Generally Speaking

GP Obstetrics in ‘the good old days’. Reminiscences of good and bad after half a century.

We talk about the good old days – but they weren’t always good.

Way back in 1972, one of the things which attracted me to coming to work here in Alton was the availability of a local GP maternity unit where I would be able to look after my mothers when they had their babies.

The practice I joined was in temporary accommodation while we were waiting for our promised health centre (another attraction) to be designed and built. Thus our surgery (office in American) was converted from one of five wooden wards dating from the Second World War, originally part of the old Alton General Hospital. One of the others was used for Medical Records, another for Outpatients – where specialists from the District General Hospital at Basingstoke held their outreach clinics, and the remaining two, right next to us, were the GP Maternity Unit.

In many ways this seemed ideal and the setup was certainly enormously popular with the mothers. They loved having their babies close to home in the quiet, low-tech environment of a small-scale unit.

But all was not always good. For example, we had one midwifery sister there who had a rigid conviction that newborn babies must be wrapped up immediately after birth and put into a cot across the delivery room beside the radiator. She insisted they needed this to keep them warm.

I used to protest that if there was one time in life when you couldn’t possibly be cold, this was going to be it. But it made no difference at all – when it was her turn to be on duty she was in charge and her control was absolute. She certainly wasn’t going to take notice of some new arrival who didn’t look old enough to be a doctor (as quite a few people used to say – I told them that would change).

It upsets me even now to think how desperately those new mothers must have wanted to hold their little babies. And of course the fathers too, in the room with us as they almost always were. And how important a part of the bonding process that, surely, ought to have been. I can’t help feeling that there was something almost vindictive in such behaviour by this severe, childless, and probably rather sad, woman.

But this was the nature of the professional autonomy that midwives enjoyed when they were in their domain. Sister S (It would be unkind to use her name, although she been dead for many years) had a colleague, Sister Thomas (I’ll celebrate her memory at least), who was her polar opposite. Warm and kind, when she was on duty the delivery room was a place of laughter, joy and love.

Arriving as a junior partner in Alton I knew more about Obstetrics and Paediatrics than General Practice. My last year in hospital medicine had been spent as a houseman (intern in American) at the Whittington Hospital, London – six months in Obstetrics, then six in Paediatrics. That meant that my preparation for the role of GP had included numerous forceps deliveries and assisting at numerous Caesars. Not to mention intubating a pair of tiny, premature twins, alone, in the middle of one unforgettable night:

Both had been ‘flat’ – in other words floppy, not breathing and turning white. As paediatric houseman on duty I had to transfer the first baby onto the sloping resuscitation table, use the smallest infant laryngoscope to lift the epiglottis to reveal the tiny tracheal opening, and then, not without the usual difficulty, slip the smallest size endotracheal tube safely home. Then, ever-so-gently, puff the oxygen mixture – and receive the glorious reward of spontaneous breathing and that wonderfully welcome cry.

But before all that was settled the mother surprised us by producing a second baby. In those days before ultrasound, undiagnosed twins were not all that unusual. Especially, as in this case, with an overweight mother and a premature labour, when the babies were, by the nature of the thing, tiny. And this time our second was just as ‘flat’ as our first.

So, with two resuscitation tables next to each other, one of the midwives took over twin number one, and I started on a repeat performance with twin number two. Equally difficult but, in the end, equally successful. Both twins turned out fine and I still think of that as one of the proudest practical achievements of my whole career.

But I digress – the point is that we GPs did do practical procedures and they were a source of great pride and satisfaction. And specifically, I did do straightforward forceps deliveries – what we called ‘lift-outs’ – in our GP maternity unit.

Now, on one occasion I had decided that a particular forceps delivery was not going to be straightforward and that instead we should transfer the mother, albeit in the throes of obstructed labour, to the main hospital, 15 miles away. A very difficult decision, because we couldn’t send her in an ordinary ambulance, we needed what was called the ‘flying squad’ – a specially-equipped ambulance with a senior obstetric registrar and an experienced senior anaesthetist drawn from specialist unit.

Sister S. did not agree that this was the right thing to do. I’m ashamed to admit it even now, but she goaded me by threatening to call one of my GP colleagues and get him to do the forceps delivery. She said he would be able to do it easy peasy (or words to that effect). So I went ahead against my better judgement.

And it quickly became apparent that it wasn’t going to work – that we had a failed forceps on our hands – and I should have stuck to my guns.

So the flying squad had to be called anyway, and when they eventually arrived the registrar decided that it was not safe to take her back to Basingstoke and we would have to do a caesar there and then.

After that everything went well. I was back in my element assisting at the caesar. Mum and baby both turned out fine. She went back with the team in the ambulance, in spite of her sleepy protests, and she returned to us a few days later for convalescence. Thoroughly delighted with everything that had happened from start to finish, she was endlessly grateful for all the care. And so she remained for the subsequent decades that I knew her growing family. The only disappointment being when she couldn’t understand why she couldn’t have her next baby with us too, just like the last time.

I used to say that all my grey hairs were maternity cases and I was not sorry when the march of progress eventually saw the unit’s closure. I had always tried to play very safe by choosing only suitable cases, and I never had a really serious mishap (nor should I – I calculated that a GP should only ‘see’ a maternal death once in 400 years – i.e. never). But I did have a few more than worrying experiences, in spite of my caution. Home deliveries were different again, because with them you really could stick to absolutely uncomplicated cases and there was none of the subtle pressure to ‘keep the numbers up’ by booking slightly less suitable mothers for what seemed to be a safer environment, but which, without the backup of a specialist unit, actually wasn’t.

But the little old GP unit did have a wonderful atmosphere of peace.  I remember one patient, who had, as it happens, arrived recently from India, developing asthma for the first time during her pregnancy. In spite of a succession of increasingly potent medications it became worryingly severe, and did not respond even to the short course of oral steroids which almost invariably worked like magic to abort an attack. I can’t remember my thought processes clearly more than 40 years after the event, but I must have judged that this resistance to treatment suggested something more than a physical cause. So what I did was to admit her to the maternity unit so that she could have a complete rest. And it was that that worked like magic. Her asthma melted away, she was able to stop all her treatment, and the pregnancy progressed quite happily.

Everything is different today. But there is no harm in writing some of this down while I can still remember.

Brexit: We are all more susceptible to persuasion than we like to think.

I was a young doctor. I had it in my power to help this guy. So I did.

He was a drug rep. Sitting opposite me in my consulting room. Half a century – most of a lifetime – ago. He had been waiting outside for much of my morning surgery, as reps used to in those days, hoping I would see him before I started on my paperwork and visits. As usual it had worked – me being too soft-hearted to say no and send away a fellow human being with a wasted morning.  ‘There but for the grace of God’, and so on… Read more…

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