Farewell To The East End

MAVE THE MOTHER

The atmosphere in the delivery room was quiet and cheerful. Sister Bernadette had a presence. She was a young woman of about thirty to thirty-five, deeply religious, and her monastic vocation filled her with happiness. She was also a highly professional nurse and midwife. She radiated control, confidence and calm, which had a soothing effect on any woman with whom she was working. Mave looked quite different. Her martyred air had gone, her eyes were bright, and she seemed excited. Contractions were regular, every ten minutes. Sister had given Mavis a dose of castor oil, and Trixie had shaved her and given her an enema (the required practice in those days).

The doctor returned at 9 p.m. and agreed that he would stay. General practitioners, although they were not trained obstetricians, were the first point of call for a midwife. In fact, a medical student’s training involved 50 per cent clinical experience in hospital under an obstetrician and 50 per cent district midwifery under a midwife. Consequently the general practitioner, unless he had a great deal of experience, frequently knew less about childbirth than the midwife. This could sometimes lead to a strained situation, particularly if the midwife did not trust the doctor’s judgement. But we were fortunate. The Sisters of St Raymund Nonnatus had been practising for so long in the East End of London, with such a good record, that all the local doctors respected their judgement.

Mave was sleeping lightly between contractions, having had a dose of chloral hydrate. At 11 p.m. the waters broke. Sister prepared to do a vaginal examination, but with the next contraction the head was visible. She told Trixie to scrub up and to take the delivery.

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.’

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 it as taut as possible. With sharp episiotomy scissors he then cut the perineum diagonally. Mavis let out a piercing scream, and Meg rushed into the room. Seeing Mavis in a lithotomy position surrounded by blood she yelled, ‘Murder!’ and rushed over to the bed. She attempted to fight the doctor, but Sister pulled her back by the shoulders. Meg turned on her like a tigress and slapped her face so hard that the poor Sister fell against the wall. But she stood up again quickly, her face burning.

‘If you interfere, Mavis will die. There is no alternative. You may not believe it, but we know what we are doing. And we are doing it to save the life of mother and baby.’ She repeated more emphatically: ‘If you interfere, your sister will die.’

Meg stared at her blankly. The shock of Sister’s words reduced her to silence.

‘Now, if you want to help, and I am sure you do, you will hold this gas and air mask over your sister’s face ... keep it firm over her nose and mouth ... turn the knob up to maximum and talk to Mavis quietly, try to keep her calm. This is going to hurt, but you can help a great deal if you do as I say. Mavis needs you. Her life depends on it.’

Meg calmed down. She administered the gas and air. Giving her something to do was the best thing that Sister could have suggested.

Sister Bernadette listened to the foetal heartbeat. It had dropped to sixty beats per minute, and was weak and irregular. The doctor inserted the first blade of the forceps into the vagina, muttering to Trixie, ‘Whatever you do keep her legs in that position. Don’t let her move.’ Trixie, who was trembling and felt sick, put all her weight on the two legs.

‘Sister, the os is still fully dilated, thank God, but the head is above the rim. Can you apply steady pressure on the fundus to try to force the baby down an inch or two? There’s not a moment to lose.’

Sister grasped the fundus with both hands and pressed down as hard as she could. There was a massive spurt of blood and meconium from the vagina, splattering the doctor all over. He hardly noticed it.

‘Quickly. The head is down a little. But more.’

Sister applied more pressure, and a contraction developed.

‘That’s better. It’s coming. Now I can get hold of it.’

The doctor inserted the second blade of the forceps around the head of the baby. Muffled screams were heard from Mavis, behind the gas and air mask, and Meg was looking grim, but held the mask in place.

Slowly, steadily, the doctor pulled the forceps, with Sister applying pressure from above.

‘Keep those legs still,’ muttered Sister to Trixie. ‘She must not move at this stage.’ It took all of Trixie’s strength to prevent Mavis from throwing herself off the bed.

Within half a minute the head was born. The baby’s face had no colour. Sister immediately left the bedside, took a couple of swabs and a fine catheter, and tried to clean the airways, but the baby did not move or attempt to breathe.

The doctor hooked a finger under the presenting shoulder and with one swift movement pulled the baby upwards towards the mother’s abdomen. It was another little girl, completely white and limp. She looked dead.

A mere ninety seconds had elapsed between the first haemorrhage and the birth of the baby, yet Trixie told us later that it had seemed like ninety minutes. Time had stretched unnaturally. Even the steady tick, tick, tick of the clock seemed to slow down, as if time itself were suspended.

The baby was separated from the mother. She was like a rag doll and seemed to be quite dead. Sister carried her near to the fire. The doctor stretched out his hand and touched a tiny arm that swung lifelessly. He looked at Sister.

‘Do what you can,’ he said sadly, ‘we might have to ...’

But there was no time to speculate. There was another spurt of fresh blood, and the cord, which was protruding from the vagina, lengthened.

‘The placenta is coming. Quick, nurse, fetch a kidney dish,’ he said.

Trixie tried to get one, but her legs were shaking and she could not move. The placenta slid out onto the floor.

‘We will examine it later,’ said the doctor, pushing it aside with his foot. ‘First, I must control the haemorrhage.’

Blood continued to seep out, then another spurt of fresh blood. The prognosis for Mavis was not looking good. She was no longer in pain, but was extremely weak and sweating from shock. Meg’s know-all arrogance had burst like a bubble. The speed and drama of events had shaken her. She sat quietly at Mave’s head, stroking her hair, whispering words of love and comfort.

The doctor massaged the uterus vigorously and squeezed out clots by further kneading and fundal pressure. Mavis groaned and weakly moved a leg.

‘I think that is all the residual blood clots. I need to administer intravenous Ergometrine, but I want you, nurse, to exert external bi-manual compression of the uterus while I am preparing the injection. Have you ever done it before?’

Trixie shook her head.

‘This is what you do, then. It will be only for a minute or two, but we cannot allow the uterus to relax. If it does we might get another haemorrhage.’

‘Right, then, stand here ... press the left hand into the abdomen just above the umbilicus, like this. Now, clench your right hand into a fist and press down as far as possible behind the symphysis pubis ... that’s it ... now push the ball of the uterus upwards and compress it between the two hands as hard as you can ... harder ... that’s it. Keep it there.’

The doctor went over to his medical kit to draw up the injection. He returned to the bedside and bound the upper arm tightly in order to inject into a vein at the bend of the elbow. But he could not find a vein. Mavis had lost so much blood that her veins were flat and slippery. He made several attempts with no success. He swore under his breath.

‘Keep that compression going, nurse. Another haemorrhage could be fatal. I must get an intramuscular injection. They take longer to work, but if I can’t get a vein it will have to be an IM.’

Trixie continued exerting bi-manual compression of the uterus. She was feeling sick and faint, but the sight of Mavis looking so ill and the thought of another haemorrhage and its consequences kept her strength up.

The doctor returned and swiftly plunged the needle into Mavis’s thigh. ‘That’ll do the trick.’ Then, to Trixie: ‘I’ll take over now. I want you to go and ring the hospital.’

Meg interrupted. ‘No. I won’ let ’em take ’er.’

The doctor turned on her savagely.

‘Will you be quiet, woman, and stop interfering. If Mavis had gone into hospital, as I advised in the first place six months ago, all this might never have happened.’

Meg held her peace.

Sister Bernadette had carried the baby closer to the fire and had wrapped a roll of soft cotton wool around her. She cleared the airways with a fine mucus catheter. Blood, mucus and meconium were sucked out of the nose, mouth and throat. She held the tongue forwards with fine baby forceps, because if the tongue is without muscle tone and flaccid, it can fall backwards into the throat, blocking the airways. She held the baby completely upside down for a few seconds, and then sucked out the airways again. She turned the baby face downwards and massaged the back from base of spine upwards, then cleared the airways once more. Next she undertook a procedure known as Eve’s Rocking – that is, alternately raising the head and feet of the baby by about forty-five degrees. The baby did not respond. Sister administered mouth to mouth resuscitation by filling her cheeks with air and puffing three puffs into the tiny white lips, then twenty seconds of Eve’s Rocking again, then three more puffs. After about two minutes of this procedure she listened to the baby’s heartbeat.

Her face became radiant. ‘I can hear a faint heartbeat – around eighty per minute. Praise the Lord.’ And she continued her efforts. Suddenly the baby gave a short, convulsive gasp, sucking air into its lungs and then lay quite still again, making no further attempt to breathe. But a baby can take shallow breaths that are almost imperceptible to the observer. Sister could still hear a faint heartbeat, so she continued. A couple of minutes later the baby gave another convulsive gasp, repeated thirty seconds later, and this pattern continued for nearly half an hour, during which time the heartbeat increased to a healthy 120 per minute.

Sister Bernadette had no drugs, no oxygen, no incubator or modern equipment for resuscitating an infant with asphyxia pallida. She had only the methods described above, and the baby did not die.

The intramuscular injection of Ergometrine given to Mave by the doctor worked within five minutes. The uterus contracted into a firm hard ball, and all fears of further haemorrhage were removed. Mavis looked terribly ill, however. Her skin was white, cold and clammy, caused by pain and blood loss. She was in a state of obstetric shock, but her condition was stable. Sleep would benefit her, so the doctor gave an injection of morphine, which he could not have done while the baby was in utero. She dozed off in Meg’s arms.

The doctor prepared for suturing. There was now no hurry, so he gave Mavis a local anaesthetic around the perineum and the vaginal wall, and sat back, waiting for it to take effect. Once the local anaesthetic had numbed the perineum, the doctor was able to repair the episiotomy. He was relieved to find that the cervix was not torn.

Meanwhile Trixie was down the road ringing the Flying Squad. She had taken off her gown and cap but had forgotten to take off her mask. There was blood on her hands and arms, and smeared down her uniform and legs. As she ran down the road she did not notice that people were looking at her rather strangely. It was not until she was inside the telephone box that she realised she did not have the three pennies on her with which to make a telephone call, so she stopped a passer-by. ‘Can you let me have threepence for an urgent telephone call?’ Only then did she notice the mask, so she pulled it off. Her hand was trembling, and she noticed the blood on it for the first time.

‘I must have threepence. I forgot to bring it. I must ring the hospital.’ Trixie’s voice was shrill. Dubiously the man dug into his pocket and produced three pennies. ‘Thanks.’ She dived into the box, but her hand was shaking so much that she could not dial the number or put the pennies in the slot, so she called the man back.

‘You’re in a bad way, nurse,’ he said.

Trixie felt too weak to answer, so she merely handed him a bit of paper.

‘Ring that number for me, please.’

The phone rang, and a voice answered immediately. Briefly Trixie explained the situation and gave the address. ‘We will send the Flying Squad immediately,’ the voice said.

‘Do you need any help getting back to the house?’ asked the man kindly.

‘I’ll be all right. Thanks for your help.’

When Trixie returned to the house, Meg was shouting at the doctor and Sister.

‘You murderers! Look wha’ you done. You’ve hurt ’er. I’ll report you to ve authorities, I will. Look at ve blood. You nearly killed ’er, you did.’

The doctor tried to defend himself

‘The placenta separated prematurely. That was the cause of the blood loss. I did not cause it.’

‘Liar! Tell vat to the judge. Medical blunderers.’

She turned on Sister. ‘An’ you, yer no better. You’ll kill vat baby afore you’re finished. An’ it’ll be your fault if she dies. I’ll not forget vis, I’ll not.’

Bewildered, the doctor looked at Sister.

‘Can you explain?’ he asked plaintively.

‘I doubt it,’ said Sister wearily. Her eye was swelling up, from the blow she had received from Meg. ‘We’ve been trying for six months with no success. I doubt if any explanation will get through.’

‘I’ll not forget vis. You jest wait. You’ll pay fer vis an’ all, the pair of you.’ Meg rolled her eyes and spat on the floor.

The Obstetric Flying Squad arrived. This was an emergency service held in readiness by all big hospitals for the support of domiciliary midwives. It was their proud boast that they could get to any emergency in twenty minutes, and they seldom failed to do so. An obstetrician, a paediatrician, and a nurse came, armed with an incubator, oxygen, drip, drugs, anaesthetics and all the other equipment used for obstetric surgery and infant resuscitation. They entered a small, hot and stuffy room that looked like a battle scene. Blood was literally everywhere. The doctor, covered in blood, was suturing the patient. The placenta still lay on the floor. Sister Bernadette, who was tending the baby, looked as though she had been in the front line. The skin around her eye was now blue, her face red and swollen, and her veil streaked with blood. A weird-looking woman in green glared at the hospital team with accusing eyes. ‘More murderers. I’ll see you don’t get ’er,’ she hissed venomously.

The doctor and the obstetrician consulted. Mavis was sleeping peacefully because of the morphine given half an hour earlier by the doctor. But she had lost a lot of blood, and the shock was severe. An intravenous infusion of blood plasma by drip was installed.

The placenta was scooped up off the floor, and the two doctors examined it. It was large, but appeared to be complete. The consultant palpated the woman’s abdomen. The uterus was firm and hard, about the size of a grapefruit, as it should be. He looked around the small, stuffy room that contained not a vestige of clinical apparatus; at the woman in a state of primary obstetric shock; at the volume of blood loss; at the first baby sleeping peacefully in the crib; at Sister Bernadette tending the asphyxiated twin.

‘In circumstances like these, undiagnosed twins, a transverse lie, premature separation of the placenta and haemorrhage could spell certain death. You have done really well, old chap.’

‘Thanks,’ said the doctor wearily. He seemed to be in a state of exhaustion. ‘We do our best.’

‘You done yer best!’ shouted Meg. ‘You wants lockin’ up, I say. If you’d done like what I said an’ put ’er on a birfin’ stool in ve first place, vis would never ’ave ’appened.’

The consultant looked at Meg in astonishment.

‘Take no notice, we’ve had this the whole time,’ whispered the doctor. ‘Nothing will convince her.’

The nurse took the baby from Sister Bernadette and placed the child in the incubator, warmed to 95 degrees F, and humidified to avoid drying of the respiratory mucous membranes. The baby was breathing, but her breaths were shallow. Her muscle tone was flaccid, and her skin tone bluish. Her heartbeat was regular, but faint. The paediatrician, after examining the baby, injected 1 cc of Lobeline into the umbilical vein in the cord and milked it towards the abdomen. Oxygen was attached to the incubator, and the oxygen input adjusted to 30 per cent.

The paediatrician advised immediate transfer to Great Ormond Street Hospital. Paradoxically, Meg, who had so violently opposed hospital for Mavis, did not object. The baby was kept in Great Ormond Street for six weeks until her weight was over five pounds, and then she returned home. Both babies thrived. They grew up to be strong, healthy girls, brought up entirely by their mother and aunt. They were a regular sight in Chrisp Street market, helping on the fruit and veg stall, and they became great favourites with the locals.

Thirty years later I was visiting Trixie, who had recently moved to Basildon in Essex. We went shopping, and she insisted we call at the market. It was a large and lively market, with open stalls and old-fashioned costers crying out their wares. I heard the strident voice of a woman calling out, ‘Best apples, only thirty pence a pound. You won’t find cheaper anywhere. Best bananas. Melons. Grapefruits.’

We approached the stall.

‘Well? Wha’choo want?’ demanded the female.

I gasped, staring at two identical women in drab brown dresses, leather belts at the waist, men’s boots, and tight headscarves pulled down low over the forehead. I could not speak.

‘If you don’t know wha’choo want, I can’t hang about. Next.’

The years rolled back. ‘Megan’mave,’ I exclaimed.

‘What?’ The two women drew together. Black eyes flashed a challenge.

‘Megan’mave! But you can’t be – it’s not possible!’

‘Mave’s our mum, an’ Meg’s our aunt. D’you wanna make somefink of it?’

No, I didn’t. Trixie grinned at me, and we slipped quietly away, chuckling.