O’Reilly shook his head. Stupid. Stupid. An experienced midwife like Miss Hagerty was one of the most sensitive diagnostic tools available. It was the height of arrogance for Fitzpatrick to ignore her expertise.
“But as far as you know there haven’t been any problems?”
“As far as I know. I asked Gertie as soon as I got here, and she said Doctor Fitzpatrick kept telling her everything was fine. No high blood pressure. Good weight gain. The baby was growing and its heart rate was normal.” He heard a disdainful tone in her words. “So as far as I know there were no difficulties before labour . . . at least none that were noticed.”
He frowned. What did that mean? O’Reilly disliked discussing a patient in so impersonal a manner in front of her, but he needed the critical information, and during a contraction she was in no position to hold a conversation anyway. He tried to reassure Gertie by squeezing her hand for a moment, and he was gratified to see her manage a weak smile as the contraction waned. It was time to examine her. He’d pursue Miss Hagerty’s implications later.
“I’m going to examine your tummy,” he said, looking questioningly at Miss Hagerty. He had no difficulty lip-reading the midwife’s silent, “I think it’s a breech.”
A breech? Christ Almighty. The risks of serious injury to the mother and of damage, asphyxia, and even death to the child were much greater when a baby came bottom first.
That would certainly explain the “at least none that were noticed” remark. It was a major responsibility of the attending midwife or physician to identify any abnormal presentations and to arrange for the patient to be transferred to a properly equipped maternity unit. A specialist obstetrician, who could if necessary call on the services of a team, ought to manage the delivery and if necessary do a caesarean section.
O’Reilly hadn’t had to deliver a breech since before the war. His palms started to sweat. Miss Hagerty might be wrong, and if she wasn’t he hoped that labour would be insufficiently advanced so he could get Gertie up to the Royal Maternity Hospital.
He stood facing her and laid his hands on either side of her swollen belly. Through the abdominal wall and the temporarily relaxed uterus, he could make out the smooth, curved contour of the baby’s back lying on its mother’s right side. He followed it upward until he could no longer feel it. He placed one hand on either side of the fundus, the top of the uterus, and moved his hands from side to side. Something solid moved back and forth between his hands. It was, in medical terminology, ballottable. Heads usually were, buttocks less so. He used his right-hand fingers and thumb curled like a claw to grasp the hard round thing, and he was sure it was the baby’s head. He met Miss Hagerty’s gaze and nodded.
Using both hands, one on either side of the lowest part of her belly immediately above the pubic bones, he was able to make out a shape that was deep into the pelvis. It didn’t feel like a head. It was narrower. He nodded at Miss Hagerty again. “Is the fetal heart rate okay?”
“It was one forty just before you arrived.”
Good. That at least was normal.
Before he could carry out any further manoeuvers, he felt the beginning of another contraction. He’d be unable to feel anything but the iron-hard uterine muscles until this contraction passed. Time to get ready to examine the patient vaginally.
“Is the bathroom on the landing?”
“Two doors down along to the right.”
Gertie’s moans pursued him, but had died away by the time O’Reilly returned from scrubbing his hands. While Kitty handed him a sterile towel and opened a packet of rubber gloves as he dried his hands, the moans started again. Then Gertie cried, “I have to push! I have to push!” while Miss Hagerty responded, “Huff, Gertie. Huff.” O’Reilly donned the gloves to the accompaniment of the patient’s short, rapid, shallow breaths. He hoped to God the cervix was fully dilated.
If, as he was almost certain, the baby’s buttocks were coming first, they were narrower than the head and could slip through a partially dilated cervix and descend into the pelvis. There the pressure the buttocks exerted on the muscles of the pelvic floor would give the woman an uncontrollable desire to push.
She might well push the narrower parts of the baby past the cervix and out into the open with no apparent difficulty, but once the neck had passed through the muscular cervical ring, the wider head would become irretrievably stuck. The consequences would be disastrous for both mother and child.
O’Reilly lifted a pair of sponge forceps that Kitty had placed on the dressing table, her makeshift instrument trolley. He chucked a handful of sterile cotton-wool balls into a bowl of dilute Savlon disinfectant and moved to the patient’s side, accompanied by Kitty, who carried the bowl.
“Can you draw up your legs, Gertie?” He waited as Miss Hagerty helped the patient bend her knees and open her thighs. The labia were gaping, and in the opening he could see something smooth and dusky. It was a buttock. Its plum colour was caused by the blood being dammed back in its blood vessels due to the constriction of the pelvic canal. That answered two questions. It definitely was a breech, and there was no time to arrange a transfer. Bloody Fitzpatrick should have made the diagnosis weeks ago. O’Reilly knew Miss Hagerty would have—had she been given the chance.
No time to get tried about that now. He’d deal with it later. Gertie Gorman needed his undivided attention.
“I’m going to give you a wash,” O’Reilly said, loading the forceps with sodden cotton-wool balls. “Sorry if it’s a bit cold.” She flinched when he started to paint her vulva, inner thighs, and her buttocks with the pale yellow Savlon solution, its fumes tickling his nose. He chucked the forceps back into the basin. “Now you’ll feel me touching you.”
“Here.” Kitty offered him an opened pack of sterile towels.
“Thanks.” He took one and draped it over the patient’s pubis and lower belly. He put his left hand on the towel and slipped the first two fingers of his right hand inside her vagina, past the buttocks, and into the pelvis. Reaching as high as possible, he could make out the baby’s thighs where the legs were flexed up against the belly. The toes would be inside the uterus close to the baby’s head, so it was a frank breech, not a footling breech where the feet came first, or a complete breech where the baby’s legs were crossed like those of a squatting tailor. Good. In the frank presentation, there was much less risk of the umbilical cord slipping out past the baby, being compressed and cutting off the oxygen supply, before the child was delivered.
His left hand felt a contraction starting. Gertie moaned and wriggled on the bed. Miss Hagerty’s instructions to huff were falling on deaf ears. O’Reilly felt Gertie’s belly muscles stiffen as she bore down and the baby’s buttocks advanced lower into the pelvis. He managed to insert his fingers more deeply, and to his great relief he could find no evidence that the cervix was not fully dilated or the cord had prolapsed.
O’Reilly, though not a religious man, offered up a small muttering of thanks.
“She’s fully dilated,” he said and then removed his fingers. Jesus, but he wished she was in hospital. For one thing, having her feet in obstetrical stirrups and her buttocks over the edge of the delivery table would greatly facilitate the manoeuvers he’d need to carry out to expedite the child’s delivery. Of even greater importance, he would have an anaesthetist there who could knock Gertie out if any difficult procedures were required.
He’d have to make do, and it wouldn’t be for the first time, with what was at hand. “Kitty, in the packs there’s a kit for putting in local nerve blocks and also a bottle of Xylocaine. Get them.” No time for the niceties of “please” and “thank you.”
“Miss Hagerty, do everything you can to stop her pushing.” He didn’t need to tell such an experienced midwife to listen to the fetal heart between contractions. She would tell him if there were any abnormalities.
“The pudendal nerve block kit’s open,” Kitty said, stepping back from the dresser. “I’ve not seen one of those since I took my midwi
fery training during the war.”
“I didn’t know you had.” O’Reilly began assembling the large syringe with its very long needle. In Ireland, state registered nurses who wanted to be midwives took two extra years of training after gaining their S.R.N. qualification.
Gertie moaned as another contraction hit.
“I thought I’d like midwifery,” Kitty said, holding the bottle of the local anaesthetic Xylocaine so he could penetrate the rubber cap with the needle and fill the barrel of the syringe.
“Didn’t you?” He drew back the plunger.
She shook her head. “I preferred general nursing.”
To each her own, O’Reilly thought, but even if her knowledge was rusty, it was a great comfort to him to be assisted by not one but two trained midwives.
It had taken two more contractions before he’d been able to identify the nerves that supplied the lower vagina and the area between the anus and pubis. Once they were infiltrated with Xylocaine, he was more comfortable because no matter what he did now, he’d not hurt the patient.
He exhaled a very large breath, used the back of his arm to wipe perspiration from his forehead, and said, “Kitty, there’s a rubber apron in the kit. Could you help me put it on?” As he spoke, he handed her the used syringe.
She slipped the straps over his head and tied the waist tie. The patient was washed and draped; the doctor was gowned and gloved. The labour was progressing, and now came the difficult part. Waiting. O’Reilly knew that more damage was done to breech babies by impetuous attendants who intervened too early.
“Get her pushing, Miss Hagerty. Open that pack, Kitty.” He made a snipping action with the first two fingers of his right hand.
She nodded and opened the pack, which contained a pair of heavy bladed scissors.
He waited until another contraction had passed and one buttock and the cleft in the backside were visible at the vaginal opening.
“Now, Gertie,” he said, “we’re going to move you a bit. See if you can help.”
Aided by both Kitty and Miss Hagerty, he managed to turn Gertie so that she lay across the bed, her head supported on pillows, her buttocks at the bed’s edge. O’Reilly picked up the scissors and moved to stand between her flexed legs. Kitty and Miss Hagerty both knew what to do. Each took a leg and supported it, acting as human stirrups so O’Reilly had the best possible access to the operative field.
He waited for the next contraction, slipped a finger inside, and guided one blade of the scissors into the vagina. At the contraction’s peak he sliced, cutting an episiotomy in the vaginal outlet to give the baby more room. He smelt the metallic blood smell and saw the drips falling on the carpet. Couldn’t be helped. He dropped the scissors.
Now for more waiting. It took self-control not to start tugging and pulling at the baby’s hips as soon as they appeared. “So why didn’t you like midder, Kitty?” he asked, as Miss Hagerty encouraged Gertie to push.
“It wasn’t so much I didn’t like it. I’d spent some time on the neurology and neurosurgery wards, and I just found those subjects much more fascinating.”
Interesting, O’Reilly thought, looking at her. He had always enjoyed obstetrics, might have specialized if the war hadn’t intervened. He’d always been a bit intimidated by the diseases of the nervous system. Their study was a very intellectual discipline. He smiled to himself. He’d not like to admit it, he knew, but it was probable that in some ways Kitty was smarter than him. He turned back to look at the patient. He mustn’t let his attention wander.
“Big push, Gertie,” Miss Hagerty encouraged. “Puuuussh.”
The baby’s body, its back to the mother’s right side, began to emerge and climb upward, forced by the uterine contractions and the configuration of the birth canal. He saw the lower buttock. He noted no evidence of a swollen scrotum, so he knew it was a girl, and then both buttocks were in the open followed by the hips, the lower belly, and finally the umbilicus and the cord.
Soon it would be time to act. He waited until Miss Hagerty told Gertie once more to push.
O’Reilly used a finger and thumb to pull a loop of cord down; then he hooked one index finger into each fold between the baby’s thighs and belly, pulling gently until the hollows behind the knees appeared. He flexed the baby’s legs each in turn, and by sweeping the lower limbs outward across the baby’s trunk, he guided the legs into the open.
He took his hands away. The trunk rotated until the back faced upward. The rotation was a function of the uterine contractions forcing the widest parts of the little body into the widest parts of the birth canal. More and more of the baby’s back slipped into view, and the trunk and legs hung down toward the carpet. O’Reilly still kept his hands to himself, allowing gravity to help the uterus move the baby out.
He glanced at Miss Hagerty, who immediately put one hand on the patient’s belly to feel for the start of a contraction and to exert pressure to prevent the child’s arms extending.
He reached under the little trunk, slipped two fingers into the vagina, and found the arms crossed in front of the chest, like the stone limbs on top of the tomb of a medieval knight. In a moment he had flipped them out, and they dangled limply.
Gertie started grunting in her throat.
“Another one coming,” Miss Hagerty said. “Puuush, Gertie.”
The trickiest bit was to come. Delivery of the head. It was just about to enter the birth canal, and as soon as it did, it would compress the umbilical cord and interfere with the baby’s oxygen supply. O’Reilly had four minutes to get the head out before the child asphyxiated itself. He knew that two of those minutes must be allowed to elapse to let the head descend slowly into the narrow bony pelvis, thus protecting the soft skull and the vulnerable brain within from compressing too rapidly.
O’Reilly knew that older obstetricians favoured using their hands—one above the pubis to push, and one with fingers in the baby’s mouth and hooked around its shoulders to pull. This Wigand-Martin manoeuver was named for the two doctors who had first described it. But a Doctor Burns had suggested a simpler method while O’Reilly was still a student, and that was the one he had been taught.
He simply allowed the baby to hang, as the infant girl was doing now, and by its own weight pull the head into the pelvis. He saw the nape of the neck appear, and he turned so he was standing with his back to the patient’s left leg. He grinned at Kitty, who was supporting the right one.
“Hard work,” she said. He wasn’t sure if she was referring to herself, to him, or to Gertie.
He concentrated on his work. Holding the child’s ankles in his right hand, he pulled gently, then lifted the legs to a vertical position above the mother’s pubis.
“Now, Doctor?” Miss Hagerty asked.
He nodded, and as the midwife started telling Gertie not to push if she could help it, O’Reilly used his left hand to put pressure on the perineum beneath the vaginal opening. The combination of that pressure and the cessation of pushes would allow him to deliver the head slowly, avoiding the risk of ripping the soft tissues of the mother.
He saw the face appear and the little mouth. He’d have sold his immortal soul for a second pair of hands. Someone should be using a suction apparatus to clear the child’s mouth and throat of mucus.
Slowly, slowly, he allowed the head to appear until finally he was holding the baby girl aloft by her heels. He used the little finger of his left hand to clean some mucus from her mouth. She screwed up her eyes, pulled air into her lungs, and gave a long high quavering howl.
“It’s a girl,” he roared, so Gertie could hear over the newborn’s noise. “A pretty wee girl.”
Miss Hagerty and Kitty flexed Gertie’s knees and set her feet on the bed.
“Phew,” Kitty remarked. “She was getting heavy.”
“Never mind that,” he said. “Open the clamps kit.”
In a trice, he’d clamped and cut the umbilical cord, bundled the child in a towel, and handed her off to Miss Hagerty, who in
turn gave her to Gertie to hold.
O’Reilly smiled. To him there were few more satisfying sights than a mother with her healthy newborn.
He’d little time to enjoy the scene.
With a small gush of blood, the cord hanging from the vagina lengthened, and in no time the placenta was delivered, looking like a big lump of raw liver. “Give her the ergometrine, Miss Hagerty,” he said, “and would one of you ladies open the suture pack, please?” He glanced at the open episiotomy wound. “I’ve a bit of embroidery to do.”
He arched his back and pulled his shoulder blades toward each other to ease the kinks, screwed his eyes shut, and blinked. Once the suture pack was opened he removed the forceps, suture, and needle holders and began to stitch.
In what seemed like a surprisingly short time, the wound was repaired, Gertie was drinking a cup of tea Miss Hagerty had made, and Baby Gorman was wrapped up and sleeping soundly in her crib.
O’Reilly snipped the ends off the last suture, put the instruments back in their towel, stripped off his rubber gloves, and asked Kitty to undo the ties of his apron. Then he headed for the bathroom to wash his hands and cleanse his forearms of blood and vernix, the cheese-like substance that coats a newborn’s skin.
When he came back, Baby Gorman had woken and was demanding sustenance.
As Miss Hagerty carried the wee one to her mother, O’Reilly bent, retrieved his jacket, slipped it on, and moved to stand beside Kitty.
She smiled at him. “That was very well done, Fingal. I’ve seen specialist obstetricians not deliver a breech as well.”
“That’s perfectly true, Doctor O’Reilly,” Miss Hagerty said.
Normally he would have brushed off any compliment like that with a gruff rejoinder, but coming from Kitty it pleased him. He felt a warmth in his cheeks. “Thanks, Kitty. It’s a bloody good thing you both were here. I couldn’t have managed without you or Miss Hagerty.”
Kitty quickly kissed O’Reilly’s cheek. “It was a great job and I was lucky to be here. I’d almost forgotten how moving a birth can be.”
An Irish Country Christmas Page 24
