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.

4 thoughts on “A Night in Three Acts

  1. So well captured. Some of my nights have looked quite similar. In fact reading this is my bed time story as I try to sleep in the on call room🙂 miss you!!

  2. Brilliant, brilliant, brilliant !

    You choose telling details to put us there and are wonderfully clear at sharing your own feelings.

    You’re a *great* writer of course and very appreciated.

    Richard Selzer would be proud to have you as an author/medical colleague.

    Bill in FL

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