Ruth placed her hand on the fundus of the uterus to assess progress of the third stage and stiffened with shock. The uterus still felt full, hard and bulky. ‘There’s something wrong here,’ she thought, ‘this doesn’t feel like a placenta.’
She carefully palpated the abdomen. ‘It’s definitely not a placenta. It can’t be ... It’s not possible ...’
She picked up her foetal stethoscope, applied it to the abdomen in several places and heard a rapid, regular heartbeat. Her mouth went dry, and she had to sit down again. Another baby! Undiagnosed triplets, no antenatal care, no assistance available, and apparently no one else in the building to summon help. She shivered as much from shock and fear as from the cold. Thoughts were racing through her mind. Would the delivery be normal? She had been lucky twice, but the third baby might be lying in any position. He might be a transverse lie, or a shoulder or a brow presentation ... or anything. She palpated the abdomen but could not feel a head or a breech. The foetal heartbeat was a steady 150 beats per minute, which was undoubtedly high, but might be normal for a third baby. She had never delivered triplets, nor even seen a triple birth. She felt numb with fear. Would he be healthy, like the others? There might be breathing problems, or other life-threatening difficulties derived from immature internal organs. Perhaps the placenta might come away first, leaving the baby with no maternal blood supply, or the cord might prolapse. She didn’t know if there would be one, two or three placentae. She couldn’t see inside, and she could not tell from external palpation.
Nearly half an hour had passed since the second birth, and there was no contraction. Kathy still slept quietly, but Ruth was trembling with anxiety. ‘If this is uterine inertia, it is a serious condition, and the baby will die. Dare I risk leaving Kathy alone for ten or fifteen minutes while I go to a telephone to call the hospital?’ she asked herself. She dithered. Should I? Shouldn’t I? Which course of action would be the least dangerous?
The situation resolved itself. In her sleep Kathy groaned in pain, and in the same instant there was a click from the electric meter and the light went out. The room was in total darkness. Ruth knew the bicycle torch was on the chest of drawers, but in trying to locate it she knocked it onto the floor, and then had to crawl around trying to find it. She could hear Kathy groaning and straining and pushing, but there was nothing she could do until she had light. She found the torch and switched it on. Kathy now lay calm and apparently asleep. Ruth went over to the bed and pulled back the blankets. A baby lay in a pool of blood, between his mother’s legs. She propped the torch on the end of the bed and picked up the baby. He was small, like the other two, but seemed perfectly formed, and even gave a little cry. She held him upside down, and he cried more loudly. ‘This is a miracle,’ Ruth thought. She cut another gauze swab into two pieces and ligated the cord, then cut the baby free from his mother. She lay him on his mother’s abdomen and covered them both to keep them warm. There was no other clothing available in the room, so she took one of the grey army blankets off the mother, cut it into pieces, wrapped a piece round the baby, and tucked him into the bottom drawer. The other pieces of blanket she tucked under and around all three babies to ensure that they were warm. Then she closed, or rather nearly closed, the drawers to keep out any draughts.
Meanwhile, Kathy was sound asleep, her body exhausted. Ruth sat beside her and tentatively palpated the uterus – would there be another one inside? But no; the abdominal muscles and the uterus felt soft. Ruth breathed a sigh of relief, but at the same time reminded herself that labour was far from over. The third stage had to be completed, and she knew that this was frequently the most difficult and the most dangerous part of delivery. She leaned back in the chair and closed her eyes. Was this a dream? Could it really be happening? She had been out the night before, followed by a busy day, and had enjoyed very little sleep in the past twenty-four hours. She very nearly dozed off, but a warning bell sounded in her brain, and she jumped up and splashed her face with cold water from the enamel jug. The shock soon focused her mind again.
About twenty minutes had been spent wrapping and settling the babies, during which time there had been no contractions. Something had to be done. Ruth picked up the torch and shone the beam of light into the bed. The mess was quite indescribable; a great pool of blood and amniotic fluid was seeping into the uncovered mattress – and she could do nothing about it. Normally a midwife would have covered the mattress with brown paper, absorbent sheets, a rubber sheet, and on top of that more absorbents, which could be changed frequently – but she had none of these. The mess would have to stay where it was. She shone the beam of light onto Kathy’s vulva. Three cords were showing. But how many placentae would she have to deal with? It could be as many as three, if the babies had developed from three separate ova. She did not know, and there was no way she could find out.
Ruth knew the risk of post-partum infection and in other circumstances she would have removed all soiled padding from beneath Kathy, washed her, cleaned the vulva with antiseptic, replaced the bedding with clean absorbent sheets and covered her legs with more clean sheeting. She would also have scrubbed her hands thoroughly, and put on sterile gloves. But none of this was possible. She also knew that warmth was essential, because a woman sweats during labour, losing a lot of body heat, and can become cold and shivery. Yet there was only one thin army blanket available.
She shone the torch despairingly around the empty room and saw her coat hanging on the back of the door. That would do. She took it off the hook and covered the girl with it for extra warmth. Kathy’s breathing was deep and regular, her pulse and blood pressure were on the low side, which was a good sign, and her colour was fine. There had been no contractions, and the uterus felt as it should feel.
In those days the management of the third stage of labour was left entirely to nature, and midwives were taught not to meddle or interfere with the process which separates the placenta from the uterine wall and controls bleeding. Today an oxytocic drug may be injected immediately after the baby is born, and a powerful contraction develops, separating the placenta, so that the third stage is over in a few minutes. We did not have that advantage. Patience, experience, observation and masterly inactivity were our guides. We were taught that meddling with the uterus or attempting to hurry the third stage would usually give rise to partial separation of the placenta, causing haemorrhage. We were taught never, never to pull on the cord, and only to knead or massage the fundus after uterine contractions had already developed, and only then if it became absolutely necessary.
Ruth sat quietly beside the bed, her left hand guarding the uterus, which she could clearly feel. The torchlight was growing fainter, so to save the battery she switched it off and sat in total darkness. Twenty-five minutes had passed with no sign of a contraction, and she was beginning to grow anxious. She might have to leave the girl alone while she summoned medical aid. But then she felt a distinct hardening of the uterus, and the fundus rose under her hand. Kathy moaned with pain and moved awkwardly.
‘This is it.’ Ruth stood up, switched on her torch and shook Kathy. ‘Wake up. I want you to push as hard as you can. Wake up and push down. Draw your knees up to your chest so that you can push as hard as possible, as though you were going to open your bowels – go on, push – harder.’