Ишемическая болезнь сердца-Ischemic heart disease

The postnatal examination, usually at six weeks, is considered by the most practical as a sort of MOT test (the obligatory government safety check on the mechanical workings of one’s car), to ensure that all parts are working properly again. Others may consider it as the secular equivalent of the Churching of Women – the Anglican ceremony of thanksgiving for having safely survived the perils of childbirth and the recognition that the woman is now ready to be received back into the community. Likewise, it may be seen as a ‘rite of passage’, the moment when she returns from the process of childbearing to ordinary life (Raphael-Leff, 1991).

In the past, couples were advised against resuming intercourse until this six week postnatal check by the doctor, although there were always a few rebels who broke the rule. The doctor was looked to as the authority who would proclaim the woman as ready to resume normal life. To a large extent, this is still the case. Some women like to feel that intercourse is prohibited until after the postnatal visit, for it is easier to refuse for good medical reasons rather than because she does not want it. For her partner, too, it may be easier to accept the sense of exclusion if it is felt to be for medical reasons. Although it is easy to give permission for intercourse, perhaps the woman who feels strongly that it is prohibited should be allowed to quote medical authority if she wants to do so.

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Mr Â., now in his early 40s, used to have a wild time in the evenings after his rock concerts. Now he is a vigorous homemaker/house parent and his wife is the main wage earner. ‘I did not really like the nymphomaniacs, and after a bit I got to saying no.’ ‘Why?’ ‘It seemed that they all wanted babies, underneath. And even if you were using condoms they were pretending, and hoping to themselves that it was for real. They were lonely really. I did not want kids, but even without that risk they were behaving like babies themselves. Within a few days you couldn’t shake them off.’ ‘And you didn’t want to have to cope with that?’ the doctor asked, pausing before he continued. ‘Children are very important to you now.’ Mr. B. thought and replied, ‘I wish I could have them myself.’ As the doctor left, Mr. B. said, ‘We have been talking about another child, but perhaps it is too late now.’

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It is fairly common knowledge that abortions carried out early are relatively easy and carry few risks. Yet a small but steady stream of women present in the mid-trimester requesting abortion. Mid-trimester abortions carry greater physical risk and the woman is more likely to suffer psychological consequences, although this may depend on the method used. A dilation and evacuation under general anaesthetic causes less psychological trauma than a prostaglandin induction (Kaltreider, Goldsmith and Margoles, 1979). For the staff involved, mid-trimester abortions are messy and distasteful. Many NHS clinics refuse to see women over 12 weeks’ gestation. Yet this small proportion of women probably require greater skills in surgical technique and counselling, and more emotional support. ‘Why did she leave it so late?’ is the commonly asked question, carrying the undertone that it was somehow the woman’s fault, therefore sparing the health worker any responsibility for helping her.

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The doctor who can tolerate a certain amount of aggressive behaviour, recognizing it as a defence against pain and uncertainty, has much to offer the young patient, who is able to test out new ideas with an adult who is not the parent. Such a role may be more difficult for the family doctor, who has often been felt to be a kind of ‘super-parent’, called in by the real parents at times of illness when they are unable to manage alone. Younger patients often say, ‘I’ve known him all my life, he’s like a father: I can’t talk to him about sex.’ The importance of an alternative source of advice, where the young person can come and go as she (or he) wishes cannot be stressed too highly.

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Conflict is not the only emotion that gets projected into those who are trying to help. The apathy and fatalism that such families generate can also overtake the professional worker. It may then be decided that nothing can be done, apart from dream about some kind of Utopian solution and, like the family itself, the worker may lurch from crisis to crisis. Debts accumulate, electricity and gas are cut off, children do not attend school and may be neglected or abused. Against this background, talk about contraception can be seen by the woman in a negative way as if it is being advocated in order to control rather than to empower her. Where the emphasis is on trying to change social conditions the subject of contraception can be overlooked, yet the failure to raise the issue and give a realistic appraisal of risks and benefits actually denies people freedom of choice.

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