What happened next was more than she, or anyone else for that matter, could have imagined in their wildest dreams.
Ruth sat down once more on the chair beside the mother, to await the third stage of labour. She had time to reflect on the situation. After a twin birth the uterine muscles are stretched and tired and can take up to half an hour to contract again for the expulsion of the placenta. Kathy lay sleeping, her fragile yet strong young body exhausted from a twin birth, and soothed by the blessed relief from pain. Ruth sat beside her and leaned her head on the wall. She glanced at her watch. What had happened to the time? Less than an hour had passed since she had got out of bed to answer the telephone. She tried to recall the sequence of events: the cycle ride through the night, the girl standing out in the street, the race to get upstairs, the waters breaking on the landing, and the birth of one baby, then two. It had been like a speeded-up film. What did time mean, anyway? There were some who said that time does not exist, others who said that past, present and future are one and the same. What did anyone know about time? Least of all herself. And Kathy was sleeping, blissfully sleeping.
Ruth placed her hand on the fundus of the uterus to assess progress of the third stage and stiffened with shock. The uterus still felt full, hard and bulky. ‘There’s something wrong here,’ she thought, ‘this doesn’t feel like a placenta.’
She carefully palpated the abdomen. ‘It’s definitely not a placenta. It can’t be ... It’s not possible ...’
She picked up her foetal stethoscope, applied it to the abdomen in several places and heard a rapid, regular heartbeat. Her mouth went dry, and she had to sit down again. Another baby! Undiagnosed triplets, no antenatal care, no assistance available, and apparently no one else in the building to summon help. She shivered as much from shock and fear as from the cold. Thoughts were racing through her mind. Would the delivery be normal? She had been lucky twice, but the third baby might be lying in any position. He might be a transverse lie, or a shoulder or a brow presentation ... or anything. She palpated the abdomen but could not feel a head or a breech. The foetal heartbeat was a steady 150 beats per minute, which was undoubtedly high, but might be normal for a third baby. She had never delivered triplets, nor even seen a triple birth. She felt numb with fear. Would he be healthy, like the others? There might be breathing problems, or other life-threatening difficulties derived from immature internal organs. Perhaps the placenta might come away first, leaving the baby with no maternal blood supply, or the cord might prolapse. She didn’t know if there would be one, two or three placentae. She couldn’t see inside, and she could not tell from external palpation.
Nearly half an hour had passed since the second birth, and there was no contraction. Kathy still slept quietly, but Ruth was trembling with anxiety. ‘If this is uterine inertia, it is a serious condition, and the baby will die. Dare I risk leaving Kathy alone for ten or fifteen minutes while I go to a telephone to call the hospital?’ she asked herself. She dithered. Should I? Shouldn’t I? Which course of action would be the least dangerous?
The situation resolved itself. In her sleep Kathy groaned in pain, and in the same instant there was a click from the electric meter and the light went out. The room was in total darkness. Ruth knew the bicycle torch was on the chest of drawers, but in trying to locate it she knocked it onto the floor, and then had to crawl around trying to find it. She could hear Kathy groaning and straining and pushing, but there was nothing she could do until she had light. She found the torch and switched it on. Kathy now lay calm and apparently asleep. Ruth went over to the bed and pulled back the blankets. A baby lay in a pool of blood, between his mother’s legs. She propped the torch on the end of the bed and picked up the baby. He was small, like the other two, but seemed perfectly formed, and even gave a little cry. She held him upside down, and he cried more loudly. ‘This is a miracle,’ Ruth thought. She cut another gauze swab into two pieces and ligated the cord, then cut the baby free from his mother. She lay him on his mother’s abdomen and covered them both to keep them warm. There was no other clothing available in the room, so she took one of the grey army blankets off the mother, cut it into pieces, wrapped a piece round the baby, and tucked him into the bottom drawer. The other pieces of blanket she tucked under and around all three babies to ensure that they were warm. Then she closed, or rather nearly closed, the drawers to keep out any draughts.
Meanwhile, Kathy was sound asleep, her body exhausted. Ruth sat beside her and tentatively palpated the uterus – would there be another one inside? But no; the abdominal muscles and the uterus felt soft. Ruth breathed a sigh of relief, but at the same time reminded herself that labour was far from over. The third stage had to be completed, and she knew that this was frequently the most difficult and the most dangerous part of delivery. She leaned back in the chair and closed her eyes. Was this a dream? Could it really be happening? She had been out the night before, followed by a busy day, and had enjoyed very little sleep in the past twenty-four hours. She very nearly dozed off, but a warning bell sounded in her brain, and she jumped up and splashed her face with cold water from the enamel jug. The shock soon focused her mind again.
About twenty minutes had been spent wrapping and settling the babies, during which time there had been no contractions. Something had to be done. Ruth picked up the torch and shone the beam of light into the bed. The mess was quite indescribable; a great pool of blood and amniotic fluid was seeping into the uncovered mattress – and she could do nothing about it. Normally a midwife would have covered the mattress with brown paper, absorbent sheets, a rubber sheet, and on top of that more absorbents, which could be changed frequently – but she had none of these. The mess would have to stay where it was. She shone the beam of light onto Kathy’s vulva. Three cords were showing. But how many placentae would she have to deal with? It could be as many as three, if the babies had developed from three separate ova. She did not know, and there was no way she could find out.
Ruth knew the risk of post-partum infection and in other circumstances she would have removed all soiled padding from beneath Kathy, washed her, cleaned the vulva with antiseptic, replaced the bedding with clean absorbent sheets and covered her legs with more clean sheeting. She would also have scrubbed her hands thoroughly, and put on sterile gloves. But none of this was possible. She also knew that warmth was essential, because a woman sweats during labour, losing a lot of body heat, and can become cold and shivery. Yet there was only one thin army blanket available.
She shone the torch despairingly around the empty room and saw her coat hanging on the back of the door. That would do. She took it off the hook and covered the girl with it for extra warmth. Kathy’s breathing was deep and regular, her pulse and blood pressure were on the low side, which was a good sign, and her colour was fine. There had been no contractions, and the uterus felt as it should feel.
In those days the management of the third stage of labour was left entirely to nature, and midwives were taught not to meddle or interfere with the process which separates the placenta from the uterine wall and controls bleeding. Today an oxytocic drug may be injected immediately after the baby is born, and a powerful contraction develops, separating the placenta, so that the third stage is over in a few minutes. We did not have that advantage. Patience, experience, observation and masterly inactivity were our guides. We were taught that meddling with the uterus or attempting to hurry the third stage would usually give rise to partial separation of the placenta, causing haemorrhage. We were taught never, never to pull on the cord, and only to knead or massage the fundus after uterine contractions had already developed, and only then if it became absolutely necessary.
Ruth sat quietly beside the bed, her left hand guarding the uterus, which she could clearly feel. The torchlight was growing fainter, so to save the battery she switched it off and sat in total darkness. Twenty-five minutes had passed with no sign of a contraction, and she was beginning to grow anxious. She might have to leave the girl alone while she summon
ed medical aid. But then she felt a distinct hardening of the uterus, and the fundus rose under her hand. Kathy moaned with pain and moved awkwardly.
‘This is it.’ Ruth stood up, switched on her torch and shook Kathy. ‘Wake up. I want you to push as hard as you can. Wake up and push down. Draw your knees up to your chest so that you can push as hard as possible, as though you were going to open your bowels – go on, push – harder.’
Kathy did as she was told, and Ruth assessed from the feel of the uterus that the placenta had separated and was lying in the lower segment. The fundus had risen higher in the abdomen and was still hard and firm.
‘Now relax, Kathy. Put your legs down and breathe in and out deeply. Relax as much as you can. I am going to press on your tummy. It will be uncomfortable, but it won’t hurt.’
Using the fundus as a piston, and with firm but gentle pressure, she pressed her left hand in a downward and backwards direction. Her right hand took hold of the cords and lifted the emerging placenta from the vault of the vagina. Two cords were attached. One remained hanging from the vagina, indicating that one placenta remained in utero.
At this point Ruth massaged and kneaded the fundus vigorously, and another contraction developed. ‘Start pushing again, Kathy, like you did before. We have to get this out with this contraction.’
‘What’s going on?’ moaned poor Kathy.
‘I’ll tell you later. Just push with all your strength.’ Kathy did so, and a few seconds later the other placenta slid out onto the mattress.
A huge gory mass of placentae lay on the bed. Ruth scooped them up into kidney dishes and placed them on the table. She had not the slightest chance of examining them, because the torchlight was dim and growing dimmer by the minute as the battery failed.
Kathy was wide awake now. ‘What’s been happening?’ she asked. ‘I’ve got twins. Where are they?’ She looked around her.
‘No. You’re wrong. You’ve got triplets, and they are in the chest of drawers.’
‘Triplets! You mean three babies?’
‘Yes.’
‘How?’
‘Well, you were exhausted and fell asleep after the second baby was born, so the third baby must have slid out with hardly any pain worth speaking of. Not enough to wake you up, anyway. I didn’t see it, because the meter had run out, and I’d dropped my torch.’
‘And I’ve got three babies?’
‘Yes. Three little boys.’
Kathy leaned back with an incredulous sigh.
‘Holy Mary, Mother of God – what’s me mam going to say? Oh be-Jesus, illegitimate triplets. Trust a sailor!’
Ruth cleared up and returned to the convent, where arrangements were made for Kathy and the babies to be admitted to the London Hospital. The girl had no one to look after her, and she was quite unable to look after the babies in the room where she was lodging. She had no money, no clothing, no heating, no food even, and the babies were small and vulnerable.
We did not find out what happened to them after they left hospital. If the sailor could not be traced and persuaded to marry Kathy and support his children, the prospects for them were bleak. Returning to the family in Ireland would have been the best thing, but in rural Ireland in the 1950s poverty and the shame of illegitimacy drove many families to reject their grandchildren. Places in a children’s nursery in London would have been offered, with access for the mother, but she would have had to live separately and support herself. It is unlikely that she would ever have earned enough money to have the boys with her and to support them. Adoption would have been possible, if Kathy had agreed, but the chances of anyone wanting to adopt all three babies were slender, so the boys would probably have been separated and would have grown up not knowing they had brothers.
Whilst I cannot record a happy ending, Kathy was buoyant, cheerful and resourceful, and we cannot be sure that life treated her harshly. It might have been quite the opposite. So often in medicine we see and become deeply involved with people at the most intimate and dramatic time of their lives. But then, like ships, they pass in the night; they are gone and we see them no more.
CYNTHIA
I was cycling back to the convent after a morning’s work, weaving my way in and out of the lorries on the East India Dock Road, singing to myself as I pedalled the old Raleigh, which was as heavy as lead with two of its three gears not working, and perfecting my no-hands-steer-with-knees-and-bodyweight technique, when I saw Cynthia ahead of me. She was cycling more slowly than me, and her bike was wobbling about on the road. I called out, ‘Hi, there!’ as I drew level; but my high spirits quickly changed to concern. She was crying.
‘What’s up? Oh, Cynthia dear, what’s happened?’
She looked round, tears streaming down her face. A lorry screeched past, hooting noisily, its driver gesticulating obscenely.
‘Here, we had better pull into the kerb, or we’ll have an accident. Now what’s up? Tell me. I’ve never seen you like this before.’
Cynthia was the peace-maker amongst us, a wise and mature influence. To see her crying in the street was a real shock. I gave her my handkerchief because hers was wet.
‘The baby’s dead,’ she whispered.
‘What? It can’t be,’ I gasped incredulously.
I knew she had been out all night. She had come into breakfast tired but happy, telling us of the delivery of a baby boy – a normal delivery, a healthy baby, and a contented mother. She had left them at 6 a.m., everything satisfactory. We were required to make a return visit within four hours. I had left to make my morning visits at 8.30, and Cynthia had remained behind to clean and sterilise her equipment and write up her notes before returning to the newly delivered mother and baby at 10 a.m.
‘What happened?’ I asked when I had recovered from the shock.
‘I went back to the house as usual,’ Cynthia explained. ‘I never thought anything would have happened. The door was open, and I went in. Everyone was crying. They said the baby was dead. I couldn’t believe them. I went and saw the baby. It was quite dead and cold.’
‘But how? Why?’
‘I don’t know.’
She blew her nose and wiped her eyes. ‘I don’t know. I just don’t know,’ she whispered and started crying again.
‘Look here, we’d better get back, but don’t try riding that bike. You’ll only fall off. I’ll push it for you.’
We started walking along the pavement, with me pushing both bikes – a noble but futile gesture. Have you ever tried pushing two bikes along a pavement crowded with people and prams and children running around? Soon Cynthia’s tears were mixed with tears of laughter.
‘I’ll take mine, or you’ll do someone a nasty injury.’
We walked along without speaking for a while. I didn’t know whether to ask more questions or to keep silent, but she said: ‘They’ve taken him away.’
‘Who? The doctors?’
‘No. The police.’
‘Police? Why? What for?’
‘Post-mortem examination. The parents didn’t want them to, but the police insisted, saying it was the law with a sudden, unexplained death.’ Her voice faltered and she started crying again.
‘I don’t know if I did anything wrong. I’ve been going over and over it in my mind. I did everything we were taught to do. The baby cried soon after birth. I cleared the airways. I cut the cord aseptically. All his limbs moved independently. His spine was straight, his breathing was normal, and the sucking reflex was there. He was a perfect baby, I thought. I don’t know why he died, or if I did something that might have caused his death.’
She shuddered and could hardly walk straight. The front wheel of her bike hit a bus stop, and the handlebars twisted and poked into her chest, making her groan with pain. We straightened out her bike.
‘Of course you’ve done nothing wrong. You are the best of midwives. I just know it wasn’t your fault in any way.’
‘You can’t be sure,’ she whispered. ‘That’s why the police took him
away.’
We continued for a while in silence. I did not like to intrude on Cynthia’s thoughts but felt compelled to ask, ‘What did you do?’
‘Well, I tried mouth-to-mouth resuscitation, but it was hopeless. The baby was quite cold and stiff.’
She was shaking, and her voice was barely audible above the noise of the street.
‘Let’s get off this main road into a quieter one,’ I said. ‘All this noise is getting on my nerves. Then you can tell me more.’
We pushed our bikes round a corner and continued in a more peaceful environment. Children were playing in the street, women were scrubbing their doorsteps or shaking mats. Several greeted us.
‘I went down the street to the phone box,’ Cynthia continued, ‘and rang Nonnatus House and spoke to Sister Julienne. She came straight away. It was wonderfully reassuring to see her. She christened the baby, even though he was dead, and prayed with the family and me, and then she went to inform the doctor and the police. I had to remain in the house with the baby’s body.’
She started crying again. I leaned over and squeezed her hand.
‘We didn’t have to wait long. The doctor came. He examined the little body and said he could see nothing to suggest the cause of death, but that a post mortem would be necessary before a death certificate could be issued. The family were terribly upset at this, saying they didn’t want to see their baby cut up, they just wanted him to have a quiet Christian burial. The doctor was ever so kind with them, but explained that a PM was unavoidable under the circumstances.’
Farewell To The East End Page 4