‘Well, as you do not seem to know, I will tell you. The stimulation of the nipple by the infant activates the posterior lobe of the pituitary gland to secrete pituitrin, which acts on the unstriped muscle surrounding the breast lobules and ducts, producing a flow of milk. But also – and this is the important point – pituitrin stimulates contraction of the muscles of the uterus.’
Sister Bernadette put the baby to the breast, but she was too sleepy and would not suck.
‘It is now thirty minutes since the birth of the first baby. Uterine inertia can go on for hours, and all the time the risk to mother and baby increases. This is where medical assistance is needed.’
The doctor was unpacking his case, laying out several drugs, syringes and instruments, including Haig Ferguson’s obstetric forceps.
‘What will be the first line of medical intervention, nurse?’
Trixie was on the spot again so she glanced at the doctor’s equipment.
‘Well, forceps, I suppose.’
‘Nonsense. Forceps will be the last thing we use. First we must get the uterus to contract. In the past I have known quinine to be used, but it is not advisable. As you may remember, a synthetic preparation of pituitrin is now available, called Pitocin, which is much more reliable and safe, and which I am sure Doctor is planning to use.’
She looked towards the doctor.
‘Quite right, Sister. I am preparing a small dose – 0.25 ml – to be injected intramuscularly. If the uterine muscles do not respond, the procedure can be repeated every half hour for two hours. But hopefully after the first injection we will see some action.’
‘Pitocin is usually effective,’ continued Sister, ‘but there are certain specific contra-indications to its use. What are they, nurse?’
Again Trixie was under interrogation. She tried desperately to think back to her lectures, but was tired and couldn’t remember a thing.
‘Come now, nurse. This won’t do at all. Pitocin should not be given if there is any risk to the mother or baby by stimulating the uterus. Firstly, disproportion; if it is apparent that a foetus cannot descend into a narrow or misshapen pelvis, as we see with a rachitic pelvis, giving Pitocin would be disastrous. Secondly, malpresentation: this baby was lying transverse or obliquely. If Pitocin had been given too early, before I carried out an external version, an impacted foetus would have been the result. Lastly, the condition of the foetus. What should be a contra-indication for the use of Pitocin, nurse?’
Finally something stirred at the back of Trixie’s mind. ‘The foetal heart.’
‘Excellent. Foetal distress can be determined from the heartbeat. And I shall want another recording, please, before the injection is given.’
Trixie listened again. ‘One hundred and seventy, Sister, and quite regular.’
‘That is satisfactory because it is regular. It is when the heartbeat is swinging wildly that we should worry about foetal distress. I think we are ready, doctor.’
The doctor injected 0.25 ml, and they all waited in silence. Mavis, warm and comfortable, had fallen asleep. Her three attendants were tense and anxious. Sister sat with her hand resting on the fundus, but no contractions came. She listened to the foetal heart a couple of times. It was 170 and rising. Half an hour had passed. She looked at the doctor, who said, ‘I think I will inject 0.30 ml this time, Sister.’ She nodded in agreement.
More waiting. The foetal heart remained rapid, far too rapid, and Sister was biting her lip with anxiety. Another twenty minutes, and still no contractions came. Sister Bernadette and the doctor exchanged glances every so often, and Trixie could feel the mounting tension in the room.
It all happened at once, Trixie said later. A powerful movement of the uterus, and immediately a violent rush of blood from the vagina, a pint or more.
‘The placenta has separated. Quick. Give me the foetal stethoscope,’ cried Sister in alarm. Mavis was awake and the foetal heart was racing so fast that Sister could not count it.
‘We have to get this baby out immediately. Mavis – you must come to the bottom of the bed – never mind about the blood, just slither down – now raise your legs to your chest. Nurse, hold the legs steady in the lithotomy position.’
There was no anaesthetic available. It was far too late even to give a Pethidine injection. Mavis had to bear the pain. The gas and air machine might have helped her a little, but no one would claim that it was a full anaesthetic.
Sister reached again for the Pinards. The heartbeat had dropped to a dangerously low eighty beats per minute. ‘We haven’t a moment to lose,’ she whispered.
The doctor placed two fingers into the vagina and hooked them behind the perineum, pulling it as taut as possible. With sharp episiotomy scissors he then cut the perineum diagonally. Mavis let out a piercing scream, and Meg rushed into the room. Seeing Mavis in a lithotomy position surrounded by blood she yelled, ‘Murder!’ and rushed over to the bed. She attempted to fight the doctor, but Sister pulled her back by the shoulders. Meg turned on her like a tigress and slapped her face so hard that the poor Sister fell against the wall. But she stood up again quickly, her face burning.
‘If you interfere, Mavis will die. There is no alternative. You may not believe it, but we know what we are doing. And we are doing it to save the life of mother and baby.’ She repeated more emphatically: ‘If you interfere, your sister will die.’
Meg stared at her blankly. The shock of Sister’s words reduced her to silence.
‘Now, if you want to help, and I am sure you do, you will hold this gas and air mask over your sister’s face ... keep it firm over her nose and mouth ... turn the knob up to maximum and talk to Mavis quietly, try to keep her calm. This is going to hurt, but you can help a great deal if you do as I say. Mavis needs you. Her life depends on it.’
Meg calmed down. She administered the gas and air. Giving her something to do was the best thing that Sister could have suggested.
Sister Bernadette listened to the foetal heartbeat. It had dropped to sixty beats per minute, and was weak and irregular. The doctor inserted the first blade of the forceps into the vagina, muttering to Trixie, ‘Whatever you do keep her legs in that position. Don’t let her move.’ Trixie, who was trembling and felt sick, put all her weight on the two legs.
‘Sister, the os is still fully dilated, thank God, but the head is above the rim. Can you apply steady pressure on the fundus to try to force the baby down an inch or two? There’s not a moment to lose.’
Sister grasped the fundus with both hands and pressed down as hard as she could. There was a massive spurt of blood and meconium from the vagina, splattering the doctor all over. He hardly noticed it.
‘Quickly. The head is down a little. But more.’
Sister applied more pressure, and a contraction developed.
‘That’s better. It’s coming. Now I can get hold of it.’
The doctor inserted the second blade of the forceps around the head of the baby. Muffled screams were heard from Mavis, behind the gas and air mask, and Meg was looking grim, but held the mask in place.
Slowly, steadily, the doctor pulled the forceps, with Sister applying pressure from above.
‘Keep those legs still,’ muttered Sister to Trixie. ‘She must not move at this stage.’ It took all of Trixie’s strength to prevent Mavis from throwing herself off the bed.
Within half a minute the head was born. The baby’s face had no colour. Sister immediately left the bedside, took a couple of swabs and a fine catheter, and tried to clean the airways, but the baby did not move or attempt to breathe.
The doctor hooked a finger under the presenting shoulder and with one swift movement pulled the baby upwards towards the mother’s abdomen. It was another little girl, completely white and limp. She looked dead.
A mere ninety seconds had elapsed between the first haemorrhage and the birth of the baby, yet Trixie told us later that it had seemed like ninety minutes. Time had stretched unnaturally. Even the steady tick, tick, tick of t
he clock seemed to slow down, as if time itself were suspended.
The baby was separated from the mother. She was like a rag doll and seemed to be quite dead. Sister carried her near to the fire. The doctor stretched out his hand and touched a tiny arm that swung lifelessly. He looked at Sister.
‘Do what you can,’ he said sadly, ‘we might have to ...’
But there was no time to speculate. There was another spurt of fresh blood, and the cord, which was protruding from the vagina, lengthened.
‘The placenta is coming. Quick, nurse, fetch a kidney dish,’ he said.
Trixie tried to get one, but her legs were shaking and she could not move. The placenta slid out onto the floor.
‘We will examine it later,’ said the doctor, pushing it aside with his foot. ‘First, I must control the haemorrhage.’
Blood continued to seep out, then another spurt of fresh blood. The prognosis for Mavis was not looking good. She was no longer in pain, but was extremely weak and sweating from shock. Meg’s know-all arrogance had burst like a bubble. The speed and drama of events had shaken her. She sat quietly at Mave’s head, stroking her hair, whispering words of love and comfort.
The doctor massaged the uterus vigorously and squeezed out clots by further kneading and fundal pressure. Mavis groaned and weakly moved a leg.
‘I think that is all the residual blood clots. I need to administer intravenous Ergometrine, but I want you, nurse, to exert external bi-manual compression of the uterus while I am preparing the injection. Have you ever done it before?’
Trixie shook her head.
‘This is what you do, then. It will be only for a minute or two, but we cannot allow the uterus to relax. If it does we might get another haemorrhage.’
‘Right, then, stand here ... press the left hand into the abdomen just above the umbilicus, like this. Now, clench your right hand into a fist and press down as far as possible behind the symphysis pubis ... that’s it ... now push the ball of the uterus upwards and compress it between the two hands as hard as you can ... harder ... that’s it. Keep it there.’
The doctor went over to his medical kit to draw up the injection. He returned to the bedside and bound the upper arm tightly in order to inject into a vein at the bend of the elbow. But he could not find a vein. Mavis had lost so much blood that her veins were flat and slippery. He made several attempts with no success. He swore under his breath.
‘Keep that compression going, nurse. Another haemorrhage could be fatal. I must get an intramuscular injection. They take longer to work, but if I can’t get a vein it will have to be an IM.’
Trixie continued exerting bi-manual compression of the uterus. She was feeling sick and faint, but the sight of Mavis looking so ill and the thought of another haemorrhage and its consequences kept her strength up.
The doctor returned and swiftly plunged the needle into Mavis’s thigh. ‘That’ll do the trick.’ Then, to Trixie: ‘I’ll take over now. I want you to go and ring the hospital.’
Meg interrupted. ‘No. I won’ let ’em take ’er.’
The doctor turned on her savagely.
‘Will you be quiet, woman, and stop interfering. If Mavis had gone into hospital, as I advised in the first place six months ago, all this might never have happened.’
Meg held her peace.
Sister Bernadette had carried the baby closer to the fire and had wrapped a roll of soft cotton wool around her. She cleared the airways with a fine mucus catheter. Blood, mucus and meconium were sucked out of the nose, mouth and throat. She held the tongue forwards with fine baby forceps, because if the tongue is without muscle tone and flaccid, it can fall backwards into the throat, blocking the airways. She held the baby completely upside down for a few seconds, and then sucked out the airways again. She turned the baby face downwards and massaged the back from base of spine upwards, then cleared the airways once more. Next she undertook a procedure known as Eve’s Rocking – that is, alternately raising the head and feet of the baby by about forty-five degrees. The baby did not respond. Sister administered mouth to mouth resuscitation by filling her cheeks with air and puffing three puffs into the tiny white lips, then twenty seconds of Eve’s Rocking again, then three more puffs. After about two minutes of this procedure she listened to the baby’s heartbeat.
Her face became radiant. ‘I can hear a faint heartbeat – around eighty per minute. Praise the Lord.’ And she continued her efforts. Suddenly the baby gave a short, convulsive gasp, sucking air into its lungs and then lay quite still again, making no further attempt to breathe. But a baby can take shallow breaths that are almost imperceptible to the observer. Sister could still hear a faint heartbeat, so she continued. A couple of minutes later the baby gave another convulsive gasp, repeated thirty seconds later, and this pattern continued for nearly half an hour, during which time the heartbeat increased to a healthy 120 per minute.
Sister Bernadette had no drugs, no oxygen, no incubator or modern equipment for resuscitating an infant with asphyxia pallida. She had only the methods described above, and the baby did not die.
The intramuscular injection of Ergometrine given to Mave by the doctor worked within five minutes. The uterus contracted into a firm hard ball, and all fears of further haemorrhage were removed. Mavis looked terribly ill, however. Her skin was white, cold and clammy, caused by pain and blood loss. She was in a state of obstetric shock, but her condition was stable. Sleep would benefit her, so the doctor gave an injection of morphine, which he could not have done while the baby was in utero. She dozed off in Meg’s arms.
The doctor prepared for suturing. There was now no hurry, so he gave Mavis a local anaesthetic around the perineum and the vaginal wall, and sat back, waiting for it to take effect. Once the local anaesthetic had numbed the perineum, the doctor was able to repair the episiotomy. He was relieved to find that the cervix was not torn.
Meanwhile Trixie was down the road ringing the Flying Squad. She had taken off her gown and cap but had forgotten to take off her mask. There was blood on her hands and arms, and smeared down her uniform and legs. As she ran down the road she did not notice that people were looking at her rather strangely. It was not until she was inside the telephone box that she realised she did not have the three pennies on her with which to make a telephone call, so she stopped a passer-by. ‘Can you let me have threepence for an urgent telephone call?’ Only then did she notice the mask, so she pulled it off. Her hand was trembling, and she noticed the blood on it for the first time.
‘I must have threepence. I forgot to bring it. I must ring the hospital.’ Trixie’s voice was shrill. Dubiously the man dug into his pocket and produced three pennies. ‘Thanks.’ She dived into the box, but her hand was shaking so much that she could not dial the number or put the pennies in the slot, so she called the man back.
‘You’re in a bad way, nurse,’ he said.
Trixie felt too weak to answer, so she merely handed him a bit of paper.
‘Ring that number for me, please.’
The phone rang, and a voice answered immediately. Briefly Trixie explained the situation and gave the address. ‘We will send the Flying Squad immediately,’ the voice said.
‘Do you need any help getting back to the house?’ asked the man kindly.
‘I’ll be all right. Thanks for your help.’
When Trixie returned to the house, Meg was shouting at the doctor and Sister.
‘You murderers! Look wha’ you done. You’ve hurt ’er. I’ll report you to ve authorities, I will. Look at ve blood. You nearly killed ’er, you did.’
The doctor tried to defend himself
‘The placenta separated prematurely. That was the cause of the blood loss. I did not cause it.’
‘Liar! Tell vat to the judge. Medical blunderers.’
She turned on Sister. ‘An’ you, yer no better. You’ll kill vat baby afore you’re finished. An’ it’ll be your fault if she dies. I’ll not forget vis, I’ll not.’
Bewildered,
the doctor looked at Sister.
‘Can you explain?’ he asked plaintively.
‘I doubt it,’ said Sister wearily. Her eye was swelling up, from the blow she had received from Meg. ‘We’ve been trying for six months with no success. I doubt if any explanation will get through.’
‘I’ll not forget vis. You jest wait. You’ll pay fer vis an’ all, the pair of you.’ Meg rolled her eyes and spat on the floor.
The Obstetric Flying Squad arrived. This was an emergency service held in readiness by all big hospitals for the support of domiciliary midwives. It was their proud boast that they could get to any emergency in twenty minutes, and they seldom failed to do so. An obstetrician, a paediatrician, and a nurse came, armed with an incubator, oxygen, drip, drugs, anaesthetics and all the other equipment used for obstetric surgery and infant resuscitation. They entered a small, hot and stuffy room that looked like a battle scene. Blood was literally everywhere. The doctor, covered in blood, was suturing the patient. The placenta still lay on the floor. Sister Bernadette, who was tending the baby, looked as though she had been in the front line. The skin around her eye was now blue, her face red and swollen, and her veil streaked with blood. A weird-looking woman in green glared at the hospital team with accusing eyes. ‘More murderers. I’ll see you don’t get ’er,’ she hissed venomously.
The doctor and the obstetrician consulted. Mavis was sleeping peacefully because of the morphine given half an hour earlier by the doctor. But she had lost a lot of blood, and the shock was severe. An intravenous infusion of blood plasma by drip was installed.
The placenta was scooped up off the floor, and the two doctors examined it. It was large, but appeared to be complete. The consultant palpated the woman’s abdomen. The uterus was firm and hard, about the size of a grapefruit, as it should be. He looked around the small, stuffy room that contained not a vestige of clinical apparatus; at the woman in a state of primary obstetric shock; at the volume of blood loss; at the first baby sleeping peacefully in the crib; at Sister Bernadette tending the asphyxiated twin.
Farewell To The East End Page 11