Hard Pushed

by Leah Hazard

  I can’t speak for every midwife everywhere, and I don’t pretend to be devoid of my own irrational preconceptions, but for me, these distinctions between women who ‘should’ and ‘shouldn’t’ be pregnant are as meaningless as they are unhelpful. Each of us exists only as a unique and infinitely unlikely cosmic coincidence: would you be here if your father hadn’t caught a whiff of your mother’s perfume one afternoon on the number 66 bus or if your grandparents hadn’t kept trying for a baby even after twelve years of wishful failure or if your great-great-great-grandmother hadn’t fled her home country to seek safety in the land where your great-great-great-grandfather lived and was lonely, desperate for a bride? To question the worth or wisdom of any pregnancy is inherently hypocritical, but for a midwife, it’s a particularly moot point. By the very nature of our job, by the time we meet a woman, she is pregnant, she is in our care. The deed is done; now keep her safe.

  Eleanor: Defying the Odds

  Eleanor was one in a trillion: a human anomaly, a pregnant fluke, a walking, gestating embodiment of improbability. As I prepared a room for her in the labour suite at the start of one night shift, I had no idea that I was creating the backdrop for a scene that would defy every possible law of luck and nature.

  The sister in charge had simply barked, ‘Set up a room’: the command that precedes every labourer’s arrival, from the bright-eyed primigravida to the world-weary para four. To the patient, the room is a blank slate: you see the bed with its starched sheets, the wipe-clean chair, the cot with its teddy-bear flannelette. Each item appears freshly minted, placed there just for you by an unseen yet benevolent hand. To me, the empty room is already crowded with the ghosts of all the women I have ever looked after in that space; the babies I have rubbed frantically with towels at the Resuscitaire, willing them to cry; the splashes of blood I have wiped off the floors; the dip and weave of all the fetal heartbeats I have listened to in the wee small hours, crossing my fingers and chewing my lips with worry. What will it be this time? I wondered as I drifted into room two, where the floors were still wet from the auxiliary’s mop.

  This particular night’s patient was still a mystery to me, but the routine of setting up was comfortingly familiar: first, arrange my stack of paperwork in a neat pile on the worktop next to two white name bands that would go around the baby’s ankles. Check the Resuscitaire: flick on the overhead lamp, placing a bundle of soft blankets and towels beneath it to warm. Check the pressure in the oxygen, in the suction; flinch as the air cylinders shriek when I turn their valves. A tiny nappy to the side, a plastic clamp for the baby’s cord; a pink hat, a blue hat and a lemon-yellow hat with a jaunty orange stripe running through it, all knitted by the anonymous grannies who provide us with a steady supply of bonnets and cardigans. I moved around the room, plumping pillows on the bed, switching on the monitors, opening the cupboards to make sure that every possible item I might need in the next twelve-and-a-quarter hours was present and correct: gloves, jelly, a selection of needles of different bores and gauges, catheters, cannulas, IV fluids, fetal scalp electrodes, the aptly but terrifyingly named Amnihook; all the tools of my trade were there, from the basic to the brutal.

  There was a brisk knock at the door and I opened it to find Fatima, a midwife from the antenatal ward, bearing a thick sheaf of case notes.

  ‘Hey, Fatima,’ I said. I looked over her shoulder. ‘Where’s the patient?’

  She laid the case notes down on the worktop and nodded towards the corridor. ‘You’ll have a good night. They’re lesbians,’ she whispered, ‘but they’re lovely.’ I laughed inwardly – should it be a surprise or an exception for lesbians to be lovely? – but I was glad of the glowing report. This informal part of the midwife’s handover is just as important as the summary of the patient’s clinical history: your hopes for a shift can live or die by an optimistic, ‘She’ll do great,’ or a dry, ‘Good luck with this one.’ I craned my neck to peer further along the corridor and heard peals of laughter before I saw Eleanor waddling towards me. She had glossy dark hair, a scattering of freckles over a golden-brown tan and a perfectly round bump straining beneath a black-and-white striped top. Everything about her overall appearance and the slow, easy roll of her hips suggested vibrant good health and the intangible energy of a woman on the precipice of labour. As she finally reached the door, she pretended to collapse against the frame.

  ‘Right, that’s it,’ she said, panting in mock exhaustion, hand on hip. ‘I’m knackered. You’ll just need to press “eject” and get this baby out for me, I’ve got nothing left.’

  I smiled and winked at Fatima as she left the room. ‘I’ve been looking for that eject button for years and I still haven’t found it,’ I quipped. I went to close the door behind her, then stopped. ‘Is there anybody here with you?’

  ‘She’s just coming,’ she replied. ‘She’s a wee bit tired.’

  I was about to say, ‘My heart bleeds for her’ – the standard midwifey riposte for the birth partner, male or female, who claims to be suffering from pains, cramps or niggles while the mother-to-be is tied up in knots with gut-clenching contractions. Anyone who is unfortunate enough to admit that he or she faints at the sight of blood is met with an even less forgiving reply: ‘If you pass out, we’ll just step over you.’ However, when I saw the gaunt figure lurching up the corridor, every snappy comeback faltered on my tongue. Where Eleanor was the archetypal picture of a glowing pregnant woman, her partner, Liz, brought tangible meaning to the phrase ‘a shadow of herself’. Her skin was so pale as to be almost translucent, eyes edged with violet smudges of fatigue, her body stiff and frail. She had obviously made an effort to look smart for the occasion – crisp white shirt, indigo jeans and buttery suede loafers – but she looked more like a gangly teenager dressed up in her big sister’s clothes, an effect heightened by the blue knitted beanie hat pulled down over her ears. Liz’s shuffling gait finally brought her to the room, where she paused, sighed deeply and braced a skeletal hand against the door.

  ‘Where’s the baby?’ she said. ‘I gave you enough bloody time getting up that corridor, I thought you’d have given birth by now.’

  Eleanor held Liz’s face in her hands and squeezed her cheeks playfully. ‘You big daftie,’ she said, laughing. ‘I’ve had twins – they’re away home in a taxi.’

  Liz smiled and kissed her wife. ‘What a woman,’ she said weakly.

  I already felt as though I were interrupting something; whatever had happened to Liz, it had obviously only served to bring her and Eleanor closer. Every couple that come to the labour ward bring their own dynamic: some are already fractious and tense, any cracks in the relationship magnified by nine tumultuous months of pregnancy, while others, like Liz and Eleanor, present an intimacy that’s wonderful to behold, but which is virtually impenetrable to even the wiliest midwife’s best efforts. Nevertheless, a good birth can sometimes hinge on the partnership and trust between a woman and her midwife, and a good midwife is skilled in establishing a rapport as quickly and effectively as time permits. This will be interesting, I thought, as Eleanor and Liz entered the room, their movements mirroring each other with the subtle twinning of the most harmonious couples.

  ‘Welcome to Labour Ward,’ I began, gesturing to the room around us. ‘This is where the magic happens. Go ahead and make yourselves at home while I have a quick read of your paperwork.’ Liz flopped into the pale green easy chair in the corner of the room while Eleanor rifled through bags for a nightie and I began to leaf through her notes, scanning the pages for any clue to Liz’s condition. So far, so normal. Eleanor was a flight attendant, Liz was a pilot; it was Eleanor’s first pregnancy, using donor sperm and Liz’s egg, but that in itself was unremarkable in a time when assisted conception has become almost commonplace. Over the course of my training, I’d become accustomed to caring for women whose babies were conceived in labs in every corner of Europe; every combination you can imagine of donor and surrogate egg, sperm and womb – I had seen it. Gone we
re the days when ‘test-tube babies’ or same-sex couples (or both at once) raised any eyebrows in a hospital seeing many thousands of births a year and getting busier all the time.

  I kept reading, flipping through sheets of routine scans and blood tests, while Eleanor shimmied into a hot-pink nightgown and Liz shifted gently in her chair. Then, in a typed letter from the consultant to the GP, tucked away at the back of the folder, I found what I was looking for:

  Eleanor underwent three cycles of IVF using her wife Liz’s eggs and donor sperm from Denmark. The final cycle has, happily, resulted in a continuing pregnancy. However, Eleanor tells me that two weeks after conception, Liz was diagnosed with breast cancer and is likely to require surgery and chemotherapy during the course of her wife’s pregnancy.

  I looked up from the notes. Eleanor was toying with the stirrups on the end of the bed and leaned over to whisper something in her wife’s ear, cackling filthily while a blush temporarily illuminated Liz’s wan face. Not only would it be difficult for me to work my way into their cosy circle of two, but they were going through an ordeal of which I had no experience. At this time, my life was remarkably untouched by cancer and although I had seen friends and colleagues grapple with its horror, the illness was something that I could then only pretend to understand.

  I cleared my throat, and ventured, ‘You’ve had quite a time of it.’ They both looked over; they seemed to have forgotten that I was in the room and were still smiling sheepishly at whatever private joke had passed between them. I was aware of my voice’s false, brittle brightness echoing around the room; nevertheless, I continued. ‘So, how are things now?’

  ‘Things are really good,’ Eleanor said, her eyes still on Liz. ‘Liz had a double mastectomy and she’s had four cycles of chemo so far. She’s still got a few more to go, but she’s been an absolute star.’

  ‘That’s amazing,’ I replied, painfully aware of the insufficiency of my words. And then, to Liz, ‘How are you feeling?’

  She leaned back in the chair. ‘It’s …’ She sighed and looked at Eleanor. ‘It’s complicated, as they say. Obviously, I’m so excited about the baby and the doctors say there’s a decent chance that I’ll be cancer-free in the long term, so that’s the main thing, but … I’m tired. It’s like the worst jet lag ever, and I mean, I’ve had some jet lag in my time.’

  ‘You’re a pilot?’

  ‘Well, I was, I mean, I am, but I’ve been grounded by this whole thing.’ She smiled grimly. ‘Cancer is a no-fly zone, apparently. And it’s shit for your hair.’ She lifted a corner of the beanie hat to reveal the smooth baldness underneath and, as she did so, I realised that her neatly arched eyebrows had been stencilled on with painstaking precision. I wasn’t sure whether to smile, laugh, commiserate or all three. I couldn’t pretend to understand what she’d been through; all I knew was that this night was only one of many staging points on a long, hard journey. The best I could do was to infuse our brief time together with a little love; not the romantic kind, but the kind that every midwife magics up for new parents whom she may never have met before. It was an instant, automatic love that I was used to giving unsparingly, and these two women were welcome to their share.

  Eleanor was sitting on the edge of the bed, listening intently to Liz. She reached over to squeeze her wife’s hand. ‘Liz might need a bit of a disco nap at some point,’ she said. ‘It’s been a while since we pulled an all-nighter.’ She winked at Liz and Liz smiled again, weakly this time.

  ‘Disco naps are no problem,’ I reassured her. ‘Eleanor and I are in the Wide Awake Club, but you chill when you need to. Sit back, relax.’ I nodded to the radio, which was thrumming gently with some late-night reggae. ‘Enjoy the beats.’

  As Eleanor and Liz settled in, murmuring softly to each other under the music and drawing their cloak of intimacy back around them, I began to make the familiar preparations for this final stage of induction of labour. In many hospitals, induction is a standard approach to childbirth for women who’ve conceived via IVF; this practice hangs by a slender thread of evidence, but as is so often the case in our increasingly litigious culture when there is even a whiff of risk, it has become the norm. 2x hormone pessaries given and cervix now 3cm dilated, Fatima’s most recent notes declared in bold, looping script. Fine, I thought; protocol dictated that I would next break Eleanor’s waters, to bring the baby’s head into direct contact with the cervix, encouraging stronger contractions. For women who have already had a baby, this is often enough to tip the body into full-blown labour, but for first-time mothers, a slow drip of synthetic hormones is usually also needed to kick-start the uterus. Just as a chef would gather all the ingredients and utensils required to bake an elaborate cake, so I began to set out the instruments and medicines that would be required to encourage Eleanor’s baby into the world. I laid an examination pack, gloves, jelly and an Amnihook on the wheeled metal trolley by the bedside before turning my attention to the drip. I opened a tiny glass ampoule of Syntocinon with a satisfying snap, then drew up its contents and injected them into a large bag of clear fluids that would be run through an electronic pump at a carefully modulated rate, ratcheted up in half-hourly increments until Eleanor was in the throes of labour. Just one millilitre of this hormone – sometimes referred to as ‘the good stuff’ or even ‘jungle juice’ by the more jaded among us – was enough to move mountains.

  ‘If it’s OK with you, Eleanor, I’d like to do a baseline examination now and break your waters,’ I said, concealing the Amnihook with careful tact behind the other packets on the trolley. ‘You’ll feel lots of cold jelly and some pressure, but it shouldn’t hurt. If it becomes too much for you at any time, tell me and I’ll stop straight away.’

  Eleanor grimaced and began to hoick up her nightie. ‘Usually I would at least get taken out for dinner and drinks before this kind of carry-on. I’ve never had so many fingers up my fanny in my life.’

  Liz raised a neat eyebrow and chuckled to herself.

  ‘Never mind,’ Eleanor said as she opened her legs. ‘Wire in.’

  I washed my hands, gloved up and did what was needed, sliding the Amnihook in towards the bag of waters and tugging gently at its membrane until I felt the familiar pop. A stream of fluid begin to run in clear rivers onto the paper mats I’d pre-emptively wedged under Eleanor’s bottom. I bundled up the sodden pads and replaced them with fresh ones, which were soaked as soon as I laid them down. Two more pad changes later and the warm flow had slowed to a trickle. ‘Job done,’ I said, smiling, as I pulled a fresh sheet up over Eleanor’s legs. ‘Your waters have gone and the drip is up. We’ve reached cruising altitude.’

  All was serene. Eleanor tied her hair up into a loose ponytail, smoothed down the front of her nightie and relaxed back onto the pillows of the bed. Liz slipped off her loafers and slung herself sideways in the chair, her feet dangling over one side. The CTG monitor drummed reassuringly; the baby who would never have existed without the many wonders of modern science was letting us know that all was well in spite of its watery pool being suddenly drained. 22.00, I wrote in Eleanor’s notes. Patient is resting comfortably, fetal heartbeat 128 beats per minute, uterine activity mild and crampy, clear liquor draining.

  Eleanor closed her eyes and shifted on the bed. I could see the first shadows of discomfort playing across her brow, but she breathed deeply and was able to sigh them away. ‘You must be so bored,’ she said, eyes still shut. ‘Don’t you want to take a break?’

  I waited for Liz to respond, but her eyes were also closed.

  ‘Who, me?’ I said.

  ‘Yes, you … it must be so tedious just watching women lie there, waiting for something to happen. I mean, I’m totally fine.’ She grimaced, shifted again, and opened her eyes. ‘I feel terrible making you wait. Don’t you want to get a coffee or read a magazine? I’ve got a few in my bag.’ She prodded Liz, who was deep into her first snooze. ‘Lizzie! Get the midwife those magazines – they’re in the side pocket of the blue case.’
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  I laughed at Eleanor, ever the accommodating flight attendant, trying to look after me and keep me comfortable even as the roles were reversed. I could imagine her striding down the aisle of a 737 with her trolley of drinks and snacks, winking and twinkling and playing to her adoring audience as she tonged ice cubes into plastic cups of vodka and Coke. It was harder to imagine Liz in the cockpit, quietly confident at the controls, sharp-eyed, healthy.

  ‘Please don’t worry,’ I said. ‘I’m pretty sure you’ll be keeping me entertained.’

  It’s a strange thing, watching someone cross over into the shady world of pain, and it’s an even stranger thing to find yourself willing them to make that journey. As a midwife, you know that it’s possible to be ‘far too comfortable’. It is your role to chaperone your patient into Labourland, giving her the odd nudge and budge, sometimes watching her rush on ahead of you, sometimes taking her by the hand and pulling her deeper into unknown territory if she straggles or strays behind. You want your patient to be niggly, to be sore, to hurt and yet, at the same time, you are desperate to give her solace, to show her that she is loved and safe. I watched as Eleanor did the familiar dance of the early labourer; she moved her weight from one side to the other on the bed, then perched on the edge of the mattress, then heaved herself over onto all fours with a groan as the drip began to work its wonders on her uterus.

  Patient becoming uncomfortable with uterine activity now moderate, 3 in 10 minutes, lasting 45–60 seconds. FH 142 bpm. Syntocinon IV runs at 36 mls per hour, I wrote, then smiled as I put my pen down. You may think this was cruel, but I knew that the quicker Eleanor embarked on her voyage across labour’s stormy seas, the quicker she would reach her destination.

  The sound of Eleanor’s pain must have reached Liz even in the depths of her fatigue; her eyes flashed open and she looked around in panic at her wife, and at her surroundings, until she realised where she was and what was happening. Leaning in to Eleanor, whose face was burrowed in the pile of pillows on the bed, she asked, ‘You OK, babe?’