Each year, the RCOG invites foundation trainees to tell us why they’ve chosen a career in O&G for the Why Obs and Gynae? prize.
This is a submission from Navneet Kaur, an FY1 in Edinburgh, from 2010.
Why obs and gynae?
I find it very difficult to understand the recruitment difficulties that the specialty is currently experiencing. As a new medical graduate, I am very much looking forward to having the opportunity to work in obstetrics and gynaecology as an FY2, and apply for a specialist training post within this field. I have had many experiences, incredibly enjoyable and immensely distressing, that have inspired my career choice. I hope that discussing some of my experiences will encourage others to consider this as a possible future career.
My initial attraction to obstetrics and gynaecology came during my intercalated honours year in reproductive biology. I chose to undertake this as I had found teaching on reproductive physiology and reproductive health very interesting in second year. I found my honours year subject both challenging and fascinating, as it enabled me to gain an understanding of the scientific background underlying the field. This included learning about the core mechanisms in reproductive biology as well as an opportunity to explore the revolutionary advances in reproductive medicine. The most rewarding aspect was undertaking my laboratory based dissertation in ‘MMP activity in the fetal membranes, decidua and placenta during labour at term’. Through this project I explored the mechanisms underlying parturition and premature rupture of membranes, in relation to identifying possible biochemical markers for preterm labour. I was also able to gain laboratory-based research experience, which I thoroughly enjoyed. This gave me an excellent insight into the difficulties faced in understanding scientific mechanisms and developing successful treatments. I realized the importance of real scientific advances within the field of research in obstetrics and gynaecology. My honours year has motivated me to devote some of my time to research as there is still so much that we don’t understand and is still to be discovered in obstetrics and gynaecology.
During my 4th year I chose to conduct a student selected component in this field on ‘The Pregnancy Outcomes of Cervical Cerclage and the NRIE’. I found learning about the technical aspects of different surgical procedures and techniques fascinating and during this project I could see that by choosing obstetrics and gynaecology, I would be able to explore my interests in both medicine and surgery. Also during my 4th year, I did my placement at Forth Park Maternity Hospital in Kirkcaldy. This attachment provided much inspiration for choosing the specialty; I was able to actively participate in deliveries, theatres, local and remote clinics and ward work. It was here that I appreciated the diversity within the specialty and the variety of opportunities for subspecialisation. I will never forget the experience of my first delivery in the midwife-led unit and the privilege of being part of this life-event. I appreciated that by specializing in obstetrics and gynaecology I could assist in providing a holistic birthing experience for the family, and as an obstetrician I will have the opportunity to get to know my patients, seeing them for prenatal care and assisting them in complicated deliveries. I was also able to see that by choosing this specialty I could make a real difference to women’s health, working with women of all ages with the challenges they face throughout life.
The experiences on my elective were the most influential in deciding to choose obstetrics and gynaecology. I undertook an elective in two contrasting developing countries. One month at Sarawak General Hospital in Malaysia-Borneo and one month at Helena Goldie Hospital in the Solomon Islands. Malaysia is an emerging and developing country and Sarawak General Hospital is a well-resourced hospital located in Kuching. In contrast, the Solomon Islands is a less developed country, consisting of over 1000 islands in the pacific ring of fire. Helena Goldie Hospital is a 55 bed hospital with registered nurses and nurse aides working alongside only 4 doctors.
The labour ward in Sarawak General Hospital was busy and what was immediately striking was the lack of midwives with all aspects of delivery managed by the house officers on the ward. Comparing this to my experiences as a medical student in the midwife-led unit in Kircaldy, I found the degree of medicalisation of childbirth was surprising, all the women were augmented with assisted rupture of membranes and they all received continuous CTG monitoring. At the time of delivery, 6-8 junior doctors would stand around the bed to deliver the baby. The turnover was very quick; the patients booked in and waited for a bed in one of the 7-8 delivery rooms (all equipped with a widescreen TV) and as soon as the mother had delivered she was immediately transferred so another patient could use the bed. Talking to the house officers and medical students on the ward in Sarawak, I found that they were very experienced in both normal deliveries and problematic deliveries, and had learned how to perform caesarean sections, basic surgery and booking scans as a medical student. I am looking forward to gaining a wider range of experience within medicine and surgery during my foundation years as it will be useful during my future practice.
My experiences in the labour ward in the Solomon Islands were some of the most difficult. Most deliveries were performed by an experienced nurse aide, with the only obstetrician available to contact often absent from the hospital. There were no facilities for fetal monitoring or neonatal resuscitation. I found the resilience of the patients in the Solomon Islands remarkable as no pain relief was available for labour and delivery, and despite this, the mothers coped astonishingly well. One experience that I will never forget was during delivery of a large (4.218kg) baby, the head had been delivered but there was significant difficulty in delivering the anterior shoulder, a probable shoulder dystocia. I sent one nurse-aide to get help and with the assistance of an experienced nurse-aide, I applied suprapubic pressure and the nurse aide encouraged the McRobert’s manoeuvre. Luckily, this was successful and the baby was delivered and after much rubbing with a towel the baby cried and turned pink. I have never experienced as much relief as the moment the baby cried, and felt so privileged to have assisted the mother and baby during this difficult experience. Choosing a career in obstetrics and gynaecology will give me the chance to be involved in the management of emergency situations, which although challenging, will also be incredibly satisfying and rewarding.
I also observed a case that was fraught with ethical dilemmas. The patient was a lady of unknown age, with learning disability, whose child was admitted to the paediatric ward with pneumonia. The child’s father was a young schoolboy, who was not involved in the care of the child. During treatment of her child, it became evident that she was having great difficulty caring for her child, and her previous children had been ‘adopted’ by family members. Her family refused to help her with the care of her most recent child so the patient agreed that a nurse would unofficially adopt her child as there were no social/child welfare services available. Furthermore, the patient agreed that she would undergo laparotomy for sterilization to prevent any further pregnancies as she had been unable to maintain regular depot injections. On the morning of her surgery, despite many discussions with various staff members, the patient refused surgery and would not allow adoption of her child. After some discussion between the doctor and nurses, it was decided that the patient would be given an injection of an opioid, under the pretence that she was receiving a depot injection, inducing drowsiness and would then be taken to theatre for the procedure. Needless to say, I found this experience very difficult to endure. On one hand the patient’s autonomy had been entirely removed, but on the other hand, in a country with such limited resources, no psychiatric care or social support, and where abortion was considered illegal, it was difficult to offer the patient an alternative choice. This case demonstrated some of the ethical dilemmas I might face in a career in obstetrics and gynaecology. I learned the importance of respecting the autonomy of my patients, giving women the chance to express their choices, and the difficult dilemmas I may face in order to act in the best interests of my patient. In the future, I will be responsible for the care of the pregnant women where I will need to consider the health of two patients, both the mother and the fetus and I am looking forward to this challenge.
The most interesting and challenging experience during my time on elective was going with the medical touring team around Roviana Lagoon where I visited 11 different villages over 4 days. We travelled by hospital canoe, carrying all our equipment with a team consisting of a doctor, dentist, dispenser, nurse aides and an experienced boatman. At each location we set up a clinic in a volunteer’s house, nurse aide post or community building such as a church and all the locals would arrive to receive treatment for a huge variety of medical complaints, as well as to receive on the spot dental treatment. The clinics would continue well into the evening and since most of the villages we visited had no electricity, we were often left to see patients by kerosene lamp-light. I was surprised by the generosity and appreciation of the local people who supplied us with food, water and even mattresses. During the tour we also had the opportunity to practice the preventative medicine aspect of obstetrics and gynaecology, offering family planning and providing antenatal checks including distributing anti-malarials and iron supplements to pregnant mothers. I also accompanied the doctor on home visits to see patients that were too old or ill to travel to the hospital. One poignant home visit was to see a 40 year old lady who was diagnosed with ovarian cancer before an earthquake in January. The patient was terminal and receiving home care from her family. I found it especially moving to see her gratitude to the doctor for allowing her to go home to die and visiting her to provide her with palliative care.
In summary, I have discussed some of the most influential experiences in my choice to practice obstetrics and gynaecology, and my aims and goals continue to develop. I would now consider spending some time working in a developing country where the presence of these skills is highly valued. I have also realized that I need to gain a range of experience within medicine and surgery during my foundation years, which will be incredibly useful during future practice. Through my range of experiences I have learned that the diversity of the field is very appealing to me, I will be caring for women of all ages and assisting them with the challenges that they face throughout life.