the end of an ideal, and also a beginning
I’ve been trying to write down the story of Elsa’s birth now for several weeks (it was exactly three weeks yesterday), and keep getting interrupted. This makes sense considering that I rarely finish an entire cup of coffee in the morning, much less secure a lengthy block of time to sit at the computer, think, and write.
I’d like to believe that I’m already moving beyond all preoccupations about childbirth now and that the need to talk about it and tell my story is fading. But a few nights ago I had a dream that I was about to get a haircut at a really nice salon and the beautician gave me an epidural before she began cutting. So, I must still be stewing. Moreover, at the very moment I write this paragraph, I can hear Esme in the bathroom giving her My Little Ponies a sink bath and explaining to the baby pony that the mama has “gone to the hospital.” Clearly the collective subconscious of our little family is still processing this major event.
I’m not sure what others might interpret in the above photo–maybe something in the range of poignant. For my own part, when I saw this photo just after Elsa’s birth, something more like a comic strip popped into my mind involuntarily. It had the caption: “Thus ends my career as granola mom.” Because there is something really funny about this picture of mom and baby both sleeping through the big birth event. This allowed me to laugh at what otherwise might have made me cry. And of course, I did cry many tears in the days, and finally the minutes leading up to Elsa’s birth. I’m sure the tears were partially due to the pregnancy hormones at work as I approached, then passed, my due date. But they were also brought on by the swelling realization that my hopes, efforts, and will were not very powerful variables in the complex equation that was quickly filling up a chalkboard where doctors stood in professorial authority over my big belly.
And it’s no secret that my will was to have a VBAC (vaginal birth after cesarean). Every mother on the playground of our apartment complex knew this, as did all of my close relatives and friends, and probably a few far-flung acquaintances who couldn’t care less. I suppose I am what you’d call transparent, and fecklessly wore my heart for a VBAC on the sleeves of my maternity shirts. But as per indicated by the surgical cap on my head, I ultimately did not get it. Elsa was born by repeat cesarean, despite my nine months of white-knuckled steering away from that destination.
Also plainly evident in this picture: mom wasn’t even conscious during daughter’s entrance into the world, but, rather, passed out from a paradoxical but potent cocktail of exhaustion, disappointment, excitement, denial, resignation, happiness, sadness, and relief.
I was relieved, in the end, to receive the powerful spinal block that sent warmth down my legs and ended the pain of contractions. I was relieved to know that I didn’t have to struggle a minute longer to bring my baby into the world– she was going to be brought out immediately and safely by a team of capable people. Jeff was standing by, ready to greet her. My doula, standing near my head, was watching the surgery, taking pictures, and, in a sense, keeping vigil, as she had been all night during my labor. Frank Sinatra, oddly, was playing from a small stereo in the surgery room.
Under such circumstances, I had the luxury of letting go, caving into my now painless exhaustion, and drifting into oblivion. And while I wouldn’t have consciously chosen to sleep through my baby’s debut, it was apparently beyond my power to resist. I didn’t even realize I had fallen asleep. When Jeff woke me up and presented me with a swaddled bundle, I was genuinely surprised that so much had transpired without my being aware. This was definitely the end of an ideal. The wrinkly red crying newborn was not brought naked up to my chest in her first moment of life to be warmed and to nurse. I didn’t even hear her first cries or the announcement of her weight. And so it was that I became what all the natural childbirth advocates preach against: a passive participant in my own child’s birth.
But not really. In the earliest weeks of my pregnancy I actively sought out a group of obstetricians in town who were willing to perform VBACs– in fact, the only practice in my town. I had a consultation with one of the doctors to ask him questions, like what was the rate of VBAC success among their patients. It was a respectable 70% and I was determined to be among that 70%. I tried to have the healthiest pregnancy I could have. I did prenatal yoga like my life depended on it. When it looked, toward the end, like I might once again have a breech baby (automatic disqualification from a trial of labor), I did more yoga, and everything else I could think of to get the baby to turn, and she finally did. I was poised to go into labor, and clinging to this fact, I waited. I wanted this child to arrive in her own time, in her own way. For reasons I still can’t necessarily explain, trying for a VBAC was deeply important to me. Simultaneously, I knew that there was a very good chance that it would not happen, and was ready to flip the switch and emotionally jump ship should the battle go ill.
The more exposure I had to the doctors in this particular practice through weekly appointments in my final months, the more I felt that it would be a miracle if I avoided a repeat cesarean. I apprehended a subtle attitude of defeatism that did not nourish my hopes. I sensed a certain nervousness and lack of trust in the birthing process in general, and my ability to give birth in particular, even though there was nothing about me to indicate that I would not succeed. There were assurances such as, “You know at any point if you’re having a difficult labor that you can throw in the towel.” There were attempts to assess the weight of my baby just in case she was “overly large,” because I might “feel differently about trying to VBAC if I knew I was carrying a ten pound baby.” (It turned out she was not even seven pounds at birth.) And there were casual, impersonal questions such as, “Have you scheduled your c-section yet?,” even though it clearly stated in my file that I wanted to try for a VBAC. Was anyone paying attention?
Looking back, I see now that although my earliest conversation with the doctor from this practice was not negative or discouraging, neither was it positive or encouraging. His tone was professional, neutral, promising nothing. He spoke in terms of statistics, percentages of risk. He said that I was currently a “good candidate” for a VBAC. Should that change at any point as the pregnancy went along, we would then “have another conversation,” about my options. Although I was hopeful in the beginning, I think I realized intuitively, even then, that within this model, within this system, I was going to have to have the perfect pregnancy and the perfect birth. Even though the risk itself (of uterine rupture) is miniscule, and even though I was a healthy person having a healthy pregnancy, I was going to be categorically treated as “high risk.” And at any point, I could lose my status as a good candidate. Should anything not go according to the book, I would be disqualified, and no one would lose a wink of sleep over it but myself. I crossed my fingers, and just hoped that the pieces would fall into place. It should not have surprised me when, in my forty-first week of pregnancy, a doctor looked at me with irritation, spoke of hospital policy and said, “This is just the nuts and bolts of how it works.”
I was treated according to the rules and regulations of the high risk category, which felt terribly impersonal and unfair. Moreover, metallic hardware metaphors are not what you want to hear from your caregiver in the last few hours leading up to what you know will among the most memorable and vulnerable events of your life. According to Ina May Gaskin, who is considered the authority on midwifery par excellence, and runs a famous birthing center in Tennessee called “The Farm,” childbirth works according to what she calls “the sphincter law.” She explains it herself in this short video. To put it succinctly and crudely: in the same way that people can’t relax and go to the bathroom in a place if they do not feel safe or comfortable, a woman can’t relax and give birth if she does not feel safe or comfortable. Likewise, if an animal such as a deer detects a nearby predator, her instincts are wired in such a way as to automatically shut labor down until she finds a safe place to have her baby. According to Ina May, some caregivers are so tense, they can have the same effect on a laboring woman’s brain as a predator by merely walking into a room, and cause the birth to stop progressing. Clearly, there is a strong and intense psychological component to childbirth which must be handled with care and understanding.
But looking back to the first conversation I had with a doctor from this practice is telling. I asked him what he thought of VBAC home births. I knew what his answer would be, but wanted to hear it just out of curiosity. He said that anyone who practiced them was irresponsible. Such a midwife was basing her practice on the premise that things turn out alright most of the time. And, he conceded, most of the time they do. But when they don’t, they go badly wrong.
I myself would not have been comfortable with a VBAC homebirth either, but in retrospect I wish I could have secured an experience for myself that would not have been so radically opposite from the personalized attention of a midwife who is able to invest a bit more heart and soul into the birth experience. I learned the hard way that the psychological (dare I say spiritual?) component to childbirth is simply ignored by the medical model of care, which thinks itself so advanced and air tight, a bastion of expertise.
In any case, I had a perfectly healthy, uneventful pregnancy, just as I did with Esme. But it seems to be my particular experience with pregnancy that it begins like a wide, safe, leisurely, tree-lined boulevard, with no traffic. And of course, I am grateful for this. It goes along like this for blocks and blocks and blocks. But then, in the final weeks, without warning, that boulevard quickly bottlenecks into a narrow, rude, traffic-filled street in a congested, overpopulated part of town. The intersection of the birth is just ahead. It turns out, unluckily, that road work is happening and the way I’d like to turn is blocked by a detour sign. To make matters worse, the traffic light is broken and blinking, and cars are backed up in all directions. In such a situation, no one gets special treatment. A grumpy, impatient policeman is directing traffic, in no mood to be reasoned with. I’m trapped behind the wheel, inching forward in a locked line of cars, and suddenly feel very naive for having trusted the generic and conventional advice of mapquest. I wish I had mapped out an alternative route on my own.
I can never entirely explain to myself how or why, at the approach of a due date, things go from emotionally ordinary to feeling nearly apocalyptic. Again, I realize that much of this is probably hormonal, and perhaps a common experience of all women as they approach childbirth, whether they can expect things to be routine or not. Maybe childbirth, though certainly common, is never just a routine, everyday affair. It quivers with too much potential for comedy, tragedy.
In seminary we discussed the meaning of the Old Testament laws about what made a person ceremonially “unclean.” A person was considered unclean if they had come into contact with either birth or death, and was required to pass through a period of cleansing in order to re-enter ordinary life. We were told as students that this uncleanliness was not something bad or sinful, but rather holy and divine– extraordinary. Birth and death are human affairs which touch the divine, and therefore they are fearful, sacred, holy, and stand apart from the ordinary. They must be treated as such.
As a baby’s due date approaches, it becomes, at least in my experience, impossible to continue pretending that something merely ordinary is about to happen. My due date with Elsa was on Monday, April 13. Until it was actually upon me, I failed to really consider the implications of the fact that this was not just any Monday in 2009, but Holy Monday on the calendar of the Orthodox Church.
Holy Monday is the first day of Holy Week, which is arguably the most beautiful but also the most spiritually intense and demanding time of year. It is well-known that emotions and passions are like taut guitar strings during Holy Week. People at church can be grumpy and short. Communities and families may bicker over nothing. With forty days of fasting behind you and the anticipation of the Feast of Feasts ahead of you, and the most beautiful and serious poetry, Scripture, hymns and prayers surrounding you in church daily, it’s no wonder. For me, even though I was too pregnant to fully participate in all the services, I did make it to many. And seemingly independent of my own participation, the aura of Holy Week seeped into our home on its own accord, as it does every year. There is a certain glow.
Time feels as if it is being compressed and events are set in motion. Christ is betrayed and will stand before Pontius Pilate. A pamphlet arrived in the mail from our seminary, a short reflection on Holy Thursday, by Alexander Schmemann. In it he talks about the mystery of this unique day in which “light and darkness, joy and sorrow are so strangely mixed.” It seemed only natural to me to find a certain synchronicity in the full-term baby pressing me at all sides from within and the liturgical drama which was leading up to the Cross and finally Easter.
On Holy Thursday, I had a doctor’s appointment that I knew would be pivotal, and which I was somewhat dreading. It was the first time I went to the doctor since passing my due date. Both Jeff, my doula, and Esme came along–quite a crowd. This was the appointment of the “nuts and bolts” comment. This particular doctor breezed into the office with my file and brusquely asked when my last ultrasound had been because “as far as she was seeing, the last ultrasound was showing that the baby was still breech.” This was not correct. The baby was not breech and there had been a more recent ultrasound showing this. But the word “breech,” with all its emotional baggage for me felt like a brick being hurled at my head. I sat there at the edge of the examination table dumbfounded and knew right away that I was not in the proper frame of mind to deal with the forceful personality of this woman. I also could tell that she was not really interested in listening to me either.
I can’t explain what happened next, except that something snapped in Jeff and whatever rhetorical skills have carried him through far too many tedious years of graduate school were suddenly marshaled and employed on my behalf in the face of this doctor. In short, he was heroic.
Up to this point, he and I had been preparing for the birth as if in two different spheres. He had been working hard at the library, trying to get as much of his course work out of the way so that he could take some time off when the baby arrived. I had been working at home, trying organize our small space and figure out how things were going to fit and flow with two children instead of just one.
As for my feelings, hopes, and fears about the birth, I felt that they were in a chamber that I alone visited throughout my pregnancy. Jeff always sympathized and supported my desires to have a particular kind of birth, but was not personally invested in them himself. I have always been mystified by couples who promote the Bradley Method, or “husband coached” childbirth, because I could only snicker at the thought of my husband being a self-taught expert on cervical dilation, or telling me how to breathe during a contraction. And while he spends his days at school pouring over the most dry academic books, I suspect he’d be bored to tears before making it through one paragraph of Ina May’s Guide to Childbirth. And honestly, this has never bothered me at all.
But this is why I was surprised when, at this appointment, he suddenly rose up and became my voice when I faltered before the pushy doctor. She seemed furious that I had somehow slipped beneath the radar and gone past my due date (merely four days) without anyone from their practice having intervened. (I suspect now that she was irritated with her colleagues and I was just caught in the crossfire.) She wanted me to go home immediately, pack my things, and head to the hospital for a c-section that afternoon. I won’t go into all the tedious details of the conversation we had with her, except to say that she interrupted me at least three times. She accused Jeff of being sarcastic when he was actually asking a sincere question at one point. We told her that I’d been having pre-labor contractions for two days and suspected that I’d go into labor naturally very soon, and that it seemed reasonable at this point just to wait at least through the weekend to see if perhaps the c-section could still be avoided. There was nothing to show that my baby was in imminent peril if she stayed in the womb for a little while longer. She barked at me and said something about ignoring the advice of three doctors (she supposedly had quickly consulted two of her colleagues without our being present), implying by her tone and body language that I was being a stubborn moron. Finally Jeff, realizing that things had reached an impass, had the presence of mind to ask if we could speak to another doctor. She said yes and left the small room, letting the door bang shut behind her.
I felt manhandled and shaken by this encounter, in which I’d barely gotten a word in edgewise. In the end we did speak to another doctor who was much more flexible, amiable, and reasonable. He had no problem with letting us wait the weekend to see what might happen. By the time we left the office after this lengthy, stressful appointment, I felt like I was suffocating and could not wait to exit into the parking lot where there would be air and sunshine. My doula told us to go eat our favorite foods, do something outdoors, and spend the rest of the day emotionally recovering. I knew, with every fiber of my being, that I had done the right thing. It would not have been right to succumb to the established protocol and go in for a c-section that very day. I knew that my baby was fine and that I was not putting her in danger by giving her a little more time. But despite this, a poisonous seed of doubt and insecurity had been planted and my strength was sapped. It would be difficult to regain a totally untainted, positive attitude about this birth.
Jeff and I stopped and got Thai food, then went home, put Esme down for a nap, and debriefed. I am not categorically anti-medical. But I realize now that the real issue for me in Elsa’s birth transcended any rivalry of VBAC versus c-section, medical versus natural. It became an issue of personal versus impersonal. I didn’t want my birth–a sacred thing– to bear the impersonal latex glove prints of science. I know science gives us many good things but I am wary of its one-size-fits-all, systematic approach, and I do not trust it implicitly. I thought that having a doula at my birth would be enough to counteract the hospital system in which, as Jeff put it in a moment of realization, “birth and death are treated like taxes.” But truly, although having a doula was a wonderful comfort amidst the whole experience, it wasn’t enough to change the ultimate outcome. In the days leading up to the birth, we realized, too late, just how powerful the system is, and how small we were within it.
As I had suspected, I did go into true labor on Friday night. I labored for a little while at home but after my contractions became close together, intense, and regular, we went to the hospital. And that’s where the story simply gets onto the fast track of inevitability. I was hooked up to an IV and a fetal heart rate monitor which I could not unhook. What’s more, it took the nurse three tries to find a vein in my arm, which I had to hold out obediently and keep still for a long time while having contraction after contraction.
All of this ensured my discomfort and kept me bound to the small area beside the hospital bed. The baby’s head was descended fairly far and, we found out later, she was also posterior, or sunny side up, which makes for a longer, more painful labor. The position of her head made it too painful for me to sit down while contracting so I had no choice but to stand and hold onto the side of the bed. I would get chilly, then hot. I recall that was shivering quite a bit and my legs eventually started shaking from fatigue.
Somehow, though hours passed, I never settled into the hospital room and had the delirious impression that we had perpetually just arrived. And of course, nothing I had read about natural childbirth really prepared me for how hard it would be. I struggled to relax and breathe during each contraction, and “get on top of it,” as my doula put it. The key is to try to relax and work with the force of each contraction, but everything about the hospital environment was working against my being able to truly relax. Standing there in a thin hospital gown with a needle poking me near my wrist and two itchy elastic bands around my abdomen, it was inevitable that, as the night wore on, I too wore down physically and emotionally, and felt incredibly discouraged. Knowing that my cervix was not progressing very fast, it became clear to me that I needed relief in some form if I was going to continue at that rate until the end. It would have been helpful to get into a warm bath or something like that, but with the monitor and IV connected, that was not an option. It would have also been helpful if the team of people caring for me were determined to do everything in their power to make me comfortable and make a natural birth possible. But obviously that was not going to happen either.
In the early hours of the morning I opted for a half dose of intravenous pain control, which seemed like the most benign choice. It didn’t totally blot out the pain, but it allowed me to lie down on my right side and rest for a bit. But in retrospect, I don’t think this was a very good choice. In such a position, feeling slightly dopey, my blood circulation was not optimal, and the baby, who was also tired from all the contractions, started showing heart rate dips on the monitor. After that it was just chaos, and I can barely say what happened. The doctor and several nurses came in, I was turned on my left side and given an oxygen mask. I was terribly uncomfortable on my left side. I had not dilated very far by this time– only four inches. It was clear that if I was going to finish the labor naturally, it was going to take a long time. Every woman’s labor is different, and I know plenty of women who have gone through long labors. One friend I know labored for three days with her first baby under the care of a midwife. It would have been possible, I believe, but only in a radically different environment, where I was allowed to move freely, find a comfortable position, and, most of all, get into water. In the context of the hospital room, where everything was working against my comfort and encouragement, it was simply not possible. And while I can’t be sure why the baby’s heart rate dropped, I do still believe that it was situational and a direct consequence of me lying down on my side, which was a direct consequence of taking the only form of relief I felt was an option, which was a consequence of having no other options for relief, which was a consequence of being bound to a small area by machines.
As soon as I stood back up, her heart rate bounced right back to normal. But how many more hours could I just stand there on the cold tile floor and continue in back labor? Why didn’t I just get an epidural? I would have, as a last resort, but my doula said that because it causes the mother’s blood pressure to drop, it would likely also cause the baby’s heart rate to drop as well and would result in an automatic c-section. If I was going to have a c-section, I didn’t want it to be an emergency due to another heart-rate drop.
As we tried to process what was happening, Jeff and I looked at each other and realized that it was scary and pointless to go on. As Jeff said, it all felt so complex and tangled at that point, there was no right choice. I could have tried to labor longer and see how it went, but truthfully, it seemed futile. Jeff said it was as if someone had told me to run a race and then put weights on my ankles. In the circumstances set up by the hospital, choosing to go ahead with the c-section sooner rather than delay the inevitable made the most sense. In radically different circumstances, perhaps at a birthing center, under the care of of midwife who trusted in the birthing process and was devoted to making me comfortable, in a place where I could truly relax and feel cared for, there is a good chance that things would have gone differently for me. Of course, there is no way to know such a thing for sure.
So this is my birth story. Elsa was born at 11:30 a.m. on Holy Saturday, the day before Orthodox Easter. We named her Elsa after Jeff’s grandmother, but I wanted her middle name to reflect something of Holy Week, which was so closely bound up in my anticipation of her arrival, so I chose the name Joanna. Saint Joanna was among the women who went to the tomb of Christ to anoint his body with spices. They are called the myrrh-bearing women in the Orthodox Church.
I do not know why things turned out as they did. I am thankful for the c-section that brought Elsa out safely and surely, even while I can never be sure if, under different circumstances, it would not have been necessary. Now it doesn’t really matter. In some ways, I wish I had never cared so much, because it would have simplified the whole matter. I am healing well and have had amazing support from dear friends and neighbors. I have two healthy daughters, and I am deeply thankful. I am also glad that I at least had the opportunity to go into labor this time and try for a VBAC, and that Elsa got to arrive in her own timing, on Holy Saturday.
In childbirth, as in all things that matter, there are ideals, and those ideals are certainly good. But I learned through Elsa’s birth that human ideals, no matter how wholesome and legitimately desirable, are not the content of my belief. There are ways that one hopes life will unfold but in a fallen world they only happen sometimes, for some– not all the time, for all– and usually without explanation. We are only asked, like the myrrh-bearing women, to be faithful should we ever be asked to live through a very dark day, to forgive seven times seventy, to rejoice with those who rejoice and mourn with those who mourn.
I wanted to add a slight correction to this birth story and am just now getting around to it (oh, a mere five and a half months later). I stated above that I was having back labor, but when I later spoke with my doula, she said that I wasn’t having back labor, because in her experience, women with back labor really need someone to maintain pressure on the lower part of their back or else they experience excruciating pain. I on the other hand didn’t want anyone to touch my back while I labored. However, during the c-section, the doctor performing it distinctly said that Elsa was in a posterior position, which is what causes a woman to have back labor. That was what made me conclude later that what I was experiencing was back labor. All I knew was that it hurt, and had no standard to measure what such a category is supposed to feel like. In any case, it all just confirms for me the nature of the whole thing in retrospect: a question mark. How is it that I wasn’t having back labor if Elsa was indeed posterior? I don’t know. Or maybe I was at the very end, the final stretch of walking to the operating room, which was admittedly the worst part of the entire labor. Still, I wanted to set the record straight since my telling of the story above was not entirely correct.