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.

*****

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.”

 

 

One Year Later: I Made It, and I Didn’t

This morning I awoke at 7am to a still-dark sky holding a perfect half moon. I had been awakened by gently insistent church bells from the village of Gissey sur Ouche, 200 km west of the French border with Switzerland, where the boat that I am aboard with my family had tied up for the night. The canal that we are traveling, the Canal de Bourgogne, was constructed some 200 years ago to connect the river Yonne at Laroche-Migennes with the river Saône 242km away at Saint Jean-de-Losne. Once an important commercial artery, the fact that this distance can now be accomplished by car in a day has rendered the canal the province of pleasure-seekers and those otherwise committed to inefficiency in their travel, which I certainly am.


My sister recently pointed out to me that it has been a year since my last post here, which is as good an excuse as any to begin writing again. During the years that I lived in China, so full of travel, love, and outward explorations of the world, I would often think, “Now this is what it means to be living.” In the year that has passed since my last post, I have had times of great happiness, but they have occurred in the context of being truly lost, overworked, sleepless, and even despairing. As I stood on the deck this morning — the cold air heavy with fog an undeniable sign that autumn is here, an unmistakable reminder of the winter that is coming — I felt a tiny dread, an echo of last year’s endless winter that broke my heart and presided over the utter disintegration of my personal life. This too, is what it means to be alive, a part of the “life’s rich pageant” to which my father increasingly refers.

One month ago I passed my comprehensive exams and national boards, which means that I have graduated and am now a Certified Nurse-Midwife, just under five years after I first realized that I was not going to work in public health forever and began hatching a plan for change. In the past year, I have provided prenatal and gynecologic care to hundreds of women, attended to the health of their newborns, lost track of the number of births I witnessed, welcomed several dozen babies into my hands. I learned how to diagnose and treat infection, how to repair lacerated skin and muscle, how to prevent death by hemorrhage, how to dislodge a baby stuck behind the pelvis, how to revive a baby who comes into the world and does not breathe. I began to learn how to tell a woman that the pregnancy she thought was healthy is now over, how to tell her that her diagnosis of infection means her husband has been unfaithful, how to tell her that she may have cancer. There was rarely a day in which I didn’t make a mistake; thankfully these usually didn’t cause irreparable damage.

I am awaiting the arrival of my license to practice midwifery in New York, regrouping mentally and physically, and looking for work.

In the course of finishing my midwifery training, I was required to do some writing by my program director, lest the entire period pass without deliberate self-reflection. I now have time to look back over this writing and I am struck by how much sadness and fear it evinces, instead of the joy you might expect from someone finally learning the craft that she had admired for so long. Perhaps this is a product of the innate seriousness of the work of caring for women and babies. Perhaps it is a product of the shadow that came over my life when I learned how to care for strangers but forgot how to care for those closest to me. It certainly reflects my ongoing criticism of the damaging institutionalization of maternity care, which does everything in its power to remove power and agency from women and transfer it to the institution itself. I hope that it doesn’t reflect taking for granted the happy outcomes — a healthy woman, a healthy baby — because I have learned how far from certain these outcomes are.

So I will begin posting some of that writing here, and maybe you’ll tell me what you see in it. Next time I’ll start, at least, on a high note: the final birth I attended as a student.

“Sometimes You Have to Just Walk Away…”

There is a particular statement that I have heard on Labor & Delivery units — not just on one, but on every single unit where I’ve attended women’s births. I have heard it from nurses, I have heard it from OBs and anesthesiologists, I’ve even heard it from midwives.

What happens before the statement is made is that a woman is laboring. She is in pain, and she is doing something to express that pain: perhaps she is calling to her family members for help; perhaps she is unable to keep still in the bed, causing the fetal heart monitor to fall off. Perhaps she is saying over and over that she can’t get comfortable, or begging to be allowed up out of bed to walk, although she will not be allowed to because of her epidural. She may be asking why she is still in pain despite the fact that she had an epidural. She may be loudly vocalizing her contractions — she may be screaming as they occur. Perhaps she has been doing some combination of these things for hours.

The nurse has wandered in and out of the room and said that the woman can’t possibly be in that much pain at only 4 centimeters dilated. The anesthesiologist has been called in and swears that the epidural is in correctly and that the woman is just feeling pressure, not pain. The midwife, shame on her, has stood three feet from the woman’s bed and said that she can ask the anesthesiologist to replace the epidural catheter, if that’s what the woman would like.

Everyone clears out into the hallway, leaving the woman alone in her room. And then someone turns and says to me, the student, as if offering some great wisdom: “Sometimes you have to just walk away and then she’ll calm down.”

I am recording this here because this statement should never become normal or acceptable to me, no matter how nonchalantly it is said, no matter how reasonably intentioned the person who says it. Bear in mind that I don’t mean a situation where a woman asks for privacy to labor (privacy being something that she will never get in a hospital), but rather one in which the clinician judges that the woman would be better off by herself.

The assumption behind this statement is, first and foremost, that the woman will essentially be alone in her labor. There is no expectation that she should be continuously supported throughout labor (as has been shown over and over again in research to lead to the best outcomes), no expectation that one should do anything other than spend a few minutes at a time dealing with her.

This statement also represents the feeling that a woman asking for help in labor is, after a certain point, just a complaining, attention-seeking, pain in the ass. Her pain, discomfort, or distress isn’t real — especially if you already gave her medication. She’s just being melodramatic, and what she really needs is for you to ignore her a little bit so that she can spend some time alone in her room. Like a child. You acknowledge that the woman is having anxiety and frustration — and your reaction is to walk out.

I have recently had the realization that the people who make this statement are also fundamentally ignorant — despite being professionally involved with women giving birth, they have almost no idea how to comfort them, calm them, and make them feel cared for. It’s not exactly their fault; most clinicians have lots of patients and are taught to use very few tools to relieve suffering apart from epidural anesthesia. Nevertheless, it is galling to see that this is apparently good enough for them, and that they consider it natural not just for women to be in pain in labor, but to suffer deeply as well. (The difference between these things is a topic for another time, but sufficed to say that they do not have to go hand in hand.)

Finally, this statement begs an obvious question: If you’ve left the room entirely, returning only hours later or when she shouts loudly that she is going to push the baby out right now so you’d better get in here, how on earth would you know if you helped her to calm down?! You left her alone, you fool — you have no idea whether she is curled up in a knot of suffering, or whether she’s actually glad to be rid of your ham-fisted, anxiety-provoking presence.

I know that there are some future midwives reading this post, so my reminder to all of us is this: the next time you hear someone offer you this particular “wisdom”,  remember that a gentle hand, a low voice, and a calm, steady presence can be the difference between a happy, healthy birth and a violent, traumatic one. Go back into the room and stay with her.

Encountering the Newborn

When I first decided to become a midwife, people would often remark, “Oh, you must just love babies!” or “You probably can’t wait to have your own babies!” (Do people who announce they want to become obstetricians get the latter reaction too? I’m guessing not so much.) In reality, midwives mostly care for babies when they’re still inside the mother. Midwives take care of women, pregnant and not; once a baby is out in the world, it’s generally the midwife’s purview only for the first few weeks of life.

The truth is that prior to nursing school, I didn’t think that babies, especially newborns, were all that fascinating. I was sure I would be fascinated by my own, but newborns as a whole seemed largely to sleep, and when they were awake they seemed largely to scream. Nothing too thrilling there.

Then I got to do my OB nursing rotation, and had an excuse to spend hours inspecting newborns: observing their entry into the world and their adjustment to its climate; their experimentation with their limbs, muscles, joints; the perpetual, quiet movements of their mouths; the almost elderly expressiveness of their foreheads.  As obvious as it may seem to anyone who has actually had a child, I discovered that for the brief periods when newborns are awake and alert, they get up to plenty of very subtle business. You just have to be paying attention to see it all.

But there is an encounter even beyond that. If you are attending a woman’s birth, and you get very lucky, you get a chance you stare into the eyes of a human being only a few minutes old. The conditions must be right: the room cannot be so bright that the baby refuses to open its eyes; the nurses cannot have applied so much antibiotic ointment that the baby physically cannot open its eyes; the baby cannot be too exhausted from a difficult labor or too dopey from analgesic drugs — and of course, the woman has to allow you to do it.

Today I got lucky. Despite enduring a long labor, the tiny girl emerged pink, alert and calm. Once she had been tidied and bundled according to hospital policy, and had a chance to be adored by her mother, I held her while the mother made herself comfortable on the bed. The girl fixed her eyes on mine, and I was reminded of the special color of the irises that only newborns have: a deep, dusky blue like the lightless ocean floor.

As a child, I remember the first time that I stared into the eyes of a bird — a pet canary — and was startled and frightened to find that they were not human eyes. It was my first understanding that my perspective was not that of all creatures, and that the minds of almost all others would be unknowable to me in the most fundamental way.

The eyes of a newborn force me to confront this fact again; there is a recognition that we come from the same root, but their look is otherworldly, ancient. As if they were a new immigrant from another universe. I am reminded that they have just gone through a process that I also went through, but have irretrievably forgotten. The preciousness with which we cradle them seems the only reasonable response.