Farewell To The East End

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