The second stage of labour was surprisingly quick. Mave was nearly forty, and this was her first pregnancy, but she was relaxed and comfortable, the uterine muscles were strong, and her perineum stretched without difficulty. Only two more contractions were necessary and the head crowned. Sister Bernadette smiled at Mave, who looked up at her trustingly.
‘Now, with the next contraction I don’t want you to push. Just pant and concentrate on your breathing, because we want the baby’s head to be born slowly.’
Mave was wonderful. We had all expected her to create a terrible fuss during labour and refuse to cooperate, but not at all. With the next contraction the head was born. Trixie waited for restitution of the head, and after only a few moments the shoulder slid under the pubic arch and the baby was born.
‘She’s a little girl.’
‘Oh, thank God. I don’t like boys,’ said Mave.
The baby gave a lusty scream, and Meg put her head round the door. She was still wearing her strange green outfit, and her black eyes devoured us all, her gloomy features contrasting with Mave’s radiant smile.
‘We wan’ed a li’le girl, Meg, and we got one.’
‘She’ll die. I seed it all.’
‘Don’t talk like that.’ Sister Bernadette was angry.
‘Worms an’ coffins. It’s in ve cards.’
‘Will you go away. I won’t have you in here,’ the nun said.
‘Vey never lie.’
‘I never heard such nonsense. Now go away this minute.’
Meg rolled her eyes, making herself look weirder than ever.
‘It’s all worms an’ coffins,’ she muttered as she left, shaking her head mournfully.
If Mavis heard these words of doom she did not seem to take any notice, as she cuddled her baby in a state of exhausted euphoria.
The cord was clamped and cut, and Sister took the baby to examine and weigh her. She was a very small baby, weighing only 4 lb 12 oz, but was not premature and appeared to be normal and healthy in every way. Trixie left the baby to Sister, and concentrated on the management of the third stage of labour. There were no contractions, so Trixie waited. After ten minutes she decided to massage the fundus to stimulate another contraction. The uterus felt bulky, and then she saw a movement, like a kick, as the wall of the uterus rose and fell briefly. She put her hand over the place, and it happened again.
‘Sister, I think there is another baby in here,’ she said.
Midwife and doctor were at the bedside in an instant.
‘That would account for a small first baby,’ Sister said as she palpated the uterus. ‘You are quite right, nurse, and I think it is a transverse lie. Pass me the Pinards, please.’
She listened carefully. The heartbeat could be heard low down, just over the pubic bone. It was rapid but regular. Sister counted 140 beats per minute. She asked the doctor to confirm the lie of the baby. He said that he could not tell and would rely on Sister’s judgement, but whatever the lie of the baby he advised we call the Flying Squad, and immediately transfer Mavis to hospital.
Until that moment Mavis had appeared unconcerned and relaxed, but at the word ‘hospital’ she wailed in anguish. Meg rushed into the room.
‘Wha’choo doin’ to ’er?’ Her voice was harsh and aggressive.
‘Vey’re goin’ ’a put me away. In an infirmary.’
‘Over my dead body.’
‘It’s not an infirmary,’ said the doctor, ‘it’s a modern hospital, where Mavis will get the best treatment.’
‘She’ll never come out alive. Or never come out a’ all. I know wha’ goes on in them places. Vey keeps the likes of Mave an’ me, an’ never lets ’em out. Uses ’em for speriments, that’s wha’ vey do.’
Mavis became almost hysterical, shrieking and sobbing, ‘I won’t go,’ and Meg threw her arms protectively around her. Sister felt Mave’s pulse, which had been normal until that moment, but had now risen to an alarming 110 beats per minute.
‘If this goes on, the baby will be in serious distress,’ remarked Sister. ‘We must prepare for a twin birth at home. You will not be sent to hospital, Mavis. But Meg, you must go. I am not prepared to deliver the second baby with you in the room.’
Meg rolled her eyes. ‘I told yer, didn’t I? It was an evil omen wiv the tea leaves. An’ ve cards. Vey’ll die. You mark my words.’
Sister pushed her out of the room. Then she scrubbed up. She was calm and controlled.
‘There have been no contractions since the birth of the first baby. If the foetus is lying transversely this will help me. First I must make quite sure of the lie of the baby, and secondly ascertain whether or not the waters have broken. If the uterus is inert, and the membranes intact, it is usually possible to turn the baby to the correct position for delivery. I want you to monitor the foetal heart every few minutes, nurse.’
Trixie listened and said the heartbeat remained at 140. Sister carried out a vaginal examination.
‘Yes. I can feel the amniotic sac bulging through the dilated os – splendid – but I cannot identify the presenting part. It is certainly not a head. It might be a breech, I suppose, but I cannot be sure. I’m not going to do too much ... remember, that, nurse. Never try poking around too much in a twin birth. You might rupture the membranes, and if an arm or a shoulder is presenting and descends into the birth canal, you will then have an impacted foetus which cannot be delivered vaginally.’
Sister withdrew her hand and removed her gloves.
‘I am going to attempt an external version – unless you want to do it, doctor?’
The doctor shook his head.
‘It would be better if you did it, Sister.’
Sister nodded.
‘What is the foetal heartbeat, nurse?’
‘One hundred and fifty; a little raised, Sister.’
‘Yes. Now Mavis, lie quite still and relax. You are not in any pain, are you?’
‘Nope.’
‘I have to turn your baby. I am going to exert a lot of pressure. I want you to breathe deeply all the time and concentrate on relaxing.’
Mavis nodded and smiled. Since the threat of hospitalisation had been removed, she had been quite relaxed, and her pulse had dropped to a steady seventy-two beats per minute.
‘I want you to watch me carefully, nurse, so that you will know how to do it another time.’ Trixie fervently hoped that would never happen.
‘Here in the right iliac fossa is the head ... feel it, nurse ... I’m correct, am I not?’ Trixie nodded, though she could feel no identifiable head. ‘And over here is the breech ... can you feel that?’
Trixie nodded vaguely. ‘I think so, Sister.’
‘Good. Now what I cannot tell is whether the foetus is lying dorso-anterior or dorso-posterior. You said that you saw and felt a kick. Where? Point to the spot.’
Trixie did so.
‘Hmmm – not much help. Now what I want to do is to flex the foetus into a ball as much as I can, which will enable me to turn it more readily.’
Sister grasped what she had identified as the head and the breech and slowly closed her hands together.
‘Yes ... it is moving ... the foetus is definitely flexing. The head is closing towards the breech, and the back is curved under the fundus. Splendid! Feel it now, nurse. Can you feel the difference?’
Trixie felt but could not truthfully say she noticed anything different. The doctor felt also and nodded approvingly.
‘You must have X-ray hands, Sister,’ he murmured.
‘I must turn the foetus now, and I want to turn it so that it follows its nose. About a quarter circle will be sufficient, and the head will be presenting. This is going to hurt, Mave, but only for a minute. I want you to relax as much as you can.’
Sister Bernadette, the expert midwife, with the ball of her right thumb behind the head, and with the fingers of the left hand beneath the breech, firmly and slowly, her two hands working together, feeling her way, successfully achieved external cephalic version of the foetus. She turned the baby.
‘The head is now lying just above the pubic arch ... can you feel it, nurse?’
To her surprise, Trixie could and she nodded enthusiastically.
‘To ensure that it remains in that position I am going to ask you to hold it there ... grasp it firmly ... and hold the breech with the other hand. After version a foetus can slip back into its former position. I am going to puncture the membranes to permit the head to engage. This can usually be done quite easily with blunt forceps.’
Sister scrubbed up again and punctured the membranes. Amniotic fluid flowed over the bed.
‘While I am here I will want to feel the foetal skull to find the position of the fontanelle, which will tell me if it is an anterior or a posterior presentation ... ah, marvellous! The head is well down in the pelvis. Couldn’t be better. Now all we need are some good contractions and your other baby will be born.’ She smiled at Mavis, who responded warmly.
They waited, but still a contraction did not come. Trixie listened to the foetal heart again. It was 160. Sister and doctor looked at each other without speaking.
Minutes ticked by. Sister looked at her watch.
‘Twenty-five minutes have passed since the birth of the first baby, and no contraction. The foetal heartbeat is going up. We cannot allow this to go on beyond thirty minutes. Why do I say that, nurse?’
Trixie was startled by the sudden question. She hadn’t a clue! She mumbled something about ‘The mother needs to rest’.
‘Nonsense!’ snapped Sister Bernadette. ‘Didn’t they teach you anything in the classroom? You’d better pay attention, because there is no teacher like experience. One day you may find yourself in a similar situation, with no one to help you.’
Trixie was terrified at the thought, but muttered, ‘Yes, Sister.’
‘We cannot allow the uterus to rest for too long because of the risk to the mother and baby. We do not know the condition of the placenta, which is the life blood of the foetus. If the twins are uniovular ... and what does that mean, nurse?’
‘It means that they have developed from one ovum.’
‘Correct. That would mean that, after the birth of the first baby, there is the possibility of the placenta separating from the uterine wall while the second twin is still in utero. I need not continue.’
Sister indicated that Mavis was listening to the viva voce, but her unfinished sentence protected Mavis from hearing that if the placenta of uniovular twins separated after the birth of the first baby and before the second was born, the second twin would be robbed of its blood supply and would die in utero. If that were not bad enough, the risk of haemorrhage might kill the mother also, because contraction and retraction of the uterine muscle controls bleeding during the third stage of labour. If a second foetus is still in the uterus, its presence will interfere with the third stage, and the raw placental site will bleed freely.
Sister asked Trixie to record the foetal heart again. It was still 160.
‘Satisfactory. Now I want to stimulate the uterus. There are three simple ways in which we can do this. What are they, nurse?’
Trixie’s mind went blank.
‘Really! I sometimes wonder what they taught you in the classroom. You did have lectures on twin births?’
‘Yes. I think so, Sister.’
‘You only think so! I trust you were not asleep during the lectures, nurse.’
‘Oh no, Sister. Never,’ said Trixie untruthfully.
‘I hope not! Well, we can stimulate uterine contractions by puncturing the amniotic sac. This I have already done, and I did it to make the head engage after cephalic version. However, it has not stimulated uterine contractions. Secondly, we can massage the fundus, just as we do to stimulate the third stage of labour.’
Sister massaged the fundus vigorously, but it did not have the desired effect.
‘If these two methods fail, we can put the first baby to the breast. And how will this help, nurse?’
Trixie was dreading another question, and this was the worst. She swallowed, and shook her head.
‘As you will doubtless be aware, nurse, the posterior lobe of the pituitary gland produces a hormone we call pituitrin.’
Trixie nodded her head, and tried to look as if she already knew what Sister was talking about.
‘Pituitrin, as you will know, plays a part in lactation.’
‘Oh yes, of course, Sister.’
‘Can you describe to me, please, the role of pituitrin in lactation?’
Me and my big mouth, thought Trixie, ruefully.
‘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.’