A Life in Medicine

by Robert Coles

  I yearned to have a more experienced professional explain to me what was going on but I was reluctant to discuss my statistics, which were becoming astounding, with my mentors back at Booth Maternity Center in Philadelphia. Once I mumbled something about them and it was suggested that I wait for the other shoe to drop. That sounded like good advice, so I kept my mouth shut and maintained my style of attending women. I kept the hospital ways I had been able to bring with me into homes. I stayed with the women through the early parts of their labor, I scrubbed carefully, I watched the clock, I shone a strong flashlight on the perineum while I worked, I recorded elaborate detail on charts.

  One August night, I was led yet another time by a typical Amish husband into a typical Amish bedroom. Silla, the mother, was propped up in her bed in a moonlit room calmly awaiting my arrival. She smiled, and then, conspiratorially, placed her index finger to her lips. She beckoned me to her side, pulled my head down so my ear was next to her mouth, and whispered. Would it suit me, she wanted to know, to leave the lamp unlit and to talk quietly? Her two-year-old, Joseph, was asleep in the corner of the bedroom and she didn’t want to wake him.

  My first reaction was to disabuse her of her easygoing confidence by lecturing her on the disasters that can accompany birth: how babies’ lives had been saved because practitioners had picked up a tint in the amniotic fluid (waters), because they had been able to use their scissors precisely, because they were able to see when the color of a baby’s face shifted. But while I was preparing this speech, my eyes followed Silla’s over to damp, tousled Joseph, sleeping in his crib as contented as a puddle after a summer rain; I glanced at Silla’s husband, who had competently assisted me at Joseph’s birth, and I realized what was bothering me. If I assisted Silla as she requested I would be admitting that birth probably could be trusted.

  My decision to do so was based on a number of considerations. I knew, for example, that Silla had had four births, each of them manifestly uncomplicated. This pregnancy had proceeded in perfect order. I knew that she was a responsible person, one who would not cling to her request for quiet and darkness if circumstances changed. I knew Joseph could flare up a lantern in an instant. I acknowledged that Joseph and Silla had a mature and subtle religious faith, one that embraced, as God’s will, the unpredictable turnings of nature. I decided, in other words, to trust the accumulation of my experience among the Amish and the judgments that followed from it.

  I held the flaps on the locks of my medical case so they wouldn’t click; I stepped out into the kitchen to tear open the packages of rubber gloves; I laid my flashlight on the doily on the bureau so it wouldn’t startle; I used my stethoscope instead of a doptone (which throws the sound of the baby’s heartbeat around the room); I heard the bedsprings creak when Silla’s husband climbed onto the bed beside her. Within the half-hour, I felt the slippery dome of a baby’s head filling my palm and their little girl eased out. I slid her onto the mounded landscape of her mother’s abdomen.

  I reached over toward her and saw that she was breathing, that her eyes were open, that they were avidly exploring the bedroom around her. She was as alert and as clear-sighted as a person who has just risen out of deep meditation. When a smile slipped across her face, her perfection skimmed through me. She had come up as effortlessly and as reassuringly as the sun.

  I had never seen a smile on the face of a child at birth; indeed, I’d never heard of such a thing. And even supposing, as I did later, that it was just a look of contentment I’d seen, the impact remained the same. If birth could be as easy for a mother as it was for Silla and as comfortable as it apparently was for her baby, then I needed to be able to explain why and how. Urged along by that confounding child, I began to think systematically about the causes of power and grace.

  I knew that my clients’ births were favorably influenced by the women’s general good health. They scrub floors on their hands and knees, sling baskets of wet wash about, climb stairs, work out in the fields, and squat in their gardens. The air they breathe is relatively unpolluted. They don’t drink or smoke and, while their diets are not ideal, they are quite adequate. Also, their bodies are not assaulted every day by the psychological stresses of urban life. These are such important physical advantages that, in theory, they should have served the women equally well no matter where they gave birth.

  The theory, however, held up no further than the local hospital where, I knew from experience, the general population of Amish women had more difficulties than those who gave birth at home. There seemed to be several possible explanations for this phenomenon: It was something that doctors, who practiced in hospitals, did at delivery; it was something that midwives, when they practiced in hospitals, did at delivery; it was the hospital environment itself; or it was some combination thereof.

  As I considered the first possibility, the doctor-assisted hospital delivery, I recalled the description one Amish woman had given me of her first birth. Mary seemed to be a good case for analysis because she’s a serene person, one unlikely to exaggerate problems. Furthermore, unusual in an Amish person, she’s quite well read. Instead of marrying at twenty or twenty-one as so many do, she taught in an Amish school for eight to ten years before she met Jonas, also a schoolteacher, and they married.

  Pregnant with their first child, they asked around and found a physician who was reputed to be both kind and informative. They went to the library and got out books on painless childbirth, which they read at night, sitting at the kitchen table. Attending classes on how to have a baby naturally, they learned that shaves and enemas were outmoded and that lying on one’s back during labor was “the worst.”

  “Apparently,” she said, telling me about her first labor, “the hospital staff and my doctor . . . hadn’t been informed [about the innovations in childbirth]. No one had told me I needed to lie on my back so the nurse in attendance could watch my contractions on the screen.” With typical Amish humility, she added, “But who was I to inconvenience the nurse”—who was constantly checking her and adjusting the “cold” monitor on her stomach “which made the contractions seem worse.”

  She, a woman accustomed to backbreaking farmwork, found the pain “well-nigh unbearable.... With each contraction I felt as though a nerve was being pinched in the vagina. I wanted to scream but dared not, fearing I would lose all control.” Entreating God to keep her from screaming, finding her praying capacity weak, she turned to Jonas and asked him to pray for her. He did, but told her later he thought she was contemplating death. “It was unthinkable,” she said, describing the retreat of her dream of having a houseful of children, “that there’d be another time.”

  When she was ready to push, the nurse said that the doctor had not yet arrived and that she should pant through her contractions. In the meantime, while she panted, they moved her from bed to stretcher and from stretcher to delivery table. “The doctor breezed in cool as a cucumber” just as a contraction rose and she moaned.

  “ ‘Don’t you start screaming!’ [he said].

  “His abrupt tone of voice was not lost on me.

  “ ‘Slide over,’ came the next command.

  “Apparently I wasn’t dead center on the table.

  “Flat on my back, feet in stirrups, sheet hiding the lower part of my body, the doctor, and some of his gazing companions, I gave birth to a son. I heard his cry. I thought he was mine. I wanted him on my stomach and at my breast.”

  She wanted to hold him, the first-born child of a long-awaited family-tobe and she wanted him for the sake of her body, she said, remembering her reading and that his suckling at her breast would contract her uterus naturally and force the placenta out. Instead, empty-armed, she felt a shot of Pitocin, the contraction-stimulating drug, stinging her thigh. Only after they extracted the placenta did they give her the baby. He was “blanketed, blond, wide-eyed” and “I laughed for the joy of him.”

  She wasn’t allowed to keep him, however, because the episiotomy gaped. They took the baby away; she
began to shiver and begged for a blanket, which they brought: a “nice skinny” one, “suitable for a July night.” The doctor began a long sew. It went “on and on. I hadn’t known this doctor to be a seamstress or a tailor.... I was no longer numb . . . I’d feel him sewing.” The pain from the stitches kept her from sitting for a week.

  “So much,” she said cynically, “for the most lauded event of a woman’s life. I cried until I couldn’t cry anymore.”

  The nurses, by contrast, called it a “lovely” birth. And for them, encountering this quiet, loving, and well-educated couple, it probably was. One becomes accustomed to routines—including cutting of the flesh—and can get in the habit of not questioning their necessity.

  But if you are not accustomed to it, it is shocking to see vibrant muscle cut. I think of muscles as being strung out on our bones like strings on a cello—vibrating with potential, as if for an extended concert. I dream about a batter with his shirt off and the graceful cresting of power that curves up from the small of his back, across his shoulders, and down his arms. To interrupt that progression of movement is an esthetic crime, and I feel sure we wouldn’t do it if it were avoidable.

  If a ballplayer was on a table in the operating room and if there was no other remedy but surgery, the prospect of cutting his muscles would still be sobering. Seeing him prepped and draped, we would know that everything possible had been done. Physical therapists with their baths, exercises, and massages would have exhausted their repertoire, specialists with slings and elastic bandages would have signed off. Only then would they resort to the knife.

  Maybe we don’t think of these women’s muscles with the same regard because of where they are located. We don’t see them crossing and gliding as they make our hips swing; we don’t watch them spreading into broad ribbony bands when we squat down. We don’t imagine them roiling with sex. Because we can’t see them, maybe we think of them as static, a crude vessel fit only for containing entrails, bowels, and other oozy organs. Maybe that’s what makes them easier to cut.

  But I have seen the muscles in women. In the delivery room, when the cut was made across three or four major muscle groups, I’ve seen them retreat and lie there, shrunk back into themselves, and I felt the same way I would if a ballplayer’s muscles had been cut. The same way I feel when a cellist’s string snaps during a concert. The music of the body, the resonance and the potential for rapture are interrupted.

  Replaying Mary’s unwieldy birth advanced me only a little in my effort to analyze the benefits of home birth. As many practitioners today would admit, there was too much wrong. The back-lying labor, the cold monitor, the painful vaginal “checks,” the waiting to push, the moves from bed to stretcher to delivery table, the strapping down, the stirrups, the harshness of the doctor’s orders, the withholding of the baby, the neglected postbirth chill, the shot, and the long sew—all of these seemingly insignificant, routine factors are known to increase anxiety and exacerbate pain. Even a nonlaboring person would find them awkward, uncomfortable, and inhibiting. It would be almost impossible for a birth to flow—as Silla’s did—in such circumstances.

  I considered the second possible variation in the hospital delivery. What about the perfectly healthy Amish woman who had her baby in the hospital with a midwife’s care? Would her birth be compromised simply by being in the hospital? Was a healthy birth dependent upon the environment in which it took place?

  The majority of women I attended in the hospital were having their first babies—“primips,” we call them. Primip births are challenging for several reasons. In the first place, the women don’t have any personal experience of birth. They are likely to be frightened or anxious, which works against relaxation, which works against easy birth. Second, their muscles are tight, and the baby has to travel against their resistance. Their hormonal systems, too, are inexperienced at birth and may be slow to blend. These psychological and physiological factors combine and create the major challenge of a primip birth: the long labor. As a midwife attending a first-time birther, I had a major interest in preserving a woman’s energy so that she would have enough strength left at the end to push the baby out.

  I managed hospital births differently than most of the doctors did. I told the women they could labor in any position they found comfortable, I did very few vaginal checks, I encouraged them to walk the halls and inhabit the showers at will, I spoke to them kindly, chatted with them about their families and farms, I said they could give birth on their sides, half-sitting, or squatting. Even with these advantages, however, the result results were disappointing. While a good proportion of the primips delivered without intervention, there were several who should have, but couldn’t. They would dilate fully, but ultimately needed forceps or a section to give birth.

  I knew energy loss was a major problem. The hospital, assessing a set of complicated risk factors, had decided it was prudent to tell women not to eat once they were in labor. While I disagreed with their analysis of the risks, I respected it. Thus the women, doing hard physical work, ran out of energy before it was time for them to push.

  There were other factors too, things that felt wrong but defied clinical analysis. In comparison to the home births I attended, hospital births were awkward. They were out of sync with Amish life. I’d tried to ease the transition: I often picked primips up at home and drove them to the hospital. I always guarded their rooms, trying to protect them from the invasion of strangers who spoke a language, bureaucratic and medical, that they couldn’t understand ; against fluorescent light, which they, being accustomed to lantern lighting, found painful; and against the uncommon, for them, sounds of machinery and phones. Obviously, I could only be partially successful.

  What felt more damaging was the distrustful atmosphere of the hospital staff. Laboring women could not be helped by nurses who, not approving of my tolerance for a prolonged first stage (the pre-pushing part), would say disdainfully, “Is she still in labor?” or “Hasn’t that girl delivered yet?” A woman in labor hears the doubt and loses confidence. Also, by similar but less direct means, the clinical review committee (it sets hospital policy) influenced the labors. They measured the time women were in labor against a table called the “Friedman labor curve.” Designed to describe the average length of labor, many practitioners and the review committee used it the other way around—to prescribe how long a labor might be. One either began pushing after twelve hours of active labor or one was a candidate for intervention. When the committee reviewed my labor records—which showed my tolerance for individual variation—they expressed unease. Although my outcomes were excellent by any hospital standards, the women I attended were not following the prescribed pattern.

  That wasn’t all. The administration expected women to give birth on a delivery table and my birthing room with its mattress and box springs did not conform; neither did my informal style. In time, their discomfort sprung up in me as anxiety and I’m sure I passed that feeling on to the laboring women. Perhaps I encouraged them too much, perhaps I implied urgency, perhaps they began to push before they were quite ready and so, in spite of their wholesome advantage, they failed....

  As a practitioner, I am guided by the strengths in my material. Like a cabinetmaker eyeing the pattern in wood, like a seamstress feeling the weight of a fabric, I search for the design of birth implicit in a woman. I can anticipate a birth best when I concentrate on information that comes to me through my hands. I glide them up over the bathed and talced mound of a woman’s belly. In first-time mothers, when I pull my hands down, tracing the path the baby will take, I feel smooth, strong muscles and a baby who rides in a taut pouch. With experienced birthers, I can close my eyes and feel the revelation of work done, of skin that has stretched and reknit, of muscles that have spread and drawn back together. I can feel tenacious parts and those that are more lax. I can anticipate muscular dynamics. I can feel whether there is a good pool of waters, whether the baby has sufficient mass, and how vital it is.

  B
irth is infinitely dynamic. We cannot adequately understand it by naming anatomical parts and describing physiological processes, nor are we done when we describe its choreography. Birth functions in the context of mind and spirit. They act directly on birth and give it the complexity we associate with life. When we acknowledge this, we invite the power of birth.

  Becca, John’s wife, weighed ninety-five pounds and was as shy as a blade of new grass. Her skin was translucent; her bones were slender and fine as light. Fragility dominated her being, easily overwhelming the mere, plain fact that her pregnancy was normal. I could not imagine her having the capacity to throw her baby out. I could not think how to embolden her. The only way I could comfort myself was to dwell on her hot-ember hair and all the passion that superstition credits to redheaded women, but even that didn’t really do, because she wore it as all Amish women do, carved in a center part and pulled back into a humble, restricted, “It’s only me” knot.

  Her husband, John, whom I wanted as an ally, was of the rough-andtumble, dog tail–pulling type. I wished he would evoke some pacing lioness in her, but all he could do was poke her in the ribs. At childbirth classes, she blushed and he feigned indifference.