In the Victorian era, social reform had swept through the country. For the first time authors wrote about iniquities that had never before been exposed, and the public conscience was stirred. Among these reforms, the need for good nursing care in hospitals gained the attention of many farsighted and educated women. Nursing and midwifery were in a deplorable state. It was not considered a respectable occupation for any educated woman, and so the illiterate filled the gap. The caricature figures of Sairey Gamp and Betsy Prig – ignorant, filthy, gin-swilling women – created by Charles Dickens, may seem hilarious as we read about them, but would not have been funny if you had been obliged, through poverty, to place your life in their hands.
Florence Nightingale is our most famous nurse, and her dynamic organisational skills changed the face of nursing for ever. But she was not alone, and the history of nursing records many groups of dedicated women who devoted their lives to raising the standards of nursing. One such group was the Midwives of St Raymund Nonnatus,* They were a religious order of Anglican nuns, devoted to bringing safer childbirth to the poor. They opened houses in the East End of London, and in many of the slum areas of the great industrial cities of Great Britain.
In the nineteenth century (and earlier, of course) no poor woman could afford to pay the fee required by a doctor for the delivery of her baby. So she was forced to rely on the services of an untrained, self-taught midwife, or “handywoman” as they were often called. Some may have been quite effective practitioners, but others boasted a frightening mortality rate. In the mid-nineteenth century, maternal mortality amongst the poorest classes stood at around 35–40 per cent, and infant mortality was around 60 per cent. Anything like eclampsia, haemorrhage, or mal-presentation, would mean the inevitable death of the mother. Sometimes these handywomen would abandon a patient to agony and death if any abnormality developed during labour. There is no doubt that their working practices were insanitary, to say the least, and thereby spread infection, disease and often death.
Not only was there no training, but there was also no control over the numbers and practice of these handywomen. The Midwives of St Raymund saw that the answer to this social evil lay in the proper training of midwives and control of their work by legislation.
It was in the struggle for legislation that these feisty nuns and their supporters encountered the fiercest opposition. From about 1870 the battle raged; they were called “an absurdity”, “time wasters”, “a curiosity”, and “an objectionable body of busy-bodies”. They were accused of everything from perversion to greed for unlimited financial gain. But the Nonnatus Nuns would not be put down.
For thirty years the battle continued, but in 1902 the first Midwives Act was passed and the Royal College of Midwives was born.
The work of the Midwives of St Raymund Nonnatus was based upon a foundation of religious discipline. I have no doubt that this was necessary at the time, because the working conditions were so disgusting, and the work so relentless, that only those with a calling from God would wish to undertake it. Florence Nightingale records that when she was in her early twenties she saw a vision of Christ, telling her that her life was required for this work.
The St Raymund midwives worked in the slums of the London Docklands amongst the poorest of the poor and for about half of the nineteenth century they were the only reliable midwives working there. They laboured tirelessly through epidemics of cholera, typhoid, polio, and tuberculosis. In the early twentieth century, they worked through two world wars. In the 1940s, they remained in London and endured the Blitz with its intensive bombing of the docks. They delivered babies in air-raid shelters, dugouts, church crypts and underground stations. This was the tireless, selfless work to which they had pledged their lives, and they were known, respected and admired throughout the Docklands by the people who lived there. Everyone spoke of them with sincere love.
Such were the Midwives of St Raymund Nonnatus when I first knew them: an order of nuns, fully professed and bound by the vows of poverty, chastity, and obedience, but also qualified nurses and midwives, which is how I came to be among them. I did not expect it, but it turned out to be the most important experience of my life.
* The Midwives of St Raymund Nonnatus is a pseudonym. I have taken the name from St Raymund Nonnatus, the patron saint of midwives, obstetricians, pregnant women, childbirth and newborn babies. He was delivered by Caesarean section (“non natus” is the Latin for “not born”) in Catalonia, Spain, in 1204. His mother, not surprisingly, died at his birth. He became a priest and died in 1240.
CALL THE MIDWIFE
Why did I ever start this? I must have been mad! There were dozens of other things I could have been – a model, air hostess, or a ship’s stewardess. The ideas run through my head, all glamorous, highly paid jobs. Only an idiot would choose to be a nurse. And now a midwife…
Two-thirty in the morning! I struggle, half asleep, into my uniform. Only three hours sleep after a seventeen-hour working day. Who would do such a job? It is bitterly cold and raining outside. Nonnatus House itself is cold enough, and the bicycle shed even colder. In the dark I wrench at a bicycle and crack my shin. Through blind force of habit, I fit my delivery bag on to the bicycle, and push it out into the deserted street.
Round the corner, Leyland Street, across the East India Dock Road and then on to the Isle of Dogs. The rain has woken me up and the steady pedalling calms my temper. Why did I ever go into nursing? My thoughts flit back five or six years. Certainly there had been no feeling of vocation, none of the burning desire to heal the sick that nurses are supposed to feel. What was it then? A broken heart certainly, the need to get away, a challenge, the sexy uniform with the cuffs and ruffs, the pinched-in waists and pert little caps. Were they reasons though? I can’t tell. As for the sexy uniform, that’s a laugh, I think as I pedal through the rain in my navy gabardine, with the cap pulled down well over my head. Sexy, indeed.
Over the first swing bridge that closes off the dry docks. All day they teem with noise and life, as the great vessels are loaded and unloaded. Thousands of men: dockers, stevedores, drivers, pilots, sailors, fitters, crane drivers, all toiling ceaselessly. Now the docks are silent, the only sound is the movement of water. The darkness is intense.
Past the tenements where countless thousands sleep, probably four or five to a bed, in their little two-room flats. Two rooms for a family of ten or twelve children. How do they manage it?
I cycle on, intent on getting to my patient. A couple of policemen wave and call out their greetings; the human contact raises my spirits no end. Nurses and policemen always have a rapport, especially in the East End. It’s interesting, I reflect, that they always go around in pairs for mutual protection. You never see a policeman alone. Yet we nurses and midwives are always alone, on foot or bicycle. We would never be touched. So deep is the respect, even reverence, of the roughest, toughest docker for the district midwives that we can go anywhere alone, day or night, without fear.
The dark unlit road lies before me. The road around the Isle is continuous, but narrow streets lead off it, criss-crossing each other, each containing thousands of terraced houses. The road has a romantic appeal because the sound of the moving river is always present.
Soon I turn off the West Ferry Road into the side streets. I can see my patient’s house at once – the only house with a light on.
It seems there is a deputation of women waiting inside to greet me. The patient’s mother, her grandmother (or were they two grandmothers?), two or three aunts, sisters, best friends, a neighbour. Well thank God Mrs Jenkins isn’t here this time, I think.
Lurking somewhere in the background of this powerful sisterhood is a solitary male, the origin of all the commotion. I always feel sorry for the men in this situation. They seemed so marginalised.
The noise and the chatter of the women engulfs me like a blanket.
“Hello luvvy, how’s yerself? You got ‘ere nice an’ quick, ven.”
“Let’s ’ave yer co
at and yer ’at.”
“Nasty night. Come on in an’ get warm, ven.”
“How about a nice cup o’ tea? That’ll warm the cockles, eh, luvvy?”
“She’s upstairs, where you left ‘er. Pains about every five minutes. She’s been asleep since you left, just afore midnight. Then she woke up, about two-ish, pains gettin’ worse, an’ faster, so we reckons as ’ow we ought ’a call the midwife, eh, Mum?”
Mum agrees, and bustles forth authoritatively.
“We got the water hot, an’ a load o’ nice clean towels, an’ got the fire goin’, so it’s all nice an’ warm for the new baby.”
I have never been able to talk much, and in this situation I don’t need to. I give them my coat and hat, but decline their tea, as experience has taught me that, in general, Poplar tea is revolting: strong enough to creosote a fence, stewed for hours, and laced with sticky sweet condensed milk.
I am glad that I shaved Muriel earlier in the day when the light was good enough to do it without risk of cutting her. I also gave the required enema at the same time. It’s a job I hate, so thankfully it is over; besides which, who would want to give a two-pint soap-and-water enema (especially if there was no lavatory in the house), with all the resultant mess and smell, at two-thirty in the morning?
I go upstairs to Muriel, a buxom girl of twenty-five who is having her fourth baby. The gaslight sheds a soft warm glow over the room. The fire blazes fiercely, and the heat is almost suffocating. A quick glance tells me that Muriel is nearing the second stage of labour – the sweating, the slight panting, the curious in-turned look that a woman has at this time as she concentrates every ounce of her mental and physical strength on her body, and on the miracle she is about to bring forth. She doesn’t say anything, just squeezes my hand and gives a preoccupied smile. I left her three hours earlier, in the first stage of labour. She had been niggling in false labour all day and was very tired, so I gave chloral hydrate at about 10 p.m., in the hope that she would sleep all night and wake in the morning refreshed. It hasn’t worked. Does labour ever go the way you want it to?
I have to be sure how far on she is, so prepare to do a vaginal examination. As I scrub up, another pain comes on – you can see it building in strength until it seems her poor body will break apart. It has been estimated that, at the height of labour, each uterine contraction exerts the same pressure as the closing of the doors of an underground tube train. I can well believe it as I watch Muriel’s labour. Her mother and sister are sitting with her. She clings to them in speechless, gasping agony, a breathless moan escaping her throat until it passes, then sinks back exhausted, to gather her strength for the next contraction.
I put on my gloves and lubricate my hand. I ask Muriel to draw her knees up, as I wanted to examine her. She knows exactly what I am going to do, and why. I put a sterile sheet under her buttocks and slip two fingers into her vagina. The head well down, anterior presentation, only a thin rim of cervix remaining, but waters apparently not yet broken. I listen to the foetal heart, a steady 130. Good. That is all I need to know. I tell her everything is normal, and that she hasn’t far to go now. Then another pain starts, and all words and actions have to be suspended in the enormous intensity of labour.
My tray has to be set out. The chest of drawers has been cleared in advance to provide a working surface. I lay out my scissors, cord clamps, cord tape, foetal stethoscope, kidney dishes, gauze and cotton swabs, artery forceps. Not a great deal is necessary, in any case it has to be easily portable, both on a bicycle, and up and down the miles of tenement stairs and balconies.
The bed has been prepared in advance. We supplied a maternity pack, which was collected by the husband a week or two before delivery. It contains maternity pads – “bunnies” we call them – large absorbent sheets, which are disposable, and non-absorbent brown paper. This brown paper looks absurdly old fashioned, but it is entirely effective. It covers the whole bed, all the absorbent pads and sheets can be laid on it and, after delivery, everything can be bundled up into it and burned.
The cot is ready. A good size washing bowl is available, and gallons of hot water are being boiled downstairs. There is no running hot water in the house and I wonder how they used to manage when there was no water at all. It must have been an all night job, going out to collect it and boiling it up. On what? A range in the kitchen that had to be fuelled all the time, with coal if they could afford it, or driftwood if they couldn’t.
But I haven’t much time to sit and reflect. Often in a labour you can wait all night, but something tells me this one will not go that way. The increasing power and frequency of the pains, coupled with the fact that it is a fourth baby, indicate the second stage is not far away. The pains are coming every three minutes now. How much more can she bear, how much can any woman bear? Suddenly the sac bursts, and water floods the bed. I like to see it that way; I get a bit apprehensive if the waters break early. After the contraction, the mother and I change the soaking sheets as quickly as we can. Muriel can’t get up at this stage, so we have to roll her. With the next contraction I see the head. Intense concentration is now necessary.
With animal instinct she begins pushing. If all is well, a multigravida can often push the head out in seconds, but you don’t want it that way. Every good midwife tries to ensure a slow steady delivery of the head.
“I want you on your left side, Muriel, after this contraction. Try not to push now while you are on your back. That’s it, turn over dear, and face the wall. Draw your right leg up towards your chin. Breathe deeply, carry on breathing like that. Just concentrate on breathing deeply. Your sister will help you.” I lean over the low sagging bed. All beds seem to sag in the middle in these parts, I think to myself. Sometimes I have had to deliver a baby on my knees. No time for that now though, another contraction is coming.
“Breathe deeply, push a little; not too hard.” The contraction passes and I listen to the foetal heart again: 140 this time. Still quite normal, but the raised heartbeat shows how much a baby goes through in the ordeal of being born. Another contraction.
“Push just a little Muriel, not too hard, we’ll soon have your baby born.”
She is beside herself with pain, but a sort of frantic elation comes over a woman during the last few moments of labour, and the pain doesn’t seem to matter. Another contraction. The head is coming fast, too fast.
“Don’t push Muriel, just pant – in, out – quickly, keep panting like that.”
I am holding the head back, to prevent it bursting out and splitting the perineum.
It is very important to ease the head out between contractions, and as I hold the head back, I realise I am sweating from the effort required, the concentration, the heat and the intensity of the moment.
The contraction passes, and I relax a little, listening to the foetal heart again – still normal. Delivery is imminent. I place the heel of my right hand behind the dilated anus, and push forward firmly and steadily until the crown is clear of the vulva.
“With the next contraction, Muriel the head will be born. Now I don’t want you to push at all. Just let the muscles of your stomach do the job. All you have to do is to try to relax, and just pant like mad.”
I steel myself for the next contraction which comes with surprising speed. Muriel is panting continuously. I ease the perineum around the emerging crown, and the head is born.
We all breathe a sigh of relief. Muriel is weak with the effort.
“Well done, Muriel, you are doing wonderfully, it won’t be long now. The next pain, and we will know if it’s a boy or a girl.”
The baby’s face is blue and puckered, covered in mucus and blood. I check the heartbeat. Still normal. I observe the restitution of the head through one eighth of a circle. The presenting shoulder can now be delivered from under the pubic arch.
Another contraction.
“This is it Muriel, you can push now – hard.”
I ease the presenting shoulder out with a forward and upw
ard sweep. The other shoulder and arm follow, and the baby’s whole body slides out effortlessly.
“It’s another little boy,” cried the mother. “Thanks be to God. Is he healthy, nurse?”
Muriel was in tears of joy. “Oh, bless him. Here, let me have a look. ’Ow, ‘e’s loverly.”
I am almost as overwhelmed as Muriel, the relief of a safe delivery is so powerful. I clamp the baby’s cord in two places, and cut between; I hold him by the ankles upside down to ensure no mucus is inhaled.
He breathes. The baby is now a separate being.
I wrap him in the towels given to me, and hand him to Muriel, who cradles him, coos over him, kisses him, calls him “beautiful, lovely, an angel”. Quite honestly, a baby covered in blood, still slightly blue, eyes screwed up, in the first few minutes after birth, is not an object of beauty. But the mother never sees him that way. To her, he is all perfection.
My job is not done, however. The placenta must be delivered, and it must be delivered whole, with no pieces torn off and left behind in the uterus. If there are, the woman will be in serious trouble: infection, ongoing bleeding, perhaps even a massive haemorrhage, which can be fatal. It is perhaps the trickiest part of any delivery, to get the placenta out whole and intact.
The uterine muscles, having succeeded in the massive task of delivering the baby, often seem to want to take a holiday. Frequently there are no further contractions for ten to fifteen minutes. This is nice for the mother, who only wants to lie back and cuddle her baby, indifferent to what is going on down below, but it can be an anxious time for the midwife. When contractions do start, they are frequently very weak. Successful delivery of the placenta is usually a question of careful timing, judgement and, most of all, experience.
Call the Midwife Page 2