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In Good Hands

Getting to know Specialist Obstetrician and Gynaecologist, Emma Parry

Emma Parry is a Specialist Obstetrician and Gynaecologist and a Subspecialist in Maternal Fetal Medicine. She is currently Clinical Director of Maternal-Fetal Medicine at Auckland City Hospital.

She is based at Auckland City Hospital which has one of the largest maternity units in the country. Emma has varied clinical interests, but is especially interested in complex multiple pregnancy, 3D scanning of fetal anomalies, information storage and retrieval and preterm labour. She established the New Zealand Maternal Fetal Medicine Network (NZMFMN) and introduced the high tech procedure of Selective Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome to New Zealand.

Emma is a member of several committees both within Auckland City Hospital and New Zealand. She is a regular speaker and organises conferences and workshops in New Zealand and Australia through several organisations. Her research fields include Preterm Labour and Induction of Labour, Health Informatics in Women’s Health and improving Maternal and Perinatal Health in the Developing World.

Growing up, had you always wanted to be an obstetrician and gynaecologist?
I wanted to be a doctor at age five, but Obstetrics and Gynaecology was something I fell in love with at Medical School when I got to deliver twins. It was such an amazing experience to be a part of such a wonderful event. It’s funny as I’m in the middle of writing a book about my life and travels and it has really focussed my thoughts around what the drivers were to the direction my career has taken.

Tell us about your first experience with childbirth?
My first experience of childbirth was as a medical student. In the UK childbirth is mainly a two person event; the mother and father so no extra supporters! I got to watch the midwives deliver five babies before I got to actually help. It is a special but sometimes frightening part of life.

Was your own experience of giving birth a positive one? What if anything would you have changed?
When I had both my girls I had midwives who I trusted completely caring for me. My eldest was born in Dunedin and I had one of my colleagues as back-up for the midwives. Being a doctor I had that as a risk factor and of course I ended up needing the Obstetrician’s help! Alice was a ‘tricky’ ventouse delivery and my six foot Obstetrician colleague/friend was sweating by the time she was out! Despite this it was an immensely positive experience. I had my husband Dave there and a final year medical student who had been following my care and had got to know me really well. So I guess I wouldn’t change anything.
For my second daughter four years later, I was convinced this would be a piece of cake having had a vaginal delivery the first time. I hadn’t figured on her having a big head. I tried everything to deliver her without help even sitting on a birthing stool, however her head was too big and so I ended up with a Caesarean section. My mum was over from the UK for her birth and was in the delivery room with Dave and I and the midwife. This was very special for me, but unfortunately she wasn’t allowed into theatre as only one support person was allowed. I guess having a Caesarean section was disappointing but there you go. That’s why I have a job, but not being able to have my mum in theatre is the one thing I would have changed if I could.
Since that time people have tried to get an extra person in theatre, ‘but doctor it’s really important...’ and although I feel for them, I hold to the party line as that is what happened to me!

Are there any children that you have worked with that immediately come to mind as ‘miracle babies’?
Gosh, loads of them! Most of my area of high risk pregnancy makes one feel impotent as we make diagnoses but often can’t do much to fix the problems. One of the procedures I perform is to transfuse a fetus with blood when it is anaemic from Rhesus disease and this means survival for a baby that would have died. This is a procedure we do a few times a year and is technically challenging and always makes me feel proud of our Unit. However, there are other cases where there is less of a standard approach and as Doctors we have gone out on a limb and done a procedure that is novel. One case is a baby who had a big tumour at the base of its spine. These are usually treated with a good outcome after birth but while the baby is in-utero it can develop heart failure and die. We had a couple of babies where this happened and when the next case came along we offered the parents a lifeline of laser treatment. We used Ultrasound to guide a needle into a position next to the biggest blood vessel and then passed a laser fibre down the needle and fired the laser to cauterise the big vessel. After this, the blood flow to the tumour shrunk and the tumour shrunk with the baby doing well. I still get phoned by colleagues in Australia asking how we did this and we have had more successful cases since.

What qualities/ characteristics does a person require to work in such an emotionally challenging area?
Maternal-Fetal Medicine is very emotionally challenging and recent research has shown that amongst Obstetricians and Gynaecologists this area has the highest burn-out rate of any sub-specialty area. I think you need to be strong yourself and able to appreciate that you are no use to the families you care for if you are feeling their pain as well. You have to keep a bit of distance, which can sometimes be hard. I have a couple of patients who ultimately became my friends after I had finished caring for them as you share so much together.
I also think that you need to be non-judgmental. It is easy to do, but actually we see a range of people in a range of difficult circumstances and I can’t ever put myself in their shoes completely.
We work as a team at Auckland and will talk through difficult cases and sometimes ask a colleague to take over the care if we are finding it too hard. It is also good to talk and we each have our own approach. I have great friends and family I can offload on as well as colleagues.

Who has been the most influential person throughout your career to date?
The person who has had the biggest effect throughout my career is Professor Lesley McCowan. Lesley is a highly committed and excellent researcher with an impressive international portfolio of papers. She was a senior academic whom I worked with in the University of Auckland. In addition, she is a Maternal-fetal Medicine Sub-specialist like myself and has an amazing capacity to check detail when it comes to a woman’s care. Nothing escapes her eye which means they always get excellent evidence based care.
In many ways I wanted to be like her.

If you could invent one thing to make your job easier… what would it be?
An ability to translate my thoughts and words when talking to women in clinics and making plans and decisions instantly into the written word so I don’t have to type or dictate or write notes!

You established the New Zealand Maternal Fetal Medicine Network (NZMFMN) in 2010. What need did this service fill? How successful has it been?
At the time the Network was established there were two driving forces; the number of Doctors with the level of expertise and qualifications available to provide care were very small and one of the only doctors in the South Island with expertise was leaving New Zealand. Another unit in the North Island was also potentially about to lose a specialist due to disappointment with support and the care that could be provided. The second driving force was that women in smaller units and in rural situations were not getting the right care at the right time as there weren’t clear pathways to get the women to the correct care and in many cases, a lack of understanding by caregivers as to what Maternal-Fetal Medicine care was available. We were often the ambulance at the bottom of the cliff rather than the fence at the top. The combined MFM doctors around the country proposed a network which was supported directly by the Ministry of Health to improve the situation.
The network has been a real success (in my opinion). We now have three well staffed units and have eight subspecialists in New Zealand (there were five) with three more in training (only one previously). The Auckland MFM unit is now considered the best training unit in Australasia by many in our field. The future for our area and the women we care for looks bright as a result. In addition, the networking out to individual midwives and doctors and the training we run means that the pathways of referral are sorted and women who need an opinion get seen in a timely fashion.

You introduced the Selective Fetoscopic Laser Photocoagulation for Twin to Twin Transfusion Syndrome to New Zealand. What exactly is this and why hadn’t it been introduced into New Zealand earlier?
Twins who share a placenta are identical twins and are particularly high risk. There are blood vessels connecting the twins within the placenta and there can be an uneven blood flow between them. This can result in one having too much blood and one not enough. If it is severe there is an almost 100% chance of losing both the babies. The most common time for this to happen is between 18 to 26 weeks gestation.
This condition can be picked up on routine ultrasound scans. In the past, the main treatment was to perform an amnioreduction. As a result of the imbalance one twin makes an excess of urine and this results in excess amniotic fluid. The amnioreduction is where a needle is placed in the uterus and often several litres of fluid are removed. It can work but often has to be repeated and doesn’t address the issue of the blood vessel connections on the placenta. Around 15 years ago, an MFM doctor in the US developed a technique where a tiny telescope is placed in the uterus and then a laser fibre passed down the scope and used to cauterise the connecting vessels on the placenta. When these two treatments were compared the laser treatment had much better outcomes.
At first there was only one centre in Brisbane in Australia performing these procedures and in time the women in New Zealand who were identified were sent to Australia for treatment. A second and third centre in Sydney and Perth then started. Starting this kind of service is complex and requires training which is hard if you are in different cities let alone different countries! The cases are also not that common. However, the two east coast Australian units fed back to us in 2008 that they felt they were seeing a lot of New Zealand women from the centres there and that it was time for us to start our own service. We then got onto the process of application of approval for a new service, fundraising for equipment and improving detection of cases for referral. Our service was officially started in May 2010 at a ceremony complete with ribbon cutting with Tony Ryall in attendance.

What comment can you give on the students coming through the medical and midwifery education system? Are graduates more prepared now than they were 10-20 years ago?
Of course I tend to look at this question through rose tinted spectacles. When I qualified, I thought I was good at my job and efficient, but looking back I cringe at some of the things I said and did. The training now is much less focussed on learning the facts and more on being able to find the facts. This is essential as there is so much information and it is increasing all the time that you can never know everything. So I think newly graduated doctors are similar to when I qualified. For midwives, I think the training has also changed a lot and for anyone involved in delivering babies in New Zealand (doctors or midwives) there is an increasing difficulty in getting enough hands on experience. A lot of this has come about as a result of birthing becoming a heightened experience where there is a lot of focus on who the woman’s carer is. Women who may have been happy to have a student as part of their birth in the past are less inclined to do so. I think this is a shame and will be a problem for our daughters when they come to have babies as their doctors and midwives become less experienced.

Do you believe the training in New Zealand is adequate? If not, how can it be improved?
I think the Obstetrics and Gynaecology training is very good and that the Consultants we produce are world class. There is a difficulty in getting enough gynaecology operating experience as more conditions are managed conservatively without recourse to surgery. One way that this area is being tackled in our specialty is to use mannequins to practice procedures such as hysterectomy on. This has been shown in studies to accelerate learning in the real life environment and reduce the number of real cases needed to reach a desired level of competency.
Across the whole specialty, there is a danger of sub-specialists such as myself allowing our general colleagues and trainees to opt out of areas which are bread and butter for all Obstetricians and Gyanaecologists. We are all at fault here!

If you could offer one piece of advice to expectant mothers, what would it be?
Keep an open mind. Things have a habit of not working out how you planned!

Medical jargon demystified by Dr Emma Parry:
Obstetrician: A doctor who has been through post graduate training and exams and is expert in pregnancy and pregnancy complications.
Gynaecologist: The same doctor as an Obstetrician as it is a combined specialty. This part of the specialty deals with women’s health issues, in particular diseases of the female genital tract and in some cases urinary tract.
Echocardiography: A scan of the fetal heart by an expert in heart scanning
Amniocentesis: An invasive test where a needle is inserted into the uterine cavity and a sample of amniotic fluid is withdrawn
Hypertension: High blood pressure
Thrombophilia: An underlying condition which leads to a tendency for blood to clot more easily.
Preeclampsia: New onset hypertension in pregnancy in association with protein in the urine (this is due to ‘leaky kidneys’). It only occurs in pregnancy and can be mild or severe.