Farewell To The East End

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 –