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.

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.