First Words

I have heard the azan, the Muslim call to prayer, under the scorching sun and the early morning cover of darkness: at the edge of the baking savanna of Sumberwaru in East Java, green mangoes fat on bowed branches; at the lunar feet of the Anti-Atlas mountains outside Tafraoute in southern Morocco, the trembling voice of the muezzin competing with low thunder from the horizon and the tinny sound of Salif Keita from my travel speaker; watching the sun sink behind the Pidgeon Rocks of Beirut, Cyprus just off in the unknowable blue distance; over the PA system of an airless Dhaka shopping mall, the smells of new plastic sandals and sour milk mixing in the fluorescently lit stairwells; curling through stone windows into the Loge of the Empress in the Hagia Sophia, the great calligraphic panes bearing the name of Allah hanging over mosaics of the Virgin Mary like the tags of rival gangs in a subway underpass; and, most quietly, among the demolished neighborhoods of the Kashgar that once was, snow falling silently in the dusty streets, mustachioed men proffering glass goblets of pomegranate juice so thick and so tart. But I now most often hear the azan on the fifth floor of my modest brick hospital in New York City just after a child has come into the world, when he is still slick and grimacing on his mother’s chest wrapped loosely in a cotton blanket.

 

On an evening like any other, I emerge from a triage room, my palms wet with hand sanitizer. I recognize Rokeya from behind by her her long, black pony tail shot through with strands of silver, now falling over the back of a wheelchair in which a nurse is conveying her to a labor room. The nurse’s leisurely pace is at odds with the fury of Rokeya’s pain so evident in her blanched knuckles and rigid arms. I have been on the floor for 12 hours and had stepped into triage for a quiet moment, steadying myself among the sterile specula and IV starter kits for a further 12 hours over night. Pressing my hand to the Purell dispenser on the way out the door is merely a tic I’m unable to break.

I feel a tiny righting of the course of my day at the sight of this woman, a relief after hours of triaging strangers. As a shift worker, I never know whose birth I’ll be attending when I wake up in the morning; when it happens that fate matches me with someone that I know and have cared for there is a locking together of puzzle pieces and a claim that I lay to her in birth: I know her, I say, I’ll take her.

By the time I enter her room, Rokeya is sitting upright on the bed wearing the standard-issue, blue-flecked hospital gown and a shocked expression, flanked by two silent women that I guess are her mother- and sister-in-law. This labor is nothing like her last, nineteen years earlier. Then she was twenty years old, in the blur of the first year of marriage, occupying a room on the first floor of her in-laws’ home on what was then the outskirts of Dhaka before a fleet of new concrete buildings swallowed the surrounding area whole. Then she was just a bride, still skinny, for whom life had proceeded largely as expected, who knew some material comfort as the daughter of a secretary to the Assistant Superintendent of Police of the Bangladesh Civil Service. Her marriage had been arranged without displeasure to Anwar, a round-faced youth hoping one day to pass the BCS examination himself and work alongside his father-in-law.

In those days, Rokeya was concerned with learning how to be a wife, having given up her study of medicine after her first year.  Whereas she had observed their preparation in her girlhood, she now took responsibility for her family’s iftar meals during the month of Ramadan, laying out dish upon dish of dried dates, ghugni and muri, jackfruit, jilapi. Rinsing blood from the cavity of a sinewy chicken’s body, she sometimes thought of the four cadavers weighed down with bricks in a secluded tank of beetroot-red formalin at the medical college; she had barely worked to hide her disgust as caustic fumes from the embalming fluid filled the laboratory and had waited as briefly as she thought respectable before accepting her mother’s suggestion of marriage instead of year two of the MBBS.

Piping thin batter into a pan of frying oil at dusk, Rokeya knew nothing of the recurrent miscarriages that were to come after the quick conception and birth of her daughter, or of the secret meetings with an elderly woman neighbor to discuss redressing whichever of Rokeya’s past misdeeds must have brought this misfortune on her family. She knew nothing of what it would mean to lose a husband after only four years of marriage, to have his name unacknowledged in a brief news report of the bus crash that would take his life, among a dozen others, on the proto-highway that cut through her neighborhood in an eruption of cracks like a dry riverbed.

She could not have foreseen her penetrating grief at the loss of that man she still only half-knew, her years of widowhood as a returnee to her parents’ house with her little girl, her eventual emigration to the United States to live with an aunt whose teeth were blackened with rot at their bases, or her remarriage at age thirty-seven to the bachelor proprietor of a 99-cent store on Church Avenue. She had never imagined our meeting in a windowless, antiseptic room of my prenatal clinic with barely enough space to fit the two of us, an exam table and a sink. Nineteen years earlier, she could not have known that the English she had so dutifully studied as a girl would be the language of our meetings, or that the first hands on her second-born’s head would be mine.

 

Before I entered midwifery, during my training as a nurse, I was taught never to sit on a woman’s bed during labor; it was deemed too intimate a posture between strangers. I often remember such admonitions from my favorite nursing instructor Moira, a warm and formidable Irish woman in her sixties, straight-backed and clad in pressed white shirts, intent on impressing upon us a respectability no longer guaranteed us by the profession alone. A nurse never sits! she chastened us students as we waited in the hall outside the simulation lab. Or, crooning over a medical mannequin: Now we’ll be administering digoxin, which we will never refer to as what? An anti-arrhythmic, yes, because it is properly called what? A cardiac glycoside, correct. That is what will set you apart… But Moira never taught us how to greet a laboring woman. I have learned by trial and error to stop asking a woman in pain how she is feeling, to avoid that temptation of the workaday greeting. I sit by her side, I call her by her name, I tell her how glad I am to see her, and I mean it. We are intimates, she and I, though we may be strangers.

On this evening, I lower myself onto the empty space beside Rokeya’s bent knees, the mattress crackling quietly beneath my weight, the air full of her moaning. She does not address me. “I am in pain–”  she says to the room in general, “– too much pain — not like before — not like last time –”

Her female relatives sit gravely at either side of her bed, their sure palms resting on her arms, as still as geckos high on the wall. These women are not the typical family members who stare alternately at the electronic fetal monitors and at their smart phones; they know something about labor and, I sense, about pain more broadly: that it requires the full attention of those in attendance, that it demands a steadiness that betrays no doubt, no impatience, and no fatigue. When everyone else in the room is poorly equipped for birth, frozen in a corner or skittishly scanning their social media, I know that the night will be long and that I will collapse into a narcotically deep sleep long after daybreak. But for Rokeya I provide only the most basic of assurances: that I will do everything in my power to ensure that she and her baby will live, leaving the rest to her own efforts and the comforts of those who truly know her.

Hers is the progression of the unanesthetized body: sweat forms at her hairline and then at her upper lip; a contraction comes and she presses her fingertips into the muscles above her pubic bone; she sticks her chin out before vomiting into a pink, plastic basin that the nurse has placed by her side; she says that she just cannot and we tell her that she already is. She pushes just six times to move the child’s head out of her body — why do I gingerly dab a whorl of his wet hair just then? One more endless push and his body emerges in a rush of fluid into my hands. I hold him suspended for only a moment before placing him on Rokeya’s chest, the pulsating, dusky coil of his umbilical cord still connecting him to the inside of her uterus. Her cries turn to weeping and she clutches this wet, squalling creature, his eyes black and open, his ten fingers splayed in taught fans like the petioles of two palm branches.

Her mother- and sister-in-law wipe drops of sweat from their cheeks and adjust the dupattas they have let fall from their heads during the work of supporting her. I take in their faces now for the first time and notice a split-second of bewilderment come over the mother-in-law. Her eyes scan the room, seeking some object unknown to me: I am not it, neither is the nurse who is occupied with injecting oxytocin into Rokeya’s thigh to prevent bleeding.

Allah, she mumbles, seemingly in spite of herself. Allah — and I remember what she is looking for: a man to whisper the azan to the baby, the first words it will hear in this world, on this side of the birth divide. Finding no man, avoiding her daughter’s gaze, she leans over her grandchild’s head:

Allahu akbar, she says in a small voice into the newborn’s right ear, and then again, more steadily, Allahu akbar. She slowly turns the baby’s head to reveal his left ear — Allahu akbar — as I see the sister-in-law dialing a number on her phone. She has called Rokeya’s husband, still detained at the 99-cent store on Church Avenue. It seems he has been expecting this call and he wastes no time by greeting the callers; the phone is positioned over the baby’s right ear and from the pinhole speaker comes the improbable, quivering voice of this man who thought he might never be a father. The room comes to a hush, the regular chatter about the baby’s activities and, worse, the nurses’ business with women in the adjacent labor rooms, silenced. His thin intonations fill the labor room:

Hayya ‘alas-salah — Hurry to prayer
Hayya ‘alal-falah  — Hurry to success

We hold onto this woman, a new mother again after so long, I at her feet, her mother- and sister-in-law at either arm. The newborn is placid, pacified, evincing life only through his pink skin, intensely concerned brow, and the occasional involuntary twitch of his limbs: his first alpha sleep on earth. The mother-in-law turns the baby’s head once more for the recitation of the iqama, which the father begins remotely and without hesitation:

Qad qama tis-salah — Prayer has begun
Allahu akbar!

I encourage the afterbirth with gentle traction on the umbilical cord, twisting the purple body of the placenta like a cheesecloth as it comes into view, gathering its membranes together to prevent their tearing, catching it all in a metal kidney basin between Rokeya’s thighs. Her bleeding stops, she needs no stitches. I look up and observe her as she murmurs in Bangla to her son, barely ten minutes old and already awash in words and words. Whole volumes are written recording our last words, our dying words, but what of these first words from the birth bed? Would there exist other such volumes if only Great Men had given birth? Is it not enough that I once knew an old midwife whose husband had died in Vietnam and who whispered into the ear of each new baby: Be well and may you never know war!

I am reminded of the words of 16th century poet Kabir, so withering in his criticism of the faddish distractions of religious practice and of the muezzin’s ostentatious cries heavenward to grab God’s attention:

Surely the Holy One is not deaf, he writes.
He hears the delicate anklets that ring on the feet of an insect as it walks.

Had he himself witnessed that thing most unassumingly holy, that sanctity that needs no naming and no exegesis? Had he himself heard the tiny, tin bell of birth?

The Useful and the Beautiful in the House That I Have Built

The midwife comes home to a many-roomed house; dim lights illuminate the windows even when she is away at her work. After a day that began before sunrise, the door to the house comes open easily. She turns no key; there is no lock. As she enters, the scent of the house comes over her: cool, humid, gently salty, as if just inland.

She reaches her hand out in the barely lit entryway and leans her weight against a section of wall painted in a woman’s hot exhalations, the exhalations that came when she insisted that all of her strength was gone. She feels for the switch of a lamp in the corner and the light appears as the pale yellow of a woman’s closed eyelids, her head thrown back against the pillow, resting atop the mountain of her success.

Underfoot, the floor is an intricate network of wooden inlay: a late gush of blood interlocking with an urgent grip on the midwife’s arm that leaves a bruise the next day. A sharp creak as she ascends the stairs; one finger held silently at a woman’s lips — Please, he can never know. Her house is this way: drawing the curtains for the night, a woman’s long black hair held away from her neck, damp with sweat. Sinking heavily into the bed, pulling starched sheets up over her legs, the delicate weight of a newborn laid in her arms — We did this together. Somewhere in the house is always the first birth: a back-issue magazine consigned to a high shelf or a deck of stiff playing cards in the side table drawer.

She can’t remember the day the house was finished — wasn’t it built by some other midwife? Some years ago she spent a single night in one of its small bedrooms looking out onto the street, the sidewalk dark and damp with late autumn rain. Over time she spent so many nights in the house that it simply made sense to stay; one day she finds that she has carved her initials into the soft wooden banister. She recalls no single moment in which this became her home, no date on the calendar to distinguish the before from the after.

But if you have time, let me tell you a story of before and after.

*****

A nurse approaches me on the labor floor, tapping a ballpoint pen to the clipboard she holds tightly in front of her. “Twenty-one years old, baby number one, 32 weeks pregnant, not feeling the baby move,” she reports. She rattles off the woman’s vital signs and most recent lab results. “She’s not ours,” the nurse sniffs — that is, she does not come to us for prenatal care. “She’s in triage room 20 whenever you’re ready for her.”

Rising from my desk I cross the floor and take a moment to read the electronic fetal monitor displaying the pattern of the baby’s heart. I watch this jittery yellow line proceed across the screen, its occasional rises and returns painting a reassuring digital picture. Below that, a line reflecting the electrical activity of the uterus: flat, quiet, no contractions at all, just as I would hope for in a woman only eight months pregnant. Without laying eyes on the woman I know that her baby is likely in fine condition.

I casually consider what I will tell her; I am also thinking of the previous two women who have appeared in triage with the same concern. I am also half-considering: a training on breastfeeding that I need to complete; the birth I attended yesterday and what I could have done to prevent the hemorrhage; the anthropological text on birth practices in south India that I haven’t yet finished; a letter I’d like to write.

Entering room 20 I find a young woman seated on the exam table; she is outfitted in clean, dark leggings, a tidy yellow sweater and glasses framed in navy plastic. Her hair is smoothed into a tight, shellacked bun. The mildly chemical scents of dandelion shampoo and laundry detergent perfume the air. I know that I will find her skin softly clammy with cocoa butter; she is presenting her body for examination.

I introduce myself and ask her what has brought her to the hospital this evening. She stares at the pastel walls of the triage room. “I don’t feel the baby moving so much,” she says. She is hoarse. “Also I think I have the flu.” I help her lie back and see her wince when her shoulders reach the worn, brown plastic of the exam table. I ask her if she is in pain. “Oh yeah,” she says flatly. “But it’s nothing new. I hurt all the time.”

As she pulls up her sweater and I place my hands on her abdomen I immediately feel the unmistakable form of a fetus changing its position, its intentions unknowable as it flexes and extends, as it draws fluid into its lungs and then expels it, an imitation of breathing. I gingerly take the woman’s hand and place it atop the mound of her belly. “Do you feel this?” I try to look her in the eye but she has shifted her gaze to the ceiling. “This is your baby moving.”

She is quiet, and I am quiet, and the grainy, electronic representation of the fetal heart is the only sound in the room, rising and returning. A thought crosses my mind of a woman’s complex perineal laceration that took me an hour and a half to repair; I wonder if she is healing. 

”Oh. Yeah well I guess I do feel him now.”

I take in the picture of this woman on the table: no sore throat, no vomiting, no diarrhea, no chills or malaise. The nurse has already told me her temperature but I place my hand on her forehead — no fever. She closes her eyes under the weight of my palm and tears begin to drop heavily from the beneath her glasses; I pull a cheap cardboard box of tissues from a drawer beside the table and touch one of the thin, white squares to her cheekbone. She takes it from my hand and covers her eyes.

I take the bulky monitors off her abdomen and wipe ultrasound gel from her skin. “Your baby is just fine,” I tell her, “and I don’t think you have the flu.” The corners of her mouth tense; her eyes are giant with tears as she stares at the fluorescent light fixtures.

“But you are not fine,” I add.

And the words surface in my head: And I am not fine. They are new to me and are quickly submerged beneath the memory of a man who assaulted his wife in triage last month, trying to pull out her IV before we called the police.

She shifts to her right and pushes herself up awkwardly to sitting. Nudging her glasses up her wet nose, she looks at me. “Doctors always say the baby is fine. I come in and they check the baby, they say the baby’s fine and they send me away. But I think I’m dying.”

And I am not fine — the thought turns over in my head.

The details tumble out: bulging discs in her spine that make it hard to walk or sit, prescription pain medications that she has been warned against taking while pregnant, chiropractors and physical therapists refusing to see her until after the baby is born. Severe depression for which her physician will no longer prescribe her medication because “it might hurt the baby.” Counselors that are angry at her for missing appointments; she doesn’t want to get out of bed anymore. No one at home to help her prepare for this baby that she doesn’t want, no one to put a hand on her lower back. Pain in her mind and pain in her body, each intensifying the other until she has come to this moment in which it seems that she is dying or would like to be. Then she asks if, when the time comes, we could please numb her and do a c-section so that she won’t have to feel anything.

I exhale heavily. Another black man was shot by the cops for no reason last week; today’s news is full of images of the protesters. And then there is this woman in front of me.

I tell her that see her terrible pain and that I will not send her out of the hospital without making a plan for her to feel better; I tell her that she is a human being not an incubator and that she deserves to feel well. I ask her if she has a plan to hurt herself or someone else and she says that she does not. I ask if she would agree to speak with our social worker and she says that she would. I ask if she would like me to take care of her for the rest of her pregnancy — she says yes, and the yes feels like a bright green tendril in the dirt.

She and I sit over a clean sheet of paper and make lists: the medications it is safe for her to take; the ways to soothe her back pain until our medicine clinic can evaluate her; names of friends and relatives that she can call on for help; problems she would like to talk about with a counselor. We write this all down because it is something for her to hold on the way home, to keep in her coat pocket, and because in writing, unlike in thinking, you must eventually come to a stop. I make her an appointment to see me in the prenatal clinic the next day at eleven o’clock and, because no one knows what a midwife is, she says: “You’re the first doctor who ever listened to me.”

I am aware of a growing pain in my chest, a crackling like circuitry on the fritz.

As I watch her leave the labor floor I imagine: the next three women who will appear in triage with the same concerns; the next birth during which there will be a hemorrhage; the long run I will take when I get home. I think of the woman whose labor I will be inducing later this evening, wonder when the first labor was successfully induced with modern medications, and think how interesting it would be to read a social history of the induction of labor. My boss’s comment to me during my recent job performance review appears in mind: “Even during an emergency we look at your face and can’t tell that there’s anything wrong — that’s a good thing.” Because I am not fine. Some time later, my shift comes to an end.

 

The next morning in the prenatal clinic my breath feels uncomfortably humid. There is a bitter taste on the back of my tongue; my body is electric and ungrounded. It is 10:50, it is 11:00, it is 11:10. I have no sooner realized that the woman from triage is never coming to her appointment than another woman’s chart appears on my desk for review. I stare at it blankly.

There is a knock at my clinic room door and, before I can answer, the midwife next door has stuck her head in the room. Katherine is a senior midwife and a comfortable presence: she speaks with calm and deliberateness; she places her hands surely. She outfits herself in soft knits and delicate beads and sits with the stillness of a cat. I see her mouth begin to form its typical inquiry into my day, “You doing ok?” — an offer of her experienced perspective, should I need it — but she sees something in me and stops, her face arranging itself into concern. Slipping into the room and seating herself next to my desk, we look at each other the way animals do, without fear or social grace. Her eyes are serious and unblinking as I recount the story of the woman from triage room 20, of my hours spent with her, of her hopelessness, of her failure to appear today as if she has broken a promise to me.

“What’s her name?” Katherine asks me.

“Her name?”

I search my memory and find only the crackling of circuitry on the fritz. Some low panic comes over me — what is her name?

I have been told that I have a memory like a steel trap: so sharp that it makes those close to me nervous. I will remember: the unstable living conditions of a woman I met once three months ago; the exact wording of an argument I had last summer; the exchange of vitamins and minerals in the kidneys as explained during a lecture in graduate school three years ago. But for the first time in months I find nothing in my mind at all — no thoughts of tasks to be completed, no blood tests or chest x-rays to be ordered, no clinical questions to which I’ve been meaning to look up the answers, no reminders of books to be added to my personal reading list.

After some pause, I say all that I can manage to Katherine: “I can’t remember.”

She trusted me, she told me that I had helped her, and today I can’t even remember her name; we are strangers to each other, after all. I cover my face with my hands and find that my cheeks are damp with single tears.

With no preamble, Katherine tells me that I have burnout, and asks me how long I’ve been at this job. I protest that it’s been less than a year, so burnout is impossible.

“And how long ago did you attend your first birth?” I don’t answer.

Yes, that first birth: five years and two months ago, as a doula in a public hospital in China’s Yunnan province. That I will always remember — the woman, her birth, her son, his name: Gabriel. Born into my bare hands because there was no one else, because the instinct is to reach out hands to catch a baby falling into the world. Dabbing my cheeks dry with a paper towel, the room smells faintly of the thin Himalayan air at 11,000 feet.

“I remember this moment when I was a new midwife,” Katherine says plainly, “before I understood about the trauma.” She outlines a plan for how I am going to complete this day and for what I will do when this day is over. I want to be listening because the plan sounds like a good one — something about rest and self-care — but I can’t, because I don’t believe her. What trauma? That total exhaustion, that dim view of humanity, that pop psychology explanation for being not strong enough or compassionate enough — that doesn’t sound like me at all. I tell her as much and she looks at me with an expression that goes some distance beyond pity.

And so, because the will to excuse our own dysfunction is so strong, that is not the moment between the before and after of this story. It is only some days later, after yet another night shift with its bleary sleepless hours punctuated by the adrenaline of birth, and after a long drive out of New York City, up the east coast to New England and back again — the miles passing beneath my feet opening some meditative corner of my heart — that it finally comes. I find myself at home slowly returning to their rightful places all of the untidy objects of my apartment: the mail that has accumulated on the glass coffee table, the shoes lying on their sides in the hall, the empty teacup on the window sill. My whole body hurts. I roll a mat out on the living room floor but there is no way to stretch out the pain; I give up and begin to fold my clothes instead.

As I sit turning back shirt sleeves I feel slow a heat come over me, rising up my spine, up my neck and behind my ears, finally settling in my forehead. For a moment I think I’m coming down with something; I actually get out a thermometer but there is no fever. I go to the mirror by my bed and, leaning towards it, hope to see the face of someone familiar to me: one who comforts a woman with a warm and steady hand, one who brings her a measure of peace. Instead, I see for the first time what Katherine saw: a tension in my face that I barely recognize; I am not fine. Although it should have been clear, although it is everywhere in my writing, I only now take in the full picture myself in this moment and on my face I see: the terrible violence in women’s lives, their stab wounds and HIV infections; their stillbirths on the sidewalk, their babies brought onto the labor floor in plastic buckets; their babies born having seizures; their babies born addicted to drugs; their infections and lacerations and hemorrhages that I have worried are my fault. I look in the mirror and see these things for what they are. I call them trauma and it sounds, suddenly, correct.

I close my eyes and feel my mind go silent, as if the plug has been abruptly pulled on that crackling circuitry, all of the painful energy draining from me in an instant. My body is cool and quiet, a long fever finally breaking.

*****

I awake in a darkness like the pupil of an eye. Throwing off my heavy blankets and feeling my way out of the bedroom, I enter the kitchen and put my hand into an open drawer, withdrawing a box of matches. I strike one and it springs into flame. Moving to the kitchen window I touch the match to the wick of a short, white taper candle waiting upright on the sill, and then to another. Long shadows appear behind the objects of my kitchen: a purple glass vase in the shape of a woman’s gratitude; she says I took away her suffering. A thin trail of sulphurous smoke from the extinguished match curls through the air: the first time I surreptitiously leaned in to inhale the finely scented skin of a newborn’s head, feeling like a pickpocket. I move from room to room in this way, lighting candles, lighting lamps.

What is this house that I have built? On what date did I see these rooms for the first time, and when did I come to dwell in them? That first day when they said Get the midwife! and they meant me? — no, years before then. My first birth of midwifery school? — no, even before then I had laid the foundations. The first time I was taken in to a woman’s confidence? — perhaps then, although that is a memory long since faded.

There is certainly this: five years ago, when I said that I would one day do this work, women began to tell me the stories of their own pregnancies and losses. So eager were they to unburden themselves that I found I needed only to hold out my hands and women would give me their stories of pain and triumph like bricks and bolts of cotton, like lengths of pine and knotted rugs. I never thought to choose among these stories or to put them aside; I collected them all in case I disrespected a woman by forgetting her, in case I might need them again, and because it was it was possible to keep them all when there were only a handful of such women, before they became fifty, then a hundred, then five hundred. When my arms could no hold no more, I stacked the bricks into walls and laid the pine into floors; I built a house from the intimacies of women, sewing the cotton into pillows and rolling out the rugs beneath my feet.

I was reminded recently of William Morris’s admonition that we should have nothing in our houses that we do not know to be useful or believe to be beautiful. Standing in the light of incandescent bulbs, taking in the walls of what has become my home, its objects illuminated by a dozen tiny fires, I see instead of such curation the horror vacui that I have created over the course of years: books stacked from floor to ceiling, all of the infections I have cured; a hundred landscape paintings, women’s internal places of retreat during the pain of labor. Paper bags of bric-a-brac wait in the hall: recollections of hard night shifts destined for delivery to the doorsteps of unsuspecting friends and lovers. My cheeks burning in this recognition, I am nonetheless grateful that in the diagnosis lies the cure. Settled at my broad mango wood table during quiet evenings and the long hours of a post-call afternoon, I am now turning these objects over in my hands: does it serve me to remember those mistakes that caused a new mother’s fever? Is my life more exquisite for the addition of a new father’s prayerful exclamations at the birth of his son?

I have a fear of the cold and dark months, associating them with the theft of my freedom, with being forced indoors away from the freezing rain. And so I am amazed to find, for the first time in years, that I feel no dread at the close of these short December days but feel instead a peace like the quiet whistling of a kettle on the stove.

In the dark of this winter, at this turn of the year, I am giving away these possessions.

A Night in Three Acts

This particular summer night on the labor floor unfolded in three acts over 12 hours, beginning just before eight o’clock in the evening. Caffeinated and in clean scrubs, I entered the floor through a set of massive metal doors, doors that require electronic hospital ID to open, doors that lock down with a blaring of alarms numerous times each day when a newborn becomes accidentally separated from the security tags attached to its wrists and ankles as if it were merchandise at the mall. I strode through the doors and glanced reflexively up at the well-worn white board in front of the nurses’ station where the labor rooms and their occupants are listed in the semi-encrypted medical shorthand meant to offer a patina of anonymity: J.L., 24, G1P0, 39+4, 3450g, 6:35A 5/90/-1 AROM cl 5:05A, neg, low, consulted. Y.C, 16, G2 P1, 34+3, 3100g, 7:45A 7/80/0 SROM lite mec 2:00A, pos, med, epi, PCN G.

But today the board was empty, the floor quiet, rooms waiting for grimacing women and their listless families. The empty board engenders in me both relief and anxiety: there is a moment available for a deep breath before the day begins, but there is no foothold in the day, no woman with whom to begin, only the promise of labor —  or no labor.

We — the midwives, nurses and obstetricians — use the time to complete rounds upstairs on the postpartum floor (Room 17 is doing well and wants to go home today…Room 8 was found sitting on the floor while her boyfriend was asleep in the bed…Room 13 doesn’t want to feed or touch the baby, but we’re not sure — maybe it’s a cultural thing?…) and I scribble notes to remind me of the tasks to be completed with these women, these new mothers, between 10pm and 6am when I will find them bleary-eyed in the dim light, clutching their infants, the hospital televisions throwing a silent, alien glow around the room.

I return to the labor floor and position myself at a computer from which I can see those hulking, metal doors in the periphery, reviewing the results of the lab work I have ordered for women in the clinic. While waiting for the sudden work of a woman in labor, I make phone calls as gently as possible (Yes, you have chlamydia, which is an infection you get by having sex without a condom with someone who also has chlamydia…The results of the fetal echo, the scan of the baby’s heart, show that everything is normal right now…) and continue developing that specific legal skill of documenting in a medical record: writing sparely, including only necessary statements of fact, making note of other clinicians’ support of my decisions, a style of writing born of professional fear and the trauma of the courtroom.

In between these points of investigation and documentation I close my eyes and allow the blackness there to create space in my mind as I learn how to deal with such utter uncertainty, as I wonder how anyone accustoms herself to the truth about this moment — which is, of course, the truth about all moments: that anything could happen.

Act I began just then: a slow opening of the doors and an uncommon sight: a pregnant woman, her face drawn not in pain but in resignation, accompanied by a starched, uniformed nurse, her eyes round and worn from years of already knowing what will come next. Puzzled by a pregnant woman with a nurse personally assigned to her, I parsed the story one leaden detail at a time: the nurse’s sole responsibility to this woman was to visit her at home to make sure that the baby still had a heartbeat. At today’s visit, 31 weeks into the pregnancy, it had not — an eventuality that the woman herself had both dreaded and, seemingly, anticipated. While this was the longest her body had been able to sustain a pregnancy, it was the third pregnancy in a row that had ended too soon, the third time she would enter a hospital pregnant and leave with empty arms. We hoped to reassure her, to find the galloping heartbeat hidden in some unlikely corner of the abdomen and to project its waveforms from the electronic bedside monitor onto the flatscreen in the hall, but there was no heartbeat to find. The task now was to induce her labor with medications, having moved her to the most remote of the labor rooms on the western side of the floor, from which we hoped she would not hear the first cries of other women’s babies being born.

It was determined that, as a brand new midwife, perhaps this should not be my responsibility; I did not object. I stirred a cup of weak coffee as her wheelchair was pushed past my desk and did a half-hearted literature review of the efficacy of inducing labor with one medication versus another. The coffee went down in hard swallows; I did not settle my imagination on the experience of losing, repeatedly, the pregnancies one so badly wants.

Some time later, the sun long since below the horizon and the moon on the rise, Act II began with a rush of voices and the high, pinched whimpering of a woman trying not to push her baby out in the hallway. She carried herself gingerly through the metal doors, eyes cast up to the ceiling, her long form clad in a simple cotton gown of midnight blue that brushed the floor. A shorter, older woman, head wrapped in a black hijab, supported her at the arm; she seemed familiar with the labor floor and knew into exactly which triage room she should steer the obviously laboring woman. The triage nurse hurried after them, surely planning to go through the standard routine of gathering a brief health history, taking the woman’s vital signs, and putting her on the electronic fetal monitor. But instead —

BABY IN TRIAGE!

At the controlled panic in the triage nurse’s voice we two midwives bounded into the room, followed by two further nurses, in time to see the laboring woman perched precariously on the narrow exam table, her cotton gown thrown up about her waist, her sinewy legs jutting straight out, the beginnings of a baby’s head emerging from between them. Our beseeching attempts to have her stop pushing were of no use;  even if she had not spoken a minority West African language unknown to our phone translation service, when a woman is pushing there is little you can do to stop her. Amid the sudden flurry of activity —  grabbing gloves and holding one tense hand at the woman’s perineum in an attempt to prevent a laceration, grabbing clamps and suction bulbs from the supply closet, pulling baby blankets from drawers — there was one slow-motion moment in which I stared at the emerging head and thought: Something is different here. In those endless few seconds I surveyed the woman’s genital anatomy and realized that something — or some things — were missing, although I could not tell exactly what. Was it the inner labia that were missing? Perhaps also part of the clitoris?

The baby emerged then, a slightly scrawny girl child, rosy and crying, eyes giant and alert. I tended to her as she lay on her mother’s chest while my fellow midwife ensured that the placenta was born and that the bleeding was controlled. Satisfied that the baby was well, her lips in an exploratory, open pucker next to her mother’s left breast, I stepped in next to the other midwife and watched as she inspected the genitalia for bleeding that would require sutures. The tissue beneath both remaining outer labia had separated slightly in descending, symmetrical lacerations but was not bleeding. The midwife decided that suturing would cause more harm than good, that the lacerations would heal on their own. I silently nodded my assent. When we stepped from the triage room to document the events of the birth she remarked that the lacerations might even allow the labial tissue to expand. “What used to be labial tissue,” I said dryly. “Oh, there’s plenty of tissue there,” she replied.

A low buzzing in my brain, static and numb. I completed the baby’s birth certificate in black ink; I did not settle my imagination on the ritual excising of women’s flesh, or on exactly how much of my own would have to be removed for it still to be considered plenty of tissue.

The clock ticked past two o’clock, and Act III began with the arrival of a stately, freshly showered, laboring woman accompanied by her boyfriend and mother. Pregnant with her third child, she had labored at home since yesterday afternoon and now leaned forward onto the clerk’s desk during the frequent contractions, swaying her hips and dropping her head while exhaling noisily. When I examined her in a triage room I found that her cervix was already six centimeters dilated. Her pregnancy had been uncomplicated, she said breathlessly and, as I searched through her medical record for evidence of anything concerning, I found no lab values out of range, no unusual social concerns, no abnormal ultrasounds or genetic screenings. Normal, then — low risk. I checked again to be sure.

The nurses moved her to a labor room and I settled onto a low stool at her bedside while they set up “the table” — a spread of all the items we had scrambled to assemble for the woman who had given birth in triage earlier on. A woman who has given birth before can move with great speed from six centimeters to fully dilated and pushing; having no one else to tend to, I stayed with her. She retreated to some remote, inner world during the contractions, her body still, her face tensed in concentration and pain, her boyfriend and mother hovering nearby, occasionally looking over to me for direction. I nodded to the boyfriend that he should sit by her other side, and together we proffered our hands and arms for her strong grip. I offered the only words one can offer in the face of another’s pain: words of soft encouragement and compassion; patient words.

The room was still. The minutes passed in unknown number.

Just then her eyes flew open and she fixed her eyes on me in desperation: “I have to push! I have to push!

“Wonderful,” I said. “I think you should have this baby then.” I rose from the bedside and removed the ID from around my neck and my watch from around my wrist — objects that might get in the way — setting them on the windowsill. I uncovered the table of birth supplies and removed a plastic sheet from among its many items. I turned back to the woman and her two family members and found them all looking at me expectantly, as though somehow I were now going to remove the baby from her body. I wedged the plastic sheet beneath her hips. I told her that she was just fine and that she should push the baby out whenever she felt like it.

“You have kids, doctor?” the boyfriend asked. I replied that I did not. “Well, you’re going to be a good mother,” he said, a compliment that is, to me, unlike other compliments.

And then she began to push, her muscled body shuddering with the effort, each push growing from a low growl to a short scream: the sound of power on the release.

Perhaps two minutes later, looking out at a starless, seamless, black sky, she gave birth to her baby: a boy, fat and healthy. The woman was well, and as I watched her meet her son and bring him close to her face, kissing him and breathing him in, I allowed myself that most modest of pleasures: to release the grip that I hold on my heart; to be overcome by relief at all that is so normal, and so good.

The Way the Day Begins

I sleep, unwisely, right next to a large set of windows. On these long summer days, I’m woken in the morning by the diffuse, white sunlight before I need to be up for work — a terrible curse for a sleep-deprived midwife. I could move my bed, of course, but I just can’t give up staring at the stars at night. As a child I had a skylight right above my bed and I seem always to be trying to get back there.

Today I wake up slowly after a 5am rain to the sound of cars passing lazily through the puddles down below, convinced in my half-sleep that it’s the sound of waves breaking on the beach. I roll over to the open window and lay my head on the sill. The dregs of last night’s activities on my tiny street are still playing themselves out: a single firework from an unknown location explodes in a sharp crack, upsetting a yappy little white dog occupying a window frame across the way. A pair of teenagers sing to each other in a tipsy drawl. A woman wanders slowly up the sidewalk repeating, sing-song, Somebody please heeeeeelp me, somebody please…

Scenes of yesterday’s prenatal clinic replay drowsily in my head: the muffled feeling of babies’ elbows and feet rearranging themselves in utero under my probing hands. The woman with an infection so severe I can diagnose it on smell alone from five feet away. The minute I take to compose myself before telling a woman that her fetus has Down Syndrome. The Syrian woman whose previous prenatal records I try to obtain before she gently stops me: The hospital over there burned down, miss. Everything burned down.

I resign myself to being awake and push myself up against my pillows. I give a glace to the other side of the bed, to the place that used to be occupied by my husband, back when I was a wife. I pull on the worn jeans and white t-shirt that will be wet through with sweat by the time I finish my hour-long walk to the hospital in the early morning humidity. I am ready to leave my apartment in minutes.

I love my walk to work; I am treasuring it particularly now that I will soon be moving to a neighborhood far from the hospital where I was lucky enough to find a job a few months ago, my first real midwife job. My mornings will consist of a long subway journey from one end of New York City to another, overground and underground, and I’ll miss the strange landscape that I now wend my way through each day, making note of the objects strewn across the sidewalks like props leftover after the actors have taken their bows:

A stiffened brown sparrow that the flies have taken to; an open bag of half-eaten green grapes; a small pile of watermelon rinds right on the concrete corner. A single stiletto in matte gold, upright on its needle heel; a boxy TV overturned on its face. A calico deli cat, ears flattened in displeasure at my approaching step. Tiny ziploc baggies that last night held heroin or cocaine.

The faintest whisper of a particular sickly odor reaches my nostrils and I hold my breath before it can overwhelm; it is the smell of dead animals that leaks out from under the rolling metal shutters of a storefront market selling poultry, rabbits and guinea pigs.

On my right I pass a caged basketball court containing a teenage boy practicing his dribbling before-hours, the ball tied up tightly in plastic shopping bags to keep it looking brand new. The train clackety-clacks relentlessly overhead, mostly empty of passengers at this hour, as I turn the corner towards my hospital. I arrive at the front doors breathing heavily, full of energy, as the hot sun punches through the clouds overhead.

Remembering Your Humanity: The De-medicalization of Language

In Memory of Sheila Kitzinger, 1929-2015
Legendary Anthropologist & Birth Activist

Learning to function in a clinical profession means not only the study of scientific principles and the navigation of new social structures, but also the acquisition of a dialect of Medical English. This dialect, with its strange combination of Latin and Greek sources combined with 20th century secretarial shorthand, serves numerous purposes: to provide legitimacy to the clinical fields through their distinctiveness; to distinguish the speaker as an “expert,” a person worthy of respect in a social and professional hierarchy; to aid in accurate diagnosis and treatment by requiring great specificity; to distance the speaker from her subject; to save time. These purposes are variously beneficial and nefarious. Beneficially, for instance: I can draw no clinical conclusions from a woman’s report that she has “heart palpitations,” but were I to know that she has atrial fibrillation as a result of third degree heart block, I would be able to understand her treatment options and the risks she is facing to her health.

Where Medical English becomes dangerous is where it distances the care-giver from the cared-for. When a midwife sees 35 pregnant women per day in a clinic setting, for instance, those women are already in danger of losing their individual humanity in the midwife’s eyes because of their sheer volume. When those women lose their names, with each becoming the seemingly endearing “Mama” or “My love” (or “the ‘primip’ in Room 3,”), each is in fact one step closer to having her agency and power in the birth process removed from her. To name a woman is to know her, and when you know her it is hard to mistreat her. But when a birth becomes “a delivery” (with its connotations of saving, rescuing, or handing over) and a death becomes “a bad outcome” the midwife puts herself in danger of forgetting the unique role that she occupies: a guide through that liminal space of pregnancy before the act of birth, miscarriage, or abortion; a witness to joy and grief in life’s most intimate moments; a guardian of the power of women in times of vulnerability. A midwife is a psychopomp in the world of the living, and any language that seeks to shield her from that truth diminishes her, and diminishes those for whom she cares.

My last few weeks of midwifery training were particularly difficult, and I began to fall back on the distancing language of medicine in order to move through it all. I am grateful that I was gently reprimanded for this by a midwifery professor, after which I wrote the following journal entry. A brief glossary can be found at the end of the post.

*****

This week I am working on human words:

I could tell you that the first thing to occur that day was an NSVD: this week I am remembering that it was a birth. The birth of a girl child.

The day became late, and I could tell you than a G6 P4104 came in, or I could tell you that a woman named Daniela came in laboring, about to give birth to only her fifth child. I could tell you that she was not giving birth to her sixth child because she had been thrown down the stairs by her ex-husband during a previous pregnancy, and that the baby had not survived.

I could tell you that Room 2 arrived shortly thereafter with the FOB, or I could tell you that a woman named Selina came to us in labor, having been physically abused by the man who accompanied her, her husband. The same man who had thrown the previous woman, Daniela, down the stairs years ago.

I could tell you that I delivered both of them within minutes of each other, or I could tell you that I attended Daniela’s birth, ran to Selina to attend her birth, and then ran back to Daniela to repair her wounded vagina. I could tell you that they both had PPHs, or I could tell you that they both kept bleeding and bleeding, and while my preceptor did not want to use these words, I said out loud that they were hemorrhaging blood and needed medication to stop it. I could tell you that Daniela had a second degree laceration, or I could tell you that she was seriously injured while giving birth, that I tried to numb her vagina with lidocaine but didn’t do a good enough job, and that I caused her enormous pain while repairing that most sensitive area of her body. I could tell you that I haven’t thought about her since, haven’t wondered how long she will have pain, haven’t wondered if she will have numbness or have pleasurable sex again — but those would be lies.

I could tell you that the next marker of the day was a patient who came in with an IUFD: I have said that several times. I am working on saying that she was a woman named Katherine and that her baby had died. That it had been alive the day before when she entered the hospital and was diagnosed with a simple infection, and left with a prescription, hysterically crying, blaming herself for her infection. But when she returned today having not felt the baby move since 1am, and labored up and down the hall, and then received an epidural, and then labored down, what happened next was the stillbirth of her baby, a boy child. An IUFD has no qualities, does nothing; this baby that died had an unnaturally open mouth, and skin that came off when its paltry blanket was adjusted.

I could tell you about the two other patients who came in with PTL at 0230, or I could tell you about the two women who arrived in the middle of the night in labor too soon, whose cervices were dilated too far to be stopped, whose babies would arrive after seven months in the womb instead of nine months, who would likely live but with uncertain futures. Unequipped to handle more complication and trauma, we sent them to a nearby high-risk maternity unit by ambulance immediately.

I could tell you that I am almost a clinician, a healthcare provider, a CNM, or I could tell you that I am almost a midwife, and let it linger on the tongue.

*****

  • NSVD: Normal, spontaneous [not extracted with instruments like forceps], vaginal delivery.
  • G6 P4104: Gravida 6 [6 pregnancies, including the current one], Para 4104 [four births after pregnancies of least 37 weeks, 1 early birth (between 20-37 weeks), 0 miscarriages/abortions before 20 weeks, 4 living children. If all 5 previous pregnancies had produced living children, this last number would be a 5].
  • FOB: Father of the baby.
  • PPH: Postpartum hemorrhage.
  • 2nd degree laceration: a tear of the vaginal skin, mucosa, and certain muscles of the perineum.
  • IUFD: Intrauterine fetal demise.
  • PTL: pre-term labor (labor that begins before 37 weeks of pregnancy).
  • CNM: Certified Nurse-Midwife. That’s me.

A Walk Among the Headstones

Being a midwife is an intensely social experience; you spend much of your work day inquiring about the intimate details of others’ lives, advising, caring, comforting. It is work that I love, but that sometimes leaves me overstimulated and emotionally exhausted. I have found that there’s no better antidote for that flowering hyperdrive of humanity than taking a stroll among the dead.

*****

The clinic is a mess; women double-booked for prenatal visits, overflowing from the waiting room to the hallway. The nurse is loudly protesting the conditions of her labor. I, like a baseball player sliding into home plate, have finished seeing women for the morning just as the medical assistants are leaving for their lunch break. I have 60 minutes before it all starts again: the belly checks; the fetal heart tones bouncing around the room; the vague descriptions of skin rashes, itches, sharp pains. Mostly from women I have never seen before and will never see again.

My car is parked outside; I should eat, but I drive instead. I can’t stand to look at the pale clinic walls any longer, or to wonder what the temperature is outside while we sit inside, shivering in the air conditioning. Despite having come to this clinic every week for almost a year, so many of the surrounding streets are practically unknown to me — I turn left, then right, then right, then straight, seeking unfamiliarity after unfamiliarity. I come to the open entrance of the Hill Cemetery. There is a sign posted that is probably forbidding or limiting my entry, but I can’t be bothered to read it. I slow to graveyard speed, and enter.

Inside is a village of the dead: rolling acres, back streets and main streets. Ostentatious neighborhoods of the wealthy, their resting places built of marble up into the sky; cramped, cement-covered quarters of the modest; dramatic lookouts over the Hudson River, today made only for me and the legions of the unseeing. I wend through the silent hills, absurdly looking for somewhere unobtrusive to leave the car. There is nowhere, so I stop in the middle of one of the streets of the deceased.

After a frenzied morning surrounded by the living, I take peace in the silence of the passed-over. I am alone, and not alone. No one advertises to me, nothing demands my attention, and gentleness is prized. There is finality here — there are no decisions to be made. I move as slowly as possible; the harsh midday sun leaves my body confused, unsure where to hide. The sudden heat of a rapid-onset summer has killed the grass in swaths. Small yellow bulldozers sit halted, dotted across the still landscape.

I become aware of a distant rumble, of a figure riding a motorized lawnmower coming towards me up the path. I make apologetic movements for being in his way, and he motions back to me that I’m ok — and then drives up the hill and around me, narrowly avoiding the headstones. I feel momentarily guilty, reading in his face pity for my status as an apparent mourner. There is no way to explain my presence otherwise.

My mind wanders and when I snap out of it I find that I have walked hundreds of meters down a winding way to a cul-de-sac of graves plotted in a generous circle. At my back are a series of giant, toppled crucifixes, each snapped off at the base in some unknown incident of weather or time. At my feet: a small brick of granite sunken into the earth bearing the capital letters: BABY NAN. To the left, an identical brick with only the dates: JULY 9-JULY 16. To my right, the same diminutive brick again, this one blank.

Notes from the Clinic

As a student, one of my favorite places was not the L&D unit but the outpatient clinic, where we saw an endless line of women with every imaginable issue come in and out of the four cramped exam rooms. Some had infections, some needed prescriptions, some were pregnant when they didn’t want to be, some couldn’t get pregnant and didn’t know why. Sometimes they came alone, and other times they brought their children, their partners, their mothers, their friends. I carried around a little notebook in my pocket on those long clinic days, scrawling clinical short-hand so that I would remember the diagnostic cutoffs for gestational diabetes, say, or the ultrasound results indicating the need for an endometrial biopsy. I spent a lot of time being nervous about what I would encounter during a day at the clinic, as indicated by the following snippet that I found today in the back of my little notebook.

*****

What will I find behind the door?

The slightest grin, a quiet anticipation of the first sounds of the muffled, aqueous heartbeat so longed for?
Or a suppressed desperation, the dread of a tiny, internal gnawing, the hope that there is some explanation for this feeling other than a child that she does not want?
Or the tired, resigned sigh of a seasoned mother who knows how many more gray hairs another baby will bring, of the honesty she does not offer — dear God, let this be the last!

I scrawl my notes in preparation, I scan them one last time, I breathe deeply and close my eyes before entering.
I make myself like a blank page to be filled with the woman’s pleas and inquiries, her interpretations, her offers of thanksgiving.

Behind door #2 I hear a metallic crash, the unruly work of a toddler’s blunt fingers against a tray of medical instruments, followed by the swift, sharp: Jorge! Basta!
Behind door #3, a soft weeping, as she understands that the child will be born, but not live.
Behind door #4, the pointed cry of the cervix being gripped, of an IUD placed, of the pain she didn’t know was coming.

And I head to door #1 to deliver the measured, non-news we all want to hear:
Everything is alright, today. Today, there’s nothing for us to worry about.

I stand outside the fern-green door: she anticipates me from one side, and I anticipate her from the other.

The Long Wait, or, Other People’s Babies

During my midwifery training I worked 24 hour shifts on the Labor & Delivery unit of a community hospital. Several independent practices run by midwives or obstetricians admitted women to the unit; the practice with which I worked almost exclusively saw women who were recent immigrants to the United States, and who were insured by Medicaid (public insurance) due to their low household incomes. Women from the other practices tended to be higher-income and covered by private insurance. As a general rule, I was not allowed to assist with births unless they were for women whom we had cared for at our prenatal clinic, which is as it should be.

  *****

A woman has been hastily escorted onto Labor & Delivery; the familiar hissing noise of the unit’s automatic double doors opening brings me scurrying hopefully into the hallway. The curse of the student is the desire always to be considered worthy of assistance (pick me, pick me!), the anxiety ever present that you will miss out on that critical experience that will make you feel, finally, competent.

But I am shooed away from the room. The woman is “not mine,” I’m told: “one of the Privates.” I stuff my hands into my lab coat pockets and skulk back to the midwives’ office, where I sit flipping through stiffened back issues of medical journals.

The days without births are the longest days. It’s the nature of the time — not electrified with the rush of an impending new being, not suffused with the peace that finally comes when everything has gone well: a contented baby clasped against the chest of a beaming new mother; a feeling like that one, perfect note for which Miles Davis claimed always to be searching. No, the days without births are staccato; my mind only half-able to engage, always in a state of tension like a muscle ready to spring into extension. Without a release of that energy my mood turns sour by nightfall.

The hours wear on with all but one room standing empty and pristine; fresh bed linens and sealed, sterilized instruments await the flurry of activity associated with a new arrival. For now, this one woman has the L&D floor to herself.

To stave off restlessness I sit outside her room and listen to the noises of her labor through the drawn curtain: the rise and fall of her moans, her labor as a stringed instrument. The low tones of her doula, the uncomfortable interjections of her husband. I watch the patterns created by the dual monitoring of her contractions and the baby’s heart on a screen at the nurses’ station, trying to find a correlation with the human sounds emanating from below the curtain; I cannot.

My calves go numb from squatting against the wall and I rise to move the minutes along. I complete my rounds on the postpartum unit early, listlessly. The women with their new babies seem uninterested in another face, another interruption, further instruction.

Returning to the labor floor, I pass the visitor’s lounge; the three silent, grey-haired occupants can only be expectant grandparents. I make the mistake of lingering too long outside the door. My white lab coat has caught their attention and they turn with a start, in unison, to hear the good news of a new baby’s arrival. No news! I say, unsatisfactorily. No news is still news, says the grandpa. We’ll just wait here, the two grandmas say. We don’t want to be a disturbance.

The light through the windows changes from yellow to grey and I watch clouds creep over the broad sky above the Hudson River. I hear sudden shrieking coming from the hallway and rush out, anticipating an imminent birth; instead I find the nurses huddled around a screen in the empty triage room cheering for Spain versus the Netherlands. The birthing woman herself remains hushed, and I wander up and down the hallway silently reciting clinical algorithms to occupy my mind: Repeat pap smear in 12 months…Colposcopy if HPV 16/18 positive…10-day progesterone challenge followed by a withdrawal bleed…TSH will be high and free T4 will be low…

Finally, the corridor is filled with the sudden vocal peaks and exhortations to blow, to pant, that mean that a labor is ending, that a baby’s head will soon be born. I tiptoe to the curtained doorway of the woman’s room — That’s it! I hear, The head is born! Now just rest before the last push. I know that I have less than a minute. I quickly slap the oversized metal button that opens the L&D doors, and see the three grandparents-to-be poised in the hallway. I gesture sharply to them to hurry, mouthing silently, Come right now! They skitter through the doors onto the labor floor, and we form a semi-circle outside the woman’s room. One more push, we hear, and then the wave of joyous cries of the woman, her husband, the nurses, the midwife.

The grandparents look to each other — has it happened?

The husband’s relieved voice reaches us from under the curtain: It’s a girl. The grandmas weep, the grandpa cups his face in his hands, and then: the short, sharp cry of their first grandchild. One of the grandmas jumps up with delight, and tears line the cheeks of all three.

I retrieve tissues from the nurses’ station, pass them around and then simply hand over the box. It will be a while now, I whisper. They nod vigorously and silently and, clutching each other, return to the worn black couches of the visitors’ lounge.

Making Sense of What You See

A critical midwifery skill is to prevent (to the greatest extent possible) and repair the damage that can occur to a woman’s body when a baby is born. Sometimes, even if a laceration (“tear”) occurs in the genitalia or perineum, the best thing to do is to let the body heal on its own. At other times, suturing (stitching) of the damaged skin or muscle is required. While the hand skills of administering local anesthesia and suturing are not very difficult, learning to identify the relevant structures of the body in their damaged state and learning how to use one’s judgment as to where and what to repair is difficult and intimidating for any student. Here I recount a complex laceration repair that I observed early in my midwifery training. The woman’s personal details have been changed to protect her privacy.

*****

I have been on the unit for two minutes, and have forgotten to eat breakfast. I have missed a birth by a hair — I arrived early, but not early enough — and have had time to change and take a breath before entering Alba’s room. Her baby has been taken away (“Smelly baby,” the nurse whispers to me); its fever and odor indicate chorioamnionitis, an infection of the membranes surrounding the baby in the uterus. Alba is propped up with her legs open as the midwife finishing 24 hours on the L&D unit investigates her vaginal laceration.

It is not the worst laceration I have ever seen, but it is the most unfathomable. Is it a “2nd degree”? A “3rd degree”? How many muscle groups will need to be brought back together? The midwife has begun suturing but Alba bleeds and bleeds — she has already lost 600cc of blood, and has received misoprostol to stop the hemorrhage. I enter with the midwife coming on for the day, her bright pink lipstick meant to inspire energetic confidence. After being awake for nearly 30 hours, the midwife repairing Alba’s laceration is showing signs of exhaustion; the repair is seeming unmanageable to her. She has missed the deepest point of the laceration, and is now wondering aloud if what she has done needs to be removed so that we can start over. The new midwife relieves her, and tells her not to worry. She positions herself at Alba’s perineum and adjusts her glasses.

Sitting by the midwife’s side, what I see is: lacerated tissue on the right, lacerated tissue on the left. Blood: rivulets, seeping, the occasional tiny spurt. Swelling. Interlocking stitches and a suture hanging from the vagina onto a clean towel. I am allowed to insert one sterile hand into the deepest part of laceration to feel the tunnel it forms under the existing suture; I am thankful for the epidural placed during labor that allows me to do this without Alba feeling pain. I am allowed to offer my opinion on how to repair it — a few deep, interrupted stitches, followed by further interlocking stitches — and I am permitted to wonder aloud how to perform such a deep repair when stitches have already been placed. (Repair on the horizontal plane, I’m told, not the vertical.)

Alba continues to bleed. I feel lightheadedness creeping over me and think about the granola bar in my bag, wishing I had stuffed it into my mouth before coming into the room.

The midwife stitches, I blot and retract labia. She instructs me: Suture like to like, and I attempt to identify any two pieces of tissue that actually look alike to me. I watch her deftly place interrupted stitches deep into the wound, and she points out the borders of the intact anal capsule; a deep 2nd degree laceration, then.

And as she slowly repairs, the bleeding stops and the muscle and skin come together — seemingly by magic, although I know very well that it is no such thing. After two midwives, nine packets of suture, 30 gauze sponges and an hour and a half, Alba’s body looks almost as if no damage had been done at all. I tell her how brave she has been, and how we will make sure that she heals properly with no infection. I am sweating.

The midwife turns to me and narrates my thoughts in a low voice: When I was a student, I was sure I would never be able to do this.

 

Telling Hard Birth Stories

Today is a quiet one on my narrow New York City street; the still, cold air, thick with snow, seems to be keeping everyone indoors. From my window I can see a lone soul scratching at the sidewalk outside his doorway with a shovel; the dull sound of ice giving way from the concrete echos distantly. Such days put me in mind of birth, of the calm needed to allow a woman to proceed unmolested, of the womb-like protection that should surround the mother. A day like today, on which I feel so grateful to be sheltered by four walls and roof, makes me want to shelter others, to bring everyone in from the storm.

For the past few months I have been wanting to use this space to tell stories from the end of my training as a midwife, but I’ve hesitated because they are often difficult stories. They are not the joyful, life-affirming tales of an eager, almost-midwife. Instead they reflect my state of mind at that time: sleep-deprived; constantly worried that I wasn’t skilled enough; convinced that I going to harm a woman or her baby.

As I was finishing my training, I was preoccupied with the transition to the very serious role of becoming a clinical decision-maker, and my concern over what would happen to the women and families that I cared for became all-consuming. All of which is, of course, a recipe for the burnout I then experienced and from which it took several months post-graduation to recover.

I’ve been wanting to tell the story of the last birth I attended as a student, mostly because it was so glorious, such a ringing high note on which to end my training. Instead of the sudden complications and near-disasters I had been witnessing, that last birth went so beautifully that there was almost nothing for me to do but admire the woman in her elemental elegance. No one laid an unnecessary hand on her, and she gave birth to her baby “in the caul” — that is, still encased in the bag of waters — like a goddess giving birth to the moon. For those of you who aren’t squeamish about human birth, here is a video of what that can look like:

 

Not long ago I realized that I had also been wanting to tell that happy story first in order to cushion the blow of all of the hard stories to come. I hadn’t wanted to scare off the students or aspiring midwives that read this blog, to have them think that this tremendous work is all anxiety and sleeplessness and heartache. But I do want to record how I actually experienced that time of transition, so I will begin with a snapshot of what happened to me at the end of last summer, when I slept very little, and with a promise that these stories won’t last forever.

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I am starting to forget things.

I always remember to check total weight gain, blood pressures, immunization status, but it’s all the other things — my parents’ anniversary, what time I’m supposed to be at the dentist’s office, which day last week I met with a friend…I’ve lost my makeup case three times this week. I definitely remember going out for dinner last night, and I definitely remember coming home and eating blackberries on the couch — and then I woke up in a haze at 8am. I have a vague recollection of announcing, at 11pm, that I was “just going to take a little nap.”

I read through a woman’s prenatal chart and see my name at the end of two of her notes; there is proof that I’ve seen her before, though I have no memory of it. I see a woman in the clinic elevator and put on the cocktail party face meant to meant to communicate all things to all people: that I’m a friendly stranger, that I’m happy to meet you, or that I’m so pleased to be seeing you again. I wait for her reaction to tell me which one is the case.

Five hours is starting to sound like plenty of sleep to me, and I’m beginning to wonder if I’m the only one unable to function after a few days of so little rest. On days off when I can sleep for eight or nine hours I wake up feeling like all is well with the world, and then wonder what on earth I would do if I had small children and couldn’t sleep for eight or nine hours on these days off. The next night I get five and half hours again and feel as if I haven’t slept in a year.

Normal people, the non-future-midwives, can’t understand why I start getting nervous and looking at my watch at 9:00pm the night before a shift. And I can’t understand how the seasoned midwife who has been on for the past 24 hours greets me looking so fresh, makeup recently reapplied and hair repositioned just so.

On the nights when I lie awake for a few minutes before sleep, after reciting the Shema, I think of Keats: “Save me from curious Conscience, that still lords/ Its strength for darkness, burrowing like a mole;/ Turn the key deftly in the oiled wards,/ And seal the hushed Casket of my Soul.”