Sunday, February 22, 2009

The Blue Cotton Gown: A Midwife's Memoir

I just finished The Blue Cotton Gown: A Midwife's Memoir, by Patrician Harman this weekend. It was an excellent memoir - very well-written and full of moving stories, both the author's story and the stories of the women she saw in her practice as a midwife.

Because this is a "midwife's memoir", I think some readers may be expecting lots of birth stories. There aren't many, in fact, just a handful, which emphasizes two important issues.

First, midwives can provide care during the entire spectrum of a woman's life - from her first gynecological check-up to discussions about menopause. Midwives do a lot more than attend births!

Second, not all midwives (or obstetricians, or family practice doctors) can afford to provide obstetrical care. Harman writes, "when the cost of medical-liability insurance almost doubled, we looked at what it would cost to continue obstetrics, and we couldn't break even. Bringing new life into the world in a gentle way was our calling, but a calling we could no longer afford" (206). For a more in-depth review of the book, and discussion of the issues in it, read Jo's review at The Modernity Ward.

When I was discussing the fact that the gender part of my recent post on Dell received more attention than the midwife part, she said - "oh! you could rewrite that part to show how a real midwife would handle the situation!"

Coincidentally, one of the few birth stories in The Blue Cotton Gown does just that:
"So we push... And we push... For two hours, we push. It's a group effort.

We try every position the nurse and I can think of. 'Can't we just do a C-section?' Nathan [the dad] asks, eyeing the tracing as the fetal heart rate dips into the nineties, then bounces back to 150 again, a nice normal baseline. 'Maybe he's too big.' That thought has crossed my mind too, but it's not time to give up yet.

'Come on, let's get back to work. We're missing some of these contractions. Here, Jeannie, pull on my hands. Pull!' An hour later, when Tom [OB, Harman's husband] returns from the OR, he enters the birthing room as if he means business, and I'm glad to see him.

'How you doin?' he asks Jeannie and shakes hands with Nathan. 'Getting tired?' I catch his eye and glace toward the monitor. The decelerations are steeper now but always returning quickly to baseline.

Another big contraction and Jeannie grabs her butt then flops back in bed, trembling. 'I don't think i can do this!' After two days of labor and three hours of pushing, the young woman is spent.

'Ready for some help?' Tom asks, slipping into a long green sterile gown. Terry, the RN, uncovers the delivery table and places the vacuum extractor, a modern alternative to forceps, near the corner. Clearly, she thinks it's time.

'You bet I'm ready!' says Jeannie. 'Is this finally gonna happen?'

Though the extractor, which comes with a soft plastic suction cup, is less risky than metal forceps, it's not without danger. It can cause bruising, laceration, a hematoma, or worse, a shoulder dystocia . . .

Dr. Harman parts the labia. 'This may hurt a little,' he warns as he applies the vacuum cup to the fetal head.

I center my attention. 'Okay, Jeannie. Tom can't pull the baby out by himself. That would be too much strain on the little neck. You've got to push as hard as you can and soon you'll be holding your little one.'

But I'm wrong. Each time Dr. Harman pulls, the head moves only a quarter inch. Once, the vacuum slips off. Then again it slips off. And again. The head is crowning now, and by protocol, the provider gets only three tries with the extractor; any more may cause damage. Tom lays the mechanical device aside, then sits on the stool between Jeannie's legs, checking the vagina for stretch. Neither of us routinely does episiotomies - in fact, rarely, if ever - but I can tell he's thinking about it. Nathan stares numbly at the top of his baby's bruised head.

I reach over and pour a little oil, which the nurse has placed on the delivery table, over Tom's fingers as he massages the vaginal opening; our gloved hands touch and he smiles. Our last delivery together. Shoulder to shoulder.

When the monitor shows a good contraction, I lean over the bed and whisper to Jeannie, 'This is it, babe! One more push. You're on your own now, no vacuum extractor. The head's almost out.' With valor, the worn-out woman pulls back her legs once again. Nathan gets into position, holding her head, and I bend over, showing more optimism than I feel, to help Tom support the perineum.

Imperceptibly, there's a shift, and the fetal head dips below the pubic bone. There's no stopping Jeannie now. All at once, the baby rotates a quarter turn and hurtles into Tom's waiting hands. I place the wet squirming bundle in Jeannie's outstretched hands, cord still attached. 'Thank you,' she cries, 'Thank you, everyone. My baby! My baby girl.' Nathan is sobbing. There are tears in Tom's eyes. Our last delivery together" (209-11).
This is obviously a much different scenario than the vacuum-assisted birth on Private Practice. Mom works for hours to push her baby out: they try lots of different positions, lots of encouragement and support, tolerance of variations of normal in the fetal heart tones. I do wish the author had included more of the informed consent conversation that I'm assuming happened. And I'm assuming that lots of the positions they worked through earlier were more upright ones, but that these last pushes happened with mom on her back because they were using the vacuum extractor as a last resort.

I'll be back on a regular schedule again now that we've recovered our power. This has been a record for how long it's taken me to write a post - I started this one over the weekend, but since we lost power when it snowed 18" on Sunday, I haven't been able to get back to it!

I keep repeating to myself: Spring is coming! Spring is coming!!

More posts coming soon!

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine
New Mothers Support Circle

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