I'm reading a great book entitled The Girls Who Went Away, by Ann Fessler. It's social history of birth mothers in the United States during the post-WWII years until Roe v. Wade was passed in 1973. During that time, unmarried women were frequently sent to maternity homes to await the birth of their child, then were pressured to surrender the baby for adoption. These young women rarely received adequate counseling about pregnancy, childbirth, social services, or alternatives to adoption. Fessler recounts the pressures they faced from social workers, peers, and their own families to surrender their own children, and the emotional devastation that followed this event. It's a gripping read and I highly recommend it. If you have a Kindle, the book is available in electronic format as well.
Reading The Girls Who Went Away got me thinking about a young woman whose birth I attended a couple of years ago. Let's say her name was Caroline.
She was about 20 years old and she and her boyfriend, Eli, had been together for a couple of years and were a dedicated couple. When Caroline got pregnant, they realized they weren't prepared to be parents. They both wanted to travel for a while, then Caroline wanted to go to college. At the beginning of the pregnancy, Caroline considered an abortion but decided against it. She and Eli went to an adoption agency and began the process of an open adoption. They interviewed a number of potential adoptive couples and decided on Dan and Amy, both businesspeople in Los Angeles who'd been trying to have children for several years.
During the last half of Caroline's pregnancy, both couples were in constant touch via telephone, email, and a number of in-person visits. Caroline and Eli were impressed by Dan and Amy's commitment to parenting, their progressive views on child-rearing, and their openness to Caroline and Eli's free-spirit philosophies. When Amy asked Eli, a nature-lover, what she could bring him back from a trip to Hawaii, Eli said: "Seeds." She obliged with some exotic-looking specimens. "He's easy to shop for, I'll say that," she told me later.
Caroline's water broke when she was about 38 weeks and I admitted her to the hospital. Eli accompanied her, as well as Tanya, an experienced doula. Dan and Amy were there too. I'd heard a lot about them from Caroline, but they weren't what I expected at all. Knowing Caroline from months of prenatal care, I had an image of Dan and Amy as being similarly laid-back, introspective, accepting and courageous as Caroline was. Instead, I found them to be a type A, southern California power couple wanna-be. Dan was pleasant but had that slightly distracted I've-got-to-be-someplace-else demeanor that has no place in a labor room, where mindfulness is the greatest resource. Amy was a highly-strung, very thin woman who arrived with her own preconceptions about labor and delivery.
"When can she have an epidural?" she asked me, almost as I walked through the door.
I wasn't ready for the question. I hadn't even said hello to Caroline yet. She was laboring in a bathtub, breathing deeply with her eyes closed.
"How are you doing?" I asked Caroline. Amy positioned herself between the two of us. I moved so I could look at Caroline's face. "How are you coping?" I didn't introduce the word pain into the conversation; many women prefer not to be asked about pain during labor, and anyway, pain isn't the only challenge to labor. Intense physical sensations, a sense of overwhelm, fatigue, impatience--all of these are part of the labor experience and they all need to be addressed. "It's up to you," I said to Caroline. "You look like you're doing well to me, but if you think you need something..."
Caroline kept her eyes closed. At the end of a contraction, she said, "I think I'm okay. I'll tell you if I'm not."
"Okay," I said to her. To Amy, I said, "It's up to Caroline. We'll see how it goes."
This is the core of my birth philosophy: We'll see how it goes. One of the reasons I like attending births, why I stay in that part of medicine even though it entails late nights, self-doubts and a lot of nail-biting, is because I like the mystery of the birth process. In this era of instant information, with CNN covering war zones via night cameras, birth remains a fundamentally unpredictable process. Which is why people ask so many questions about it: when will the baby be born? how much longer? how many more pushes? how much do you think he weighs? To these questions, I usually answer: if I knew, I'd be a millionaire.
Facing the unknown takes uncommon courage. Caroline faced it heroically. Throughout the labor, she went into that deep place many women find when the birth of their baby is imminent. Tanya was the perfect support person for Caroline: humorous, laid-back, knowing when to speak up and when to hold back, and a master back-rubber. Labor progressed slowly but steadily. The pace clearly wasn't what Amy had in mind. She paced restlessly. She took out a breast pump and pumped her own breasts. (Apparently some adoptive mothers are able to produce some milk, although one adoption counselor I know told me later, "It usually causes more grief than good" to try to induce lactation in this way.) She paced some more. She looked at me every time I came in the room, as if to say: when is this going to happen?
"Does she get the epidural now?" Amy asked when I examined Caroline and found she was six centimeters dilated.
"That's up to you," I said, looking straight at Caroline. "I think you're doing great, but I'm not inside your body. How are you doing?"
"It's intense," said Caroline. "Is there anything else beside an epidural?"
We talked about other options: getting into the tub again, intravenous fentanyl, an intrathecal or "walking epidural," or a continuous epidural. I explained the risks and benefits of each. Caroline decided on a dose of fentanyl, which worked well for her.
Over the next two hours, Caroline labored on a birthing ball, standing up, on her hands and knees, leaning against Eli in the hospital bed. When she was completely dilated, Amy asked if Caroline should start pushing now.
"Do you feel like you have to push?" I asked Caroline.
"Sort of," she said.
"Well, how about this," I said. "Why don't you start by humming with your contractions, or making little grunty pushes, but not big ones. Save the big ones for when you really feel like you can't help but push." This is the advice I give most women. One mistake a lot of birth attendants make is encouraging a woman to push too early, which can result in a couple of hours of inefficient pushing which is both exhausting and, if misinterpreted as failure to progress, can lead some patients and birth attendants to assume a C-section is needed. Much better to wait until the urge to push is stronger, even irresistable, and then initiate pushing. All of us who attend births have seen the difference between early, uncertain pushing and the "oh yeah, now you've got it!" pushing that brings a baby. Humming and grunting gives a woman something to do with the contraction and probably helps the head descend a little bit, but doesn't fatigue the woman as much as full-blown pushing.
Caroline hummed and grunted, grunted and hummed. Sometimes she panted through the contractions. Sometimes she cried out. Eli had his arms around her and murmured encouragement into her ear. Tanya rubbed her back. Dan was seated on the bed, watching the action unfold before him as if it were a TV show. Amy wrung her hands and whispered to me, "Wouldn't this be better if she had pain control? Is it too late for an epidural?"
I looked at her with annoyance. Why was she so invested in an epidural? Caroline's labor was progressing beautifully. Physically she was holding up well, laboring hard but not showing any signs of fatigue. She still occupied that deep place women find when they are laboring, that birth attendants recognize as an intense concentration and a fierce internal quietude. Usually, watchers retreat into a respectful silence when they see a woman in this state. Not Amy. Why?
Then I looked at Amy again, and I saw she was afraid. Of what? I wondered, and then I realized: she was afraid of Caroline feeling her birth too deeply, as if the physical sensations would connect Caroline irrevocably to the baby Amy wanted to adopt. Offering the epidural was a way of eliminating the physical connection between Caroline and the baby. Maybe Amy didn't consciously make this connection, but I felt it in her.
I said, with more kindness than I felt, "Caroline's doing what she has to do. She's doing wonderfully."
Then pushing got going in earnest. Caroline's grunting became deeper and more sustained, and next thing we knew she was bearing down hard. She didn't want anything to do with lying down, so we tried hands and knees, squatting, then kneeling, which worked for her. She pushed for about forty minutes, the last pushes showing a dark-haired baby's head. "He's there, he's right there!" Eli said in delight when he saw the baby crowning, and even Dan moved from his perch to watch the Moment.
Caroline's son was born lusty and crying. I suctioned him and handed him up to his mother. She looked at him in amazement, her eyes wide open now after having been closed in concentration for many, many hours. Congratulations, Caroline. You did it.
Caroline roomed-in with her son for three days. During that time she nursed and diapered him, cleaned his cord, told him the story of her life. Amy and Dan roomed next door the first night, but returned to their hotel for the rest of Caroline's hospital stay. "Amy was exhausted," Caroline explained to me. "She couldn't deal with being awake all night because of the hospital noise." Figures, I thought.
On the third day, Amy and Dan packed the baby up in their SVU, hugged Caroline goodbye, and left. I arrived to discharge Caroline just after they'd gone. "How are you doing?" I asked Caroline.
"I'm sad," she said, and her eyes showed it.
"What are you going to do when you go home?" I asked, wondering who would be there to help her.
"Probably cry," she said, with that perfect truthfulness I'd always known in her. I hugged her goodbye, and for a moment we both cried a little.
Months later, I saw Caroline for a family planning visit. She and Eli were doing well. Amy and Dan sent them photos of little Jeremiah regularly. "They're going to be great parents," Caroline said confidently, and I actually believed her. She and Eli had postponed traveling for a while, and she was taking a few classes. Her life was truly moving forward. She thought about Jeremiah every day, sometimes with sadness but never with real grief, because she didn't feel that she'd lost him. She could go and see him anytime. "We're going to see them in a few months, after class is over," she said. "Then we'll see what's next."