“Get in here quick.” O’Reilly shouted. “Bring the gear.”
Barry lifted the bags and followed the noise along a carpeted hall where three plaster mallard climbed a white-painted wall beside an umbrella stand and a wall-hung, gilt-framed, oval mirror. He turned into a bedroom. Miss Hagerty and Doctor O’Reilly stood on opposite sides of a bed. O’Reilly, who had removed his jacket and rolled up his shirtsleeves, wore a pair of rubber gloves. Barry immediately recognized the patient, Jenny Murphy, remembered having seen her last week. Then she’d been calm, self-possessed, and apparently unconcerned about her impending second labour.
Now she lay on her back, eyes never leaving O’Reilly’s, her face screwed into a rictus, upper teeth white against her bloodless lower lip, sweat glistening on her forehead. She was groaning. One hand clutched at her swollen belly, the silvery striae gravidarum on both flanks shining in the light.
Barry could smell the once-experienced-never-to-be-forgotten pungency of amniotic fluid and saw the puddles on a red rubber sheet Miss Hagerty must have spread on the bed earlier.
“Doctor Laverty,” she said. Her face betrayed no hint of emotion, but then as O’Reilly once told Barry, Miss Hagerty had attended more than a thousand deliveries. Anyway, it was clear O’Reilly was in charge.
“Miss Hagerty,” Barry said.
“Get the packs open, Barry,” O’Reilly called, his back turned to Barry. “I’m going to examine you, Jenny.”
Barry started to unpack the equipment as O’Reilly bent to his work. He straightened and turned to Barry. “Have a listen to the fetal heart.” For the first time in his short few weeks working with the big man, Barry thought he could hear concern in O’Reilly’s voice.
Barry moved up one side of the bed, smiled at Jenny, and palpated the uterus, searching for the baby’s back. Listening over the back was the best place to find the sounds of the fetal heart. He could feel the uterus, firm, but not rock hard, now that the pain had passed, but . . . his hands moved more quickly . . . he couldn’t make out any convexity in either flank. He took the Pinard fetal stethoscope from Miss Hagerty. “I’m going to listen in,” he said, even though he knew that not being able to identify the lie of the baby would force him to try blindly to hear the faint, rapid tones.
Jenny nodded and tried to smile, but another labour pain hit. Her head tossed from side to side on the pillow. She screamed.
Barry knew he’d have to wait until the contraction passed. The short, aluminium trumpet was cold in his hand. Not being able to feel the baby’s back was worrisome. It usually meant that the infant was lying with its spine in the middle of the uterus. If it was, the baby’s head, which he knew was not a perfect sphere, would have the occiput, the back part of the skull, to the rear of the birth canal. Babies in this occipitoposterior position presented a broader diameter of the head and were more difficult to deliver.
“Get on with it,” O’Reilly snapped, which surprised Barry. O’Reilly should know it was a waste of time trying to listen at the height of a contraction.
Jenny sat up. “I’ve to push,” she screamed. “I have to push.”
More evidence. A back-to-front baby’s head often reached the pelvic floor muscles before the cervix was fully dilated, giving the labouring woman an overwhelming need to bear down. Pushing too early could hinder further dilatation. Barry felt Miss Hagerty sidle past.
“Puff out of this, Jenny.” She held a face mask over the patient’s nose and mouth. The plastic cone was connected to a small metal bottle, which Barry knew contained Entonox, a mixture of nitrous oxide and oxygen. It wasn’t very effective, and judging by the way Jenny’s eyes rolled above the mask’s upper rim, the gas was not doing much to relieve her pain.
“Is she fully dilated, Fingal?” Barry glanced at O’Reilly. He’d never seen the big man sweat before.
“Don’t bother to wash your hands,” O’Reilly said. “Put on a pair of gloves and come and feel for yourself. Hurry.”
Barry pulled off his coat, chucked it in a corner, ripped open the packet, and slipped on a pair of gloves. It bothered him that he didn’t have time to scrub, but he was experienced enough to realize that sometimes in obstetric cases time was of the essence. Risks of infection, although small, must be taken.
O’Reilly nodded. “Well?” This time, Barry knew his opinion was not being sought because O’Reilly was trying to show a patient that he trusted his assistant. Fingal wanted Barry’s advice either to confirm a diagnosis that he himself had already made or to give an answer that he could not find. It was a daunting thought.
“Sorry, Jenny,” Barry said, moving past O’Reilly and sitting on the bed. He put his left hand on the abdomen just above the pubic symphysis and slipped the first two fingers of his right hand into the vagina. There was something solid just inside, but it didn’t feel like the normal hard contours of the top of a baby’s skull. He let his fingers explore, first to one side then the next. Could this be a breech presentation? He frowned and wished he were back in the Royal Maternity. A quick X-ray would give the answers.
He turned to O’Reilly. “Fingal, did you feel a head at the top of the uterus when you examined her abdomen?”
“I didn’t examine it. Miss Hagerty was certain the head was in the pelvis.”
Barry would have liked to have been sure, but he couldn’t fault O’Reilly for not having examined the abdomen. The opinion of an experienced midwife was money in the bank. No head palpable at the top of the uterus meant that a breech presentation was unlikely, but even an experienced midwife could be wrong.
“Big breaths, Jenny. Big breaths,” Miss Hagerty urged.
Barry’s left hand felt the uterus beneath harden; it was becoming the great muscular piston that drove the baby deeper and deeper into the pelvic canal and in most cases out into the world. His right hand felt some advance. At the height of the contraction he forced his fingers higher. Normally it would hurt, but Jenny would be too preoccupied by the pain of the contraction—or so he hoped—because he had to know the condition of the cervix and try to ascertain exactly how the baby’s head was lying.
His fingers told him that the cervix had vanished—it had thinned and opened. It would prove no barrier to delivery. But the shape of the baby’s head was wrong. “She’s fully, Fingal.”
“Good.”
Barry expected O’Reilly to ask about the presentation, but he said nothing more.
Barry groped and then his fingers stopped. Two tiny bony ridges ran laterally near the back of the birth canal, and above them he felt a rubbery protuberance, on each side of which was a dimple. His fingers retraced their steps. Yes. No question. He was feeling the baby’s eye sockets and its nose and nostrils. It wasn’t the top of the skull coming first. Somehow the head had become extended and was in the position a man might assume with his head thrown back, straining to look at a high-flying aircraft.
He heard Jenny grunting through what must be clenched teeth. Her belly muscles tightened as she bore down. His fingers felt the baby’s head move further into the birth canal. “Face presentation,” he said, trying to remember what he’d read about the condition. It occurred in one in five hundred births, was often associated with prematurity—and was frequently caused by some kind of fetal malformation. Was that why O’Reilly was tense? Had he already suspected that the baby would be abnormal, or had he simply not made the diagnosis?
As far as Barry could tell, the baby’s chin was pointing at its mother’s pubic symphysis. “Mento-anterior,” he said. Thank God for that. If the chin had been to the rear, in the mento-posterior position delivery would be impossible. To attain the outside world, the wee one would have to tuck its chin against its chest. With the chin forwards, the back of the skull would have room to move against the soft tissue at the back of the birth canal. But facing the other way, the pubic symphysis would hold the skull back as effectively as a crossbeam bars a door. The only solution was a Caesarean section, and there wasn’t time to transfer the patient to t
he Royal Maternity.
“You certain, Barry?”
Barry hesitated, then again palpated the landmarks—the nose, the nostrils, the eyebrows. He withdrew his hand and turned to O’Reilly. “Absolutely.”
“That’s what I thought too.”
Barry glanced at O’Reilly. From the open look on the man’s face, he was convinced his mentor had withheld the information, not to test Barry, but to let him bring an open mind to bear on the problem. Face presentation. Barry swallowed and said in a low voice, “Fingal, I’ve never delivered a face presentation.”
He saw O’Reilly frown, purse his lips, glance at Miss Hagerty, then slowly say to the patient, “We’d no trouble delivering your first, had we, Jenny? And he was a big lad.”
Jenny pulled the mask aside. “Connor was eight pound two and . . . uuunh . . .” She screwed up her face, clamped the mask over her nose, and inhaled deeply. “It’s coming,” she gasped.
Barry started to step aside to let his more experienced colleague take over, but O’Reilly shook his head, put one hand on Barry’s shoulder, and said, “Get on with it. I’ll assist. Here.” He produced a red rubber apron, shoved the strap over Barry’s head, and tied the waist string firmly. Barry was surprised that even at this moment, when he could feel his hands trembling, he had time to be grateful that his pants would be spared.
He heard clattering as O’Reilly finished opening the packs. “Here.” O’Reilly nodded to a large syringe. Barry grabbed it and filled it with local anaesthetic. In face presentations there was no choice. He would have to make a large episiotomy.
Miss Hagerty would be able to see what he was doing. “Take a few really deep puffs, Jenny,” she said.
Barry smiled his thanks to the district midwife. He drove the long needle in at the bottom of the vaginal opening and, at a sideways angle of forty-five degrees, advanced the tip beneath the skin between the vagina and the anus. The tissues bulged and blanched.
“Uuuuunh.”
At the now distending opening of the vagina he could see the tip of the baby’s eyelids, tightly shut and bulging; the nose; and above it, the lips, pouting, blue, and horribly distended. The pressure of the uterus ramming the head through the birth canal had trapped fluid in the baby’s facial tissues, forcing them to swell.
“Sorry, Jenny,” he said, praying the local had taken. Some of his older, more senior colleagues were certain that the distension of the perineum by a baby’s head effectively deadened any pain sensation. But by the way most patients screamed when the incision was made, Barry remained unconvinced of the accuracy of that firmly held belief.
He slipped one blade of a pair of heavy scissors inside the vagina along the line of the local, narrowed his eyes, and cut hard. Blood ran from the incision, and its edges gaped. Ugly, he thought, but now there was room for the baby’s head to swing without causing violent stretching and tearing of the flesh and, if too forceful, ripping right through the skin and muscle and into the rectum.
He glanced at O’Reilly, who nodded once and said, “Right, Jenny. Put one foot on my hip and one on Miss Hagerty’s.”
Barry waited until O’Reilly and the midwife, one on either side of the bed, had settled the patient’s feet on their hips. In hospital, the more difficult deliveries were always facilitated by the use of stirrups. But in district midwifery a simpler method had to be used.
“Can you ask Jenny to push with the next contraction?”
O’Reilly and Miss Hagerty each put an arm behind Jenny’s shoulders to help her half sit. “Ready, lass?” O’Reilly asked. “Deep breath, hold it, close your lips, and puuush.”
Barry was surprised by how easily the baby’s head advanced, and under the control of his hands, slipped into the world. As soon as the chin appeared, the head pivoted around the mother’s pubic symphysis.
Even before Barry had delivered the shoulders, the wee one took its first breath, screwed up its puffy eyes, and expressed its discontent at having been pushed from the cosy womb, crammed down a constricted passage, and put out into a cold world. The baby cried, a long, harsh, wobbly little howl.
It was the most beautiful sound Barry had ever heard, but he did not let it distract him from easing out the child’s arms, body, and legs. He held the baby in both hands to keep it from the pool of amniotic flood and blood on the rubber sheet. “Can you get the cord, Fingal?”
Both O’Reilly and Miss Hagerty lowered Jenny’s feet to the bed and moved towards him. As O’Reilly clamped and cut the umbilical cord, Miss Hagerty handed him a thick warm towel.
“Is it a boy or a girl, Doctor?” he heard Jenny ask.
“It’s a wee girl,” he said, “and she’s beautiful.” Liar, he told himself. With the facial oedema and horribly pouting lips, she was grotesque. “We’ll just clean her up a bit.” He handed the towel-wrapped infant to Miss Hagerty, inclining his head towards the swollen face and raising a questioning eyebrow. He wasn’t sure if the child should be shown to her mother.
“You wee dote,” said Miss Hagerty to the baby. To Barry, she said, “Don’t you worry, Doctor Laverty; sure a baby always brings its own welcome. As long as she’s got all her bits and pieces, and we’ll have Doctor make sure, mother’ll be delighted, won’t you, Jenny?”
The baby looked perfectly normal to Barry, apart from the facial swelling, which would, he knew, settle soon. He was concerned about how Jenny might respond when she saw her infant, but practical matters must take precedence. He still had to deliver the placenta and sew up the episiotomy.
He laid one hand on Jenny’s belly to feel for the now empty uterus. It was shrunken and firm. The stump of cord hanging on the rubber sheet grew slightly longer, and there was a small gush of bright red blood. “Can you push again, Jenny?”
She did. The afterbirth came into view and flopped onto the sheet. Barry picked it up and made sure it was intact. A detached piece remaining in the uterus would lead to massive postpartum bleeding. It was complete.
“Well?” O’Reilly asked.
“Fine,” Barry said. “Ergometrine.”
“A wee jab, Jenny,” O’Reilly said, driving a hypodermic into her thigh to inject the drug that would make the uterus contract firmly. “Well done, Barry.”
Barry smiled at O’Reilly, who pushed over the suture pack. “I’ll take a look at the wee one and have a chat with Mum. You do the embroidery.”
Funny, Barry thought, when he’d been a student, repairing episiotomies was regarded as scut work by the senior staff. They always delegated the task to a junior so they could get home sooner. Now he was pleased to have the responsibility and bent happily to his work. As he put the third, deep, catgut stitch in the muscles, he could hear O’Reilly talking to the mother.
“My God,” Jenny said, “what’s wrong with the wee one’s face?”
Barry flinched. Was she going to blame him?
“Not a thing,” O’Reilly rumbled. “She was in such a hurry to see the world, she shoved her face out first and it’s swollen with fluid. It’ll all go away by tomorrow, and she’ll be as beautiful as her mother.”
“Are you sure, Doctor?” Jenny sounded uncertain.
Barry waited, knowing how O’Reilly disliked having his word challenged. “Don’t believe me,” he said. “Ask Miss Hagerty.”
“Miss Hagerty?”
“The doctor’s right, dear. She’ll be right as rain tomorrow.”
“If you say so, but what’ll I tell my husband when he sees her?”
“That’s easy,” said O’Reilly. “Tell her she’s the spitting image of him. But she has her health and that’s all that matters.”
Barry heard Jenny laugh, then say, “You’re a terrible man, Doctor O’Reilly, but I do believe you. You’d not make jokes like that if you weren’t telling me the truth.”
O’Reilly grunted.
“Now, you’ll be tired, dear. Would you like a cup of tea?” Miss Hagerty asked.
Barry smiled and knotted the last deep stitch. Tea. The universal
Ulster cure-all. He heard Jenny say, “Yes, please.” O’Reilly added, “And maybe Doctor Laverty would like one. He’s earned it.”
Barry smiled. He clipped the suture and started to repair the skin with one continuous, dissolvable suture, starting at one end of the wound and running it from side to side along the length. A subcuticular stitch would be less uncomfortable as the wound healed and wouldn’t need to be taken out. He could hear Jenny making little cooing noises; then he heard a tiny burbling from the baby. He’d always known it. Nothing, nothing in his whole world was as satisfying as conducting a delivery and ending up with a healthy mother and a healthy baby.
He finished stitching and grabbed a handful of damp swabs. “Just going to clean you up a bit, Jenny. Don’t be scared.”
“Go ahead, Doctor,” she said.
When he’d finished and had stripped out the soiled rubber sheet and his gloves, he stood and put a hand in the small of his back. Lord, he was stiff.
This was the second confinement he’d conducted in Ballybucklebo. Maureen Galvin’s son, Barry Fingal, had been his first delivery.
For a moment he remembered that Addenbrooke’s Hospital in Cambridge had an obstetrics department. But then he looked at O’Reilly, craggy-faced, beaming down at a smiling mother as she cradled her now sleeping newborn girl, rocked her gently, and crooned:
“Bring no ill wind to hinder us,
My helpless babe and me—
Dread spirit of Blackwater banks,
Clan Eoin’s wild banshee,
And Holy Mary pitying us,
In heav’n for grace doth sue.
Sing hush-a-bye loo, la loo, lo lan.
Sing hush a bye loo, la lo.”
As he watched O’Reilly and listened to Jenny’s lullaby, Barry realized that pursuing a training position in obstetrics seemed less and less attractive and that even after only three days, it was getting much harder to consider going from.
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