Ep803 - Susannah's Twins

A Very Special Delivery

NOTE: These discussions presume you have seen the episode listed above, and there are also brief mentions of events in episodes from seasons 1 and 2 and a single detail from Ep805 that’s not really a spoiler. If you haven’t seen these episodes, be forewarned: there be spoilers here!

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire at work in her garden at the New House. (right) Agnes Whitaker comes to fetch her.

In episode 803, Abies Fraseri, Claire is happily digging in her garden at the New House on Fraser’s Ridge when a young girl, Agnes Whitaker, approaches her asking if she’s the healer. Claire confirms that she is and asks the girl if she’s hurt?

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire arrives with Agnes to the wagon where Susannah lies in labor with the midwife Binta.

No, she replies, it’s her mother, who is with child and needs help. Claire goes with Agnes to where the woman, Susannah, lies in the bed of a wagon nearby in the agonies of labor.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire palpates Susannah’s belly (left) then listens for the baby’s heartbeat (center and right) with her wooden stethoscope.

Claire takes the woman back to her surgery and examines her, listening with her beautiful wooden Pinard stethoscope and then palpating her pregnant belly. Binta, the midwife who came with Susannah, tells Claire she has helped dozens of babies into the world, but something is wrong. ‘I think him stuck,’ she says with her beautiful island lilt. ‘What is it?’ Susannah fearfully pants out.

Credit: Outlander Ep803 - Abies Fraseri. Claire tells Susannah she carries twins (left). ‘Are you sure?’ she asks. At right Claire helps her feel the two different babies.

‘Twins,’ Claire adds, looking up with a smile, proving the point to a doubting Susannah by taking her hand and helping her feel one baby’s head and the other one’s back. ‘The babies are stuck on each other. And one is keeping the other one from making its way through.’

What’s correct here, and what’s not?

The first odd thing I noticed was Susannah’s belly size. (See photos above.)

She’s a tiny woman, and as such, I would have expected with so little abdominal/pelvic room to house two babies that her belly would have been considerably larger, unless the babies were very small, which is often the case with twins. The mother’s belly isn’t always extra large with twins, of course, but more typically so.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire and Binta help Susannah walk, which doesn’t totally relieve her discomfort (center). At right, her husband arrives to take her home, not risking trusting a white healer, but relents and lets Claire help her.

Then, when the labor can’t progress, Claire and Binta get Susannah to her feet and start walking, hoping, she tells them, to encourage the babies to move and reposition themselves. Walking to facilitate labor is an age old remedy and although it would seem to make sense that moving about would help, and walking can sometimes make the mother feel more comfortable, I was surprised that I couldn’t find any verifiable medical research that in a situation like this, with one baby impeding the other, walking would do any good to ‘unlock’ the babies’ positions. I supposed it couldn’t hurt, but at least according to the medical literature, it isn’t probably going to help.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire struggles at left to deliver the first twin. At right we see her reach for her scissors to cut the cord. Note there are two ligatures on the tray.

But in this case, it works, and at last the babies apparently shift enough that the first is able to move. Between Susannah’s pushing and Claire’s encouragement her first twin, a baby boy, enters the world. He cries immediately and lustily, and Claire snips the cord without tying it first, which she never seems to do, and which if left undone puts the baby at risk of bleeding profusely through the cut cord.

Note in the image above there are two black ligatures (coils of suture) still waiting on the tray to be used to tie the cord when Claire reaches for the scissors. To be fair, maybe she already tied the cord in two places with two other ligatures and was preparing to snip between the ties and we just didn’t see it. Leaving the other two ties for the second twin. (This would be good technique, but at least tying off the cord once on the baby side of things is critical.)

Credit: STARZ Outlander Ep803 - Abies Fraseri. Susannah holds her newborn first twin. Note he’s pretty robust for a twin in the 18th Century.

Then she swaddles him and hands him to his mother.

For a twin, he’s an unusually large baby. I’d guess at least 8 or 9 pounds, which would be about twice the typical weight for a twin, even nowadays.

I know we have to make allowances because there are all manner of rules about working with infants and kids in film and tv, and I wondered at first if might be because of age restriction on infant actors — for instance, in America they have to be at least 15 days old. But when I looked up the rules in Scotland (where Outlander is filmed) there is no such prohibition. They can work from day one, so it would seem they could have found infant actors of a more realistic newborn twin size, but perhaps not, and to be fair that’s a pretty insignificant quibble that doesn’t affect the storyline. It’s just an observation.

The bigger story is that the second twin is malpositioned; it’s breech – head up, butt down – and something has to be done to facilitate its arrival. Usually that something is a maneuver called internal podalic version, which involves reaching inside the vaginal canal and through the cervical canal, right up into the uterus, locating the baby’s feet, and pulling the child through by its heels and ankles. And this is what Claire did.

Credit: STARZ Outlander Ep803 Abies Fraseri. Claire struggles to get the feet of the breech twin through safely.

She even tells Susannah, who is weak and weary from the labor, ‘I have the feet. I’m going to help you.’ (And if we harken back to season 1, it’s also what she did to help Jamie’s sister, Jenny, deliver wee Maggie Murray, discussed here, which at the time by her own admission was Claire’s first experience delivering a baby (having been a combat nurse in WWII where she’d have not had much call for delivering babies) let alone handling a breech birth. But in typical undaunted Claire fashion, she rolled up her sleeves and did it.)

This complicated delivery would present difficulty for a veteran obstetrician in a modern Labor & Delivery suite, let alone someone trained as a general surgeon who’s doing it in a rustic home in the 18^th Century Carolina back country. A lot can go wrong here, and time is of the essence, because once the first twin is out, the cervix can begin to contract, which greatly increases the risk for head entrapment, cord compression, hypoxia, and fetal distress (or worst of all death) in the second twin.

The extraction itself has to be done with speed, but cautious speed, as well as with great care, putting just enough traction on the feet to bring them, the legs, and the breech (butt) smoothly through the birth canal, and then with both hands inside the vaginal canal and cervical opening, one hand supports the baby’s body while the fingertips of the other press on the back of its head to keep the head tilted forward slightly, guiding it out as it’s coming through the cervical canal so that it doesn’t become trapped by the contracting cervix.

Too much traction too quickly can result in fracturing a limb, dislocating a joint, or permanently damaging the nerves of the brachial plexus in the neck, leaving one arm stunted and crippled as the child grows. Not tipping the head properly can result in the cervix closing around the neck and trapping the baby’s head , which could cause anoxic brain damage or even prove fatal. As I say, there’s a lot that can go wrong here.

In a modern Labor & Delivery unit, these procedures would be done under anesthesia, and if the podical version and breech extraction failed, emergency Caesarean section would be the next step. (To be honest, nowadays, many OB docs would opt to go straight to emergency C-section, a procedure done too freely IMHO, but that’s just me.)

Poor Susannah didn’t have the benefit of any sort of anesthetic or other pain relief, and I’m not sure what Claire would have done in her surgery at the Ridge had she not been able to guide the baby safely through, but somehow, she did, so whew! And poor tiny Susannah somehow survived it all with a smile on her face.

The last time the issue of doing a Caesarean came up, discussed here, when Marsali struggled to deliver wee Henri Christian, Claire told Jamie she might be able to do a C-section to save the baby but likely would lose the mother. I doubt much has changed in the few years since then.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Claire vigorously rubs the unresponsive twin trying to get it to take a breath.

Unfortunately, when the baby is finally delivered, it had already been stressed sufficiently (hypoxia maybe from being hung up for an extended period on its sibling) that it doesn’t breathe or cry spontaneously or even with vigorous stimulation. It appears to have been still born.

Credit: STARZ Outlander Ep803 - Abies Fraseri. (Clockwise) The second twin lies inert on Claire’s table and Claire grieves that she couldn’t revive the baby. Claire performs rescue breathing and chest compressions on the baby (which I’ll note looks appropriately smaller, but that’s because it is probably a prop, not an actual baby.)

Claire performs CPR on the baby with chest compressions and rescue breathing (and does a credible of job of doing it properly) but the infant still doesn’t respond.

Credit: STARZ Outlander Ep803 - Abies Fraseri. (L to R) Claire holds the inert baby, channels the memory of the blue light and the heron from Faith’s birth, and we see a pale blue light wash over the baby.

Claire is crushed, and Jamie tries to take the baby from her, but she refuses. She cradles the baby in her arms, thinking of her own lost Faith, and later tells Jamie that from within her she felt a pale blue light seep from her fingertips into the infant girl’s body, felt the tiny heart begin to beat again, and the baby roused and cried.

Credit: STARZ Outlander Ep803 - Abies Fraseri. (L to R) The baby revives, smiles, moves, and cries. Claire is astonished herself that the baby is alive. Biinta and Susannah hold the newborn twins.

In episode 207 (Faith), we saw Master Raymond heal Claire from puerperal fever after Faith was born, and she tells Jamie he ran his hands over her, and she felt a pale blue light originating in her bones, radiating out, and traveling through her body, burning the infection out of her. She believes this same blue light power is what brought the Whitaker baby back to life. Seems fantastical, but this is an historic romantic fantasy, after all, so we can happily submit to the validity of the healing power of a magical blue light, and I’m perfectly OK with that from a viewer’s perspective.

But is a super power required? Could there be another medically valid explanation?

The short answer to that is ‘yes’. As I wrote in more detail here in a discussion about whether it was medically possible for Faith to have survived (which we learned in the opening scenes of season 8 — to the everlasting consternation of book-canon devotees in the Outlander fandom — was apparently the case in the series at least) there are numerous reports in the medical literature of newborns, toddlers, and even adults being pronounced dead – having no detectable vital signs – and being found alive and breathing in the morgue hours later. The most credible medical reason is clinical misdiagnosis of the presumptive ‘death’ because of inability to detect weak vitals. There’s apparently dead, and there’s really most sincerely dead.

Especially in a premature or distressed newborn, which (despite the unusually large size of these twins) is what we surely are dealing with here, the infant’s breathing may be so shallow and the heartbeat so faint that they simply aren’t detected at first. And premature babies are often hypotonic (not a lot of muscle tone) and so all visible signs — no pulse, no respirations, no movement, no crying — point to their being dead. Then over time the heartbeat and respirations strengthen.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Lacking a mirror at the New House, Claire asks Jamie ‘what color is my hair?’ And he responds, ‘it’s all the colors of the earth. Except here, around your face, it is the color of moonlight.’

That’s not nearly as enthralling a storyline as a heroine who develops the powerful medicine the Cherokee medicine woman Adawehi predicted she would (in Ep404, Common Ground) when her hair turned white, which, I’ll note in this episode it has begun to do. This miraculous revival is easily explained by blue light magic, but just know it could also be explained medically. And on that score, you may take your pick.

What was left out?

What we don’t see here (and must assume Claire got back to after handing the revived baby to Jamie) was delivering the placentas after the second baby was safely out. With fraternal twins (i.e., developing from two separate eggs) there would usually be two placentas, though they sometimes fuse into one larger mass. Delay in delivering the after birth raises the risk of postpartum infection and hemorrhage from a uterus that can’t promptly and properly contract, especially so in the case of a twin birth that distends the uterus tremendously and following a hard, protracted labor that exhausts the uterine muscle. So, Claire would have gotten with the program quickly on that. Or maybe Binta stepped in to help there. She’s a midwife and would know what to do.

And, to help the tired uterus contract, Claire might also have given Susannah a tonic or tea of one of the common botanicals employed for such ‘woman issue’ purposes in Revolutionary era America, such as raspberry leaf or motherwort (Leonurus cardiaca, a mint family herb) that help increase uterine tone. They’re not as potent as modern uterotonics, such as oxytocin, ergot alkaloids, or misoprostol, but they would have been all she had to work with. And they’d likely have helped some.

Credit: STARZ Outlander Ep803 - Abies Fraseri. Cleaning up after, Claire tells Jamie that she doesn’t have any reasonable explanation for what happened with the baby. He asks her to give him ‘one that isna reasonable then.’

We don’t see any of that, because once the second twin is revived the episode skips forward to Jamie and Claire alone, cleaning things up afterward, suggesting to us that Binta and the Whitakers have gone home with the two new babies, and from that we can assume everything went well. Then we later learn (in Ep805, Send for the Devil) when Aaron Whitaker comes to tip Jamie off about a danger that he felt he owed Jamie a favor in return for what Claire did for him and his family, giving us a bit more evidence that Susannah and both babies are well.

Chalk another one up for Claire’s incredible skill!

Overall Medical Verity Score: This is another of those episodes that’s hard to score in some ways, because it involves both medicine and magic surrounding the same event, the latter of which I’m not qualified to address, but then who is?

I’ll give the scene an A for Claire’s making the correct diagnosis and doing the correct procedures in handling a harrowing, difficult delivery successfully. (Although, as I said, a typical general surgeon wouldn’t likely have that degree of obstetrical skill, but then Claire’s never been typical, and besides who knows how many difficult deliveries she might have been called on to performed throughout her years in the past that we didn’t witness.)

And here’s an A as well for the correct CPR effort (and perhaps it was actually a delayed successful one and what actually brought the baby around).

But I’ll give the tiniest ding to medical authenticity because tiny Susannah ought to have had a fake pregnant belly about twice as big to carry a set of twins, even typical 4 to 6 pounders, let alone these robust infants. But that’s just me being overly nitpicky of a tremendously engaging, exciting story. We got from the storyline what we needed: Susannah was pregnant with twins and in trouble; Claire stepped in to help her, successfully; and the potency of Claire’s medical wisdom and blue light healing power is growing. As a viewer, I’m good with all of that. (And as those who’ve seen the entire series know, she’s going to need all that white hair and a lot more before it’s over.)