Title: General Precepts on the Operations of Childbirth

Artist: José Ventura Pastor

Year: 1789-90

Medium: Illustration

Elizabeth continued her weekly appointments at the Downton antenatal clinic well into the summer and each time she left the appointment visibly exhausted and entirely silent. Her most recent appointment had been filled with an extra dose of tension after the midwife had excitedly informed her that the baby would be with them sooner rather than later signaling that it was nearly time for Elizabeth to head to the maternity home in York.

Once they'd gotten home Elizabeth had made a beeline up to her bedroom and she hadn't been seen since. Phyllis and Joseph left her alone for most of the day but eventually it was time to try to convince her to eat something.

Phyllis knocked at the door several times before opening it and softly announcing, "I brought you supper."

Elizabeth's body was well-concealed beneath her bedding leaving only her face exposed, but she didn't look towards her mother at all as she mumbled back her reply. "Not hungry."

"Alright." Phyllis masked her frustration at her daughter's recent aversion to food as she placed the plate on the chest of drawers before crossing over to Elizabeth's bed where she gently pushed her fringe from her face. "How are you feeling?"

Elizabeth immediately shifted herself towards the wall to make space for her mother next to her. "Nervous."

"That's normal." Phyllis assured her as she sat in the offered space. "Do you want to talk about it?"

"Not really." Elizabeth replied quietly, still refusing to make eye contact.

Phyllis nodded as she pulled her daughter into a gentle hug, more than content to just sit with her to make sure she knew she wasn't alone. However, despite her claim, Elizabeth couldn't help the words that started to fall from her mouth.

"It's only that I don't want to be away from home." Elizabeth admitted sheepishly. "And honestly I'm not all that keen on staying in that room full of women who want their babies."

Phyllis sighed sympathetically as she tightened her arms around her daughter. "Oh, my darling. I'm so sorry for the position you've been put in. It's not fair in the slightest."

Elizabeth moaned miserably in agreement before continuing her confessions. "Also I'm not entirely sure any of this is going to work."

"What do you mean by that?" Phyllis asked with slightly narrowed eyes.

"Look at this." Emma cried exasperatedly as she pointed to her large stomach. "All of this is supposed to come out of me? It hurt when that man put that tiny thing inside and I'm supposed to put a baby through there?"

Phyllis had to stifle a smirk at the likely unintentional slight her daughter's last statement delivered as she tried to focus on comforting her obviously anxious daughter. "I can't promise you it will be easy." She admitted honestly. "In fact, what you've been through might make things more difficult. But I can tell you that when I was waiting for your sister to be born I was afraid of exactly that."

"Really?" Elizabeth's eyes widened in surprise.

Phyllis nodded sadly. "I don't know how much you've learned about when Emma was born, but I actually delivered her alone."

"What?" Elizabeth shook her head in disagreement. "That doesn't even make sense. You were in pris…"

"It's alright to say it." Phyllis gently reassured her daughter. "I'm not ashamed of what happened to me. It's the truth. And you're not wrong, it shouldn't have happened the way it did. I was in the infirmary alone which as far as I know is a distinct improbability."

"How did you do it?" Elizabeth asked earnestly, desperate for some sort of answer on how she was going to survive her upcoming task.

"I know this may sound silly, but I just wanted Emma to be okay." Phyllis explained softly. "I obviously didn't know she was Emma then, but I just needed to do my best for my baby. It was important to me that regardless of how much I resented the circumstances of their creation, that I did everything I could to get them to this world safely."

Elizabeth stared blankly across the room before nodding in agreement. "I want that too."

Phyllis gave Elizabeth's shoulder an encouraging squeeze. "You've done everything you can to make sure you're well-supported in doing exactly that. You and this baby are in good hands."

Elizabeth awkwardly wiped at the tears that had spread across her cheeks as she managed a quiet, "Thank you."

"Of course. Phyllis assured her easily. "You deserve nothing less."

Elizabeth shook her head. "It's not only about helping this baby. You and Dad have supported me through things most parents would have disowned me for. You've told me over and over that this isn't my fault and it's the only thing that's kept me sane." Her rambled explanation broke off for a brief sob as she began gasping through her words. "You stopped me from getting myself killed that day you found me…"

"I'd do it all again in a heartbeat." Phyllis stopped her gently. "You deserve to be believed about what happened to you and feel loved not despite your experience but because you will always be worthy of it."

Elizabeth snuggled firmly against her mother's chest as she gave a heavy sigh of what her mother hoped was relief. The pair lay in comfortable silence for some time before Elizabeth sleepily asked, "Will you stay with me tonight?"

"Of course." Phyllis agreed easily as she pulled down the quilt from beneath herself to join her daughter in her bed. "You just focus on getting some rest, alright?"

When she didn't get a response, she shifted herself slowly so she could see Elizabeth's face which thankfully showed that her daughter was already fast asleep.

The next morning brought the final Saturday before Elizabeth's planned departure to York and Johnny Bates's weekly visit. Phyllis had left early that morning to meet with Beatrice at the maternity home to ensure that everything was ready for both Elizabeth's care and the baby's adoption which left Joseph at home alone with Elizabeth and Johnny.

"I've made some sandwiches and left them in the larder." He announced late that afternoon after neither of them had left the sitting room for lunch."You both help yourselves whenever you'd like, alright?"

Elizabeth blanched slightly at the mention of food but lifted her unoccupied hand up to offer a thumbs up in response.

"Darling, are you sure you're feeling alright?" Joseph asked for what must have been the tenth time that afternoon as he began to approach his daughter tentatively. "Can I do anything for you?"

"I'm fine." Elizabeth insisted exasperatedly as she kept her focus on carefully stroking Pepper's ears in the right way to elicit more purrs from the kitten. "Just because I'm the size of a bloody house–"

"Alright." Joseph held up his hands in surrender. "I'll be in the study working on revision tables, but if either of you need anything just holler."

Though Elizabeth continued to ignore him Johnny nodded in thanks. "Thank you, Mr. Molesley."

"Joseph." The older man reminded him with a smile before ducking out of the sitting room and heading through the kitchen to the small bedroom that was home to a large portion of his library.

Johnny waited for about half a minute before hopefully asking, "Do you want a sandwich?"

"Absolutely not." Elizabeth stated immediately, pulling a face of disgust in response.

Johnny nodded in understanding, waiting another minute before his next query. "Can I eat a sandwich?"

Elizabeth sighed dramatically. "If you do it in the kitchen where I can't smell it, I suppose I'll allow it."

Johnny gave a wide grin as he got up from the settee and he was almost out of the room when Elizabeth let out a sharp groan.

"Oooooh." Elizabeth groaned as she moved Pepper from her lap.

Johnny turned around immediately. "Hey, are you–?"

"I just need the loo." Elizabeth stopped him tersely, tired of being questioned every time she expressed the constant discomfort she'd been experiencing for weeks. "Can you help me up?"

Johnny did as she asked before making his way to the kitchen in search of the aforementioned food on offer.

He was halfway through his second sandwich when he heard Elizabeth call out his name from the washroom next door. "Johnny!"

"You stuck or something?" He joked as he approached the bathroom door in confusion. "What do you need?"

"I need my Dad." Elizabeth replied quietly.

Her tone immediately set Johnny on edge. "Is everything alright?"

"Just…" Elizabeth trailed off into a brief silence before whimpering, "Get my Dad. Please."

He immediately sprinted down the corridor to the open door of Joseph's study where he found the man engrossed in several books that were splayed across his desk. "Mr. Molesley?"

"Johnny." Joseph immediately turned his attention to the younger man. "Do you need something?"

"Lizzie's in the toilet and she's asking for you." Johnny explained quickly. "She sounds scared."

Joseph was out of his study in an instant, racing to the other end of the hall to the closed bathroom door that he quickly began to knock on. "Lizzie." Joseph called through the door nervously. "I'm right here, darling. What do you need?"

"I think…" Elizabeth's voice was obviously shaking before it trailed off into a scream.

Joseph instantly reached for the doorknob, thankful to find it unlocked as he wasn't sure what he would've done if he'd needed her help to get in as he took in the sight of his daughter sitting on a toilet seat that was absolutely covered in blood as she dug her fingernails into her thighs in an obvious attempt to manage an overwhelming amount of pain.

"That's a lot of blood." Johnny whispered as he watched from the corridor as Joseph quickly moved in front of his daughter to try to get her to communicate with him.

"Lizabet." Joseph pressed firmly as he reached up to her cheek to get his attention, waiting until he was sure he was holding her shaking gaze before asking, "What do you feel?"

"Pain." Elizabeth choked out as she bent forward. "On top of pain, on top of pain."

"Okay." Joseph nodded in understanding. "Do you want to stay here, or move?"

"Move." Elizabeth replied immediately. "Too hard."

Joseph nodded, quickly wrapping his arms beneath her back and legs before lifting her from the toilet and rushing her into the sitting room."Johnny go to the phone and call the number on the pad beneath the receiver for the York maternity home." He instructed firmly as he did his best to read his daughter's non-verbal cues about how to make her most comfortable. "Tell the receptionist you need to speak with Mrs. Molesley or Nurse Ellis urgently and come get me when you've got one of them on the line."

"Lizze, how long have you been feeling pains?" Joseph asked gently once Johnny had rushed from the room.

"I don't know." Elizabeth admitted anxiously. "I really just thought I needed the loo."

Joseph nodded in understanding, offering her his hand as she bent forward with a groan as another pain overtook her body.

Johnny returned out of breath just as the contraction was ending with more fear in his eyes than he'd had when he left. "They said they'd just left."

Joseph clenched his jaw as he tried not to panic. He didn't know enough about childbirth to help his daughter through this alone in the best of circumstances and these were clearly far from ideal. As he wracked his brain for anything that might help him decide how to proceed he looked up at the clock and bobbed his head in recognition. "Johnny, you stay with her and hold her hand, you hear me? She is not going to be alone. You don't leave her alone."

Johnny nodded seriously. Offering a nervous, "Yes, sir." as he moved to take over holding Elizabeth's hand while her father raced out the front door.

Joseph had walked as quickly as he could towards the Downton Hospital, hoping that he had remembered things correctly until he eventually sent up a silent prayer of thanks as he saw who he was looking for in the distance. He broke into a sprint in her direction as he called out in an attempt to catch her before she turned the corner, "Emma!"

Emma looked up in obvious surprise, turning around to see her father running toward her after months without contact with him was extremely disorienting and she found herself questioning her sight. "Dad?"

"It's Elizabeth." Joseph explained hurriedly as he arrived at her side. "She needs help. Now."

Emma immediately froze and began stuttering an excuse, "I… I can't–"

"Emma, I don't give a shit about what's been said between you two." Joseph stopped her angrily. "I need you to come help me keep your sister alive."

Emma nodded slowly, her mind slightly hazy at the mention of her little sister possibly dying, and when her father took her hand she didn't question him as he dragged her back to the cottage as fast as he could manage.

She wasn't sure exactly what she was expecting to see when they arrived, but it certainly involved her mother at her sister's side in a comfortable bed rather than where she found her sister on her knees, bent over the back of the sitting room sofa, with Johnny Bates of all people at her side.

"Lizzie, I'm back." Joseph comforted his youngest daughter immediately as he slid his hands into hers to give her something to hold onto. "I'm right here and your sister's with me to take care of you. Tell Emma what hurts."

Elizabeth cried out sharply in response for some time before eventually managing to moan, "Everything."

"Where's Mum?" Emma asked as she hastily pulled her hair up and away from her face before carefully kneeling just behind her sister to offer her support in her current position.

"She's in York." Joseph explained quickly. "She and Beatrice were meeting with the maternity home to finalize plans for the baby's birth and adoption. We called a few minutes ago but they'd already left."

"Okay." Emma nodded in understanding, while she looked around the room for any signs of what may have already happened before giving up and asking, "What do you know?"

"There's been a lot of blood." Joseph replied immediately as he motioned towards the dark red stain across the settee cushions. "There was more in the toilet."

Emma nodded once again, doing her best to assess the situation before she stopped suddenly as she stared across the room in confusion."When did you get a cat?"

"Emma!" Joseph cried back in disbelief. "What do we do?"

"Sorry." She shook her head in an attempt to refocus. "Just let me think for a minute."

It wasn't until Elizabeth cried out again, this time falling backwards into Emma's chest that Emma snapped into action. "Johnny, I need you to go to my house and get Sybbie." She directed firmly. "You'll need to stay with the twins. Can you do that?"

Johnny nodded earnestly. "I've got plenty of experience with Annabeth's kids."

"Tell her that I think she may have had a placental abruption and that the head is already engaged." Emma dictated quickly. "That last part is important. We don't have time to move her and I need supplies."

"There's a birth kit in Lizzie's room." Joseph interjected suddenly at the same time that Johnny asked, "Supplies?"

"She has antenatal supplies that I don't carry in her kit." Emma hurriedly explained as she began rifling through her own bag that had been abandoned at her feet when she'd arrived. When both men continued staring at her, seemingly waiting for instructions she let out a groan of disbelief. "What are you two doing here? Go get the supplies!"

Within a moment Joseph was up the stairs and Johnny was about to open the door when Emma called out for him once more. "Johnny!"

"Yes?" His head poked around the wall between the sitting room and foyer with a confused expression on his face.

"Whiskey." Emma added with a nervous edge to her additional instruction. "She's going to need… just tell her to bring the whiskey."

By the time Sybbie arrived twenty minutes later Elizabeth's labor had progressed considerably and she opened the door to the Molesley cottage to the sound of a desperate scream and the sight of Elizabeth laid across the sitting room floor, propped up against several bloodied cushions.

"How long has she been like this?" Sybbie asked as she joined her wife at her sister-in-law's side.

"Since before Dad got me." Emma replied quietly. "I don't know if she's going to–"

"Stop." Sybbie cut her off as she quickly tied her apron around her waist. "We're not going down that road. It's not an option. You understand me?"

Emma nodded nervously before following her wife in turning her attention back over to her sister and explaining everything she knew. "The head is engaged but she's not fully dilated. If she pushes now she'll tear more than she already has."

Sybbie's eyes widened even further in concern. "Has she tried to push?"

"No." Emma assured her. "I think she's just… fragile."

"Alright, Lizzie?" Sybbie did her best to get Elizabeth's attention through her cries. "I need to do a brief examination of your vaginal opening to see what I can do to help you and baby. Is that alright?"

Elizabeth cried out tiredly but managed a clear nod as she squirmed through a contraction.

"I'm going to tell you everything I'm doing." Sybbie assured her gently as she placed her hands softly on Elizabeth's thighs. "Emma and your Dad are going to help me by holding your feet up so I can examine you. None of us are going to hurt you."

Emma and Joseph quickly followed directions, each taking one of Elizabeth's feet while Emma quickly gave her father instructions on how to properly achieve the needed lithotomy position to give Sybbie the best workspace.

"Alright, Lizzie." Sybbie spoke quietly as she moved closer to assess her. "I can see baby's head, and I'm sure it's causing you a lot of pain from that pressure, but your sister is right that you're not ready to push. I'm going to press along the edges of your vulva - that's the tissue around your vaginal opening - to see if I can learn anything else."

Emma waited silently for several moments as she watched her wife before softly asking, "The tear?"

"There is scarred tissue everywhere." Sybbie whispered back nervously. "I think it's from…"

"It is." Emma confirmed icily. "It's from a knife."

Their conversation ended abruptly when Elizabeth screamed once again

"Alright, let's get you as comfortable as we can." Sybbie directed quickly as she stood to grab the supplies she'd brought with her. "I know this isn't going to sound very appealing, but I've brought some alcohol and I'm going to need you to try to drink as much as you can."

Elizabeth shook her head miserably as she watched Emma pour the brown liquid into a glass. "It's going to give you some pain relief." Emma explained gently as she crouched down next to her sister. "We're not going to be able to move you so this is the best we've got on that front. I'm so sorry."

"She's right." Joseph seconded their advice. "The alcohol will give you some pain relief."

Eventually Elizabeth nodded and Emma gently tipped the glass into her mouth until she choked harshly on the liquid as a pain took over and she shouted out, "I can't do it!"

"Hey, Lizzie, look at me." Emma demanded firmly. "You are going to be just fine."

"I don't want to die." Elizabeth continued to shake her head in distress.

"I know." Emma assured her confidently. "We've got you. We're going to make this happen, okay?"

Elizabeth's pain waned as the alcohol flooded her system and they took the brief reprieve to prepare everyone in the room for the impending delivery and by the time Elizabeth started squirming in pain again Sybbie and Emma were thankful that her body was finally ready to push. It took some lengthy negotiations with everyone else in the room before Elizabeth agreed to give pushing a try but eventually they fell into a pattern of pushing and comfort that was thankfully yielding results.

"Just a few more pushes and we'll be done with the brunt of it." Sybbie added, her tone a schooled patience honed by years of deliveries in Downton Hospital. "If you can manage it, I want you to take a deep breath in and start pushing hard."

Elizabeth let out a ragged sob as she asked, "At the next pain?"

"No, my love." Sybbie shook her head sympathetically. "Baby and you need this delivery over with as soon as possible. I won't lie to you, it's going to hurt, but baby's head is right here and as soon as I can get my hand in to help it along, we're going to get it out, okay?"

Elizabeth wanted to protest but instead she simply let out a scream of pain as she did her best to follow the instructions she'd been given before collapsing back against her father again and bursting into tears. "I can't do it."

"You can." Emma argued back as she grabbed the bottle of whiskey once more. "You are so very brave, and so very strong, and you can do this. Just take a sip of this for this pain and we're going to get you through it together. I promise."

Elizabeth nodded in agreement, shuddering as the bitterness of the alcohol caused her to gag violently before she cried out in pain once more, this time shouting, "I want my Mum!"

"I know you do, but we're going to have to settle for Dad." Emma soothed as calmly as she could manage as she watched her wife continue her work below. "He helped Mum deliver you and he's going to help you deliver your baby. He's not going to let anything bad happen to either of you. You know that."

"Baby's almost here." Sybbie reported confidently. "Just one more good push."

"One more." Emma encouraged with a quick kiss to her sister's forehead. "You've got this."

As promised the push Elizabeth gave was enough and within moments Sybbie was placing the squirming infant on its mother as she kept all of her focus on the task of ensuring that Elizabeth was alright.

In an instant Elizabeth's arms were crossed over her face, shielding her vision from the baby she had never planned to feel outside of her body. "Please. I don't want to see it. Please. Please."

Emma carefully retrieved the baby from her sister's stomach as Sybbie continued her work, wrapping it in the cardigan of her uniform after realizing that all of the towels and blankets had been soaked in blood during the trauma of the birthing process so far.

"Dad, will you take them into your room?" She asked softly as she secured the sleeves of her cardigan into the wrap around the newborn.

"I want to be here for Lizzie." Joseph protested immediately, motioning to his hands that were firmly within his daughter's grasp.

"That would be nice, but she needs to focus and she can't do that with them in here." Emma insisted firmly. "Take care of the baby and we'll take care of her. I promise."

Joseph nodded nervously as he moved out from behind his younger daughter and took the bundle from his older daughter's arms before quickly making his way up the stairs and out of sight.

"The placenta is in pieces." Sybbie groaned in frustration. "The bleeding hasn't stopped and it must be because she's retained some of it."

"Lizzie, I'm sorry but we've got to get the rest of the placenta out." Emma sighed tiredly as she joined her wife in front of her sister.

"How?" Elizabeth asked between anxious pants.

"I'm going to have Emma massage your lower tummy firmly to encourage some contractions that will hopefully expel the remainder of the organ." Sybbie explained seriously. "I'm afraid it's going to hurt quite a bit, but I promise it's our best chance of getting through this quickly."

Thankfully things went as well as they could hope and within minutes they'd been able to complete the placenta and work on cleaning Elizabeth up from the ordeal she'd been through over the last several hours.

It wasn't until they were lifting her into her bed that she began to shake her head in confusion. "Is it done?"

"You did it. It's over." Emma assured her as she carefully tucked her sister into her bed. "You did so well."

"The baby?" Elizabeth questioned groggily.

"We've got them." Sybbie nodded reassuringly. "There's nothing left for you to do other than get some rest."

After that, for Elizabeth, everything went black.

NOTES:

Content Warnings:
Descriptions of Abuse & Rape/Non-Con; Mild Sexual Content; Pregnancy; Medical Trauma; Childbirth (Traumatic); PTSD/Panic Attacks

Chapter Recap (Contains Spoilers):
Phyllis and Elizabeth discuss Elizabeth's anxiety about the upcoming birth. The next morning Phyllis heads to York and Elizabeth spends the day at home with Johnny and Joseph. That afternoon she goes into labor and Johnny and Joseph scramble to help her through it. Joseph convinces Emma to help him who in turn recruits Sybbie. After a difficult delivery brought on by Elizabeth's existing trauma the baby is delivered safely, and Elizabeth falls out of consciousness.