagging foetal growth, but common things are commonest, as the saying goes. If the change is small, it usually merits only observation at first. If it persists over time, it shouldn’t be ignored, though. Wouldn’t be ignored… Investigations then would become necessary.

I explained this to them in as reassuring fashion as I could, ever mindful that I was doing so on camera. But even so, the questions poured out as I knew they would. It was a small difference, I explained, but they were so anxious I felt I needed to begin an investigation rather than waiting to see if the changes represented a trend, or mistaken measurements. At their insistence, I ordered an ultrasound to check the amniotic fluid around the baby as well as parameters of baby’s growth and well being. But I could see they were still worried –her especially.

“Do you have any other questions?” I asked, trying to keep the smile on my face.

“Do you think it might be the fluid around the baby?” she said, her smile weakening considerably.

“It’s a possibility, I suppose,” I said, trying to stay neutral. “But I really think it’s just baby’s position…”

She strengthened her smile, but I could see it was an effort and she hesitated at the door. “The fluid is the responsibility of the placenta, isn’t it?”

I nodded carefully. The placenta plays a roll in amniotic fluid production, but the whole process is complex and interrelated with multiple other contributing factors. And yet her pregnancy had been, and continued to be otherwise unremarkable. She was only a week or two away from her due date so even if there were problems developing, induction of labour was not out of the question…

She shrugged –also carefully, I thought- and left the examination room holding her partner’s hand.

The ultrasound was normal of course –normal fluid, normal growth of baby… all parameters were normal. I’d also sent her for an NST (Non Stress Test) –a form of monitoring for the baby that correlates its heart rate with various things such as movement, contractions, etc.- and it, too, was normal.

She came to the office the day after the tests without the camera. Her smile was back, and she wore her enthusiasm like a brightly coloured blouse.

“Where’s the camera?” I asked in mock surprise. I hoped she hadn’t been so frightened by the tests that it had discouraged her video blog.

Each time I see her, I am amazed that she can extend the width of her already face-swallowing smile when asked a question. “I’ve decided to shift the focus” –she rolled her eyes at her unintended pun- “and concentrate on the compartments…” I must have looked puzzled, because she explained immediately. “Some things are just meant to stay in the background,” she said. “Important, yet anonymous.”

I didn’t pursue the reasons. I suppose some things –background things- feel more comfortable in the shadows and away from public scrutiny.

As luck would have it, I was not on call for the delivery. And because it occurred over a weekend, she was not even in the hospital when I returned on the following Monday. I only saw her several weeks later for her post partum check.

She was the same ebullient woman, though; nothing could dampen her enthusiam –not even the crying infant she was snuggling as she came into the office. Everything had apparently gone well and she had no complaints or problems. But I just had to ask. “Did you manage to video the delivery?” I said with a smile. She nodded excitedly, obviously pleased that I had remembered. “And the Delivery..?”

She looked puzzled and her forehead furrowed, but only briefly. “Oh, the placental delivery, you mean?” She immediately shook her head and her unstoppable eyes twinkled yet again. “It’s so…disgusting,” she said after searching for the best word. “And once it came out, they put it in a little bowl somewhere in the background and I guess we forgot about it… We didn’t even name it.”

Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…