For Olivia

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This story could begin in any number of places, but there is only one way it ends. I’ll spare you the suspense.  She dies.

Beginning at the beginning, I grew her, held her body from the inside and then from the outside, and in the end, I crawled into her bed in the ICU and held her there too.   She was as warm then as on the day she was born.

People have been unbelievably, impossibly, unbearably kind.  They brought love and food and hands to clean my house and they played music and brought photos and told stories. Karen deserves a special mention, an award, Companion of the Order of Bereaved Mothers—now there’s a club you never want to join— but there are many other nominees.  You brought coffee and tea and hot chocolate and this amazing vanilla chai stuff in a can, we have run out and I would like more.  Except that I don’t know who you were to ask where you got it, let alone thank you. You brought wondrous things:  a Leunig print, a child’s drawing, a maple tree.   Later, others of you hung that tree with fairy lights.  Did you know how much I loved you?   You bearers of soup, you doers of laundry? You even put laundry away; I can’t find my blue sweater now.   You took my boys shopping for clothes, my girl for a dress, and you took my husband’s suit to the dry cleaners.

It wasn’t your fault that later on, with minutes to spare, me having left with Olivia in the hearse and the menfolk only having one job left to do,  said husband could not do the suit up.  It was ten sizes too small.  In a panic he checked the lining: Tip Top Tailors Toronto, yes;  no possibility of a mix up at the cleaners.  They must have shrunk it.  Which, dear husband, is an impossibility, the very purpose of waterless dry cleaning. The men try to hammer him into the pants but it will not work. They, marine biologists in their rank, line up like hermit crabs, an elaborate game of suit trading ensues.  In the end my older son puts on the too small suit which fits him perfectly, my husband puts on the son’s—modern, low cut pipe pants,  which he can button up underneath his (smallish) gut, like pregnant woman do.   I alone recognize the suit my son wears—vintage perfection– from wedding pictures 26 years old.   The other suit, the one my husband wore two weeks before to a meeting, the one that actually does fit, hangs in the cupboard still, exactly where I said it did.

And it rained and rained, which they say happens when someone important dies.   Our septic tank could not cope and in the middle of everything we had the poo hoover arrive.  The disimpaction was not a success.    We ordered in a port a loo.  My friend David made funny signs directing our guests, they made me laugh.

Over the septic tank’s tile bed, a duck died.  I worried it had been overcome by fumes, but David plucked and dressed it, performing an autopsy at the same time.  The post mortem exam revealed it had been -thankfully- shot, and in a desperate, dying last flight, this dear duck managed get away from the hunter, instead, laying down its life in my semi-vegetarian yard.   It felt like an offering too sacred to pass up.  Justine, playing the role of Nigella, cooked it with rosemary and red wine.

Take, eat, this is my body, given for you.

We retrieved Olivia’s from the coroner’s own section of the morgue. I think it is the equivalent of first class for the dead. Jessie climbed into the back of the hearse and rode with her that way to the funeral home, lying beside her and chattering like the two good friends they were.   We, the women who were Olivia’s mothers, cared for and bathed her body, washed her hair, and clothed her, and brought her home.    I hardly need mention that I hoped it would be the other way around.

There is a lot written about death.   It feels ridiculous, embarrassing, and deeply presumptuous to add my two cents.   What I might as a mother and a semi-atheist contribute to that huge lexicon?   People send other people’s words to me, hoping I’ll find some comfort there.  Thank you and please keep trying, though nothing works as yet.   Death isn’t merely in the next room.  There’s no God for me where Olivia is.  You can believe that but I cannot.    Let’s state the obvious here: there is a three year old with an exact match of her mother’s eyes and you dare to tell me – and her– that your gods are good with that.

Yes, the angry-at-God part, so predictable when there isn’t any other suitable target.

Oh, but there is, you see.   Writers are a vengeful lot: and oh, I promise you my daughter, that day will one day come.  I always thought I wrote stuff down to try to make sense of things.  I always thought there was sense in things to make.  There is no sense in this.  Which is why the only stories that are sensible are fairy tales, once upon a time, and happily ever after.  In her coffin, which we placed in her old bedroom, my daughter looked like an exact replica of Sleeping Beauty.  An exact replica of a figment of someone’s imagination. Iris said, “Mommy, wake up!” Except she died for realisies.

I spend these days in memories.  I open her closet, and smell her clothes, the scent ignites them.   In that paper mache head of mine, edges curl and smoke and then they lift here and there, lit up in flames of green and yellow and blue.    Inside my brain the memories are dancing like the northern lights.   I stand, in awe, gasping with the memory of her birth, satin sliding out from me, heartbreak beauty die laughing funny. Biddiee biddie bee. She snorts, she cries with laughter trying to get the stories out, she is riding horseback, higher Mommy, higher she squeals. Inside my own head, I rummage deep, holding up my favourite parts to the flickering aurora lights.   Her belly swollen with Iris, she is floating in a birth pool, huge brown eyes locked into mine, and she gives me one small gift. “Oh Mom.  Why does it hurt so much?”

Because, my own sweet girl, I am whispering, we don’t know the pain ahead of us.  You don’t know, in the future what will be asked of you.  I myself back then didn’t know what kind of daughter I would get.   This, I tell you, is preparation.   She nods, and reaches in.    I am watching her, a woman at the peak of strength.

I am grateful.  I am grateful. I am grateful.

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Molly Aug 2014 (100)

The obstetrician’s dark gallery

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The writer Anne Lamott tells her writing students that they should always write out of vengeance, as long as they are nice about it. I mainly write out of a longing to make sense out of things, but maybe there is room for improvement.  According to Anne, there is a trick to doing this vengeance writing thing without getting sued.   You can go ahead and write about the boss you hate, the ex-husband you despise, in fact, you really should write about them, says Anne, but if you have a boss or an ex-husband who has an identifiable set of unfortunate personal characteristics she says you should probably change these details dramatically.   So, she tells us, if they are known for their long toenails, give them tufts of nasal hair instead. I think that filling their ears with tufts of hair too, would be a nice touch, as a good crop of ear hair can explain perfectly why they don’t hear anything but the sound of their own voices.  It is a good idea to alter a few things in their personal lives, marry them off to unfaithful spouses if they are single, and divorce them several times over if they are married.  Leave out the plastic surgery they had, and the membership in the hair club for men (So unfair, how hair follicles are assigned!)  And —I saved her best advice for last— give them a small penis.  They will never sue you when they recognize themselves in your writing, if you make a few alterations to their physical self and life, and give them a teenie little penis.

It’s not like I’m not tempted to write about any number of previous or current bosses, but what I’d really like to write about are my patients, and the midwives I work with, and my  friends and colleagues, and there’s a problem with that.   I can’t give them small, or even large penises.  In the first place, the big dramas, the things I’d most like to tell you about, the things that fill my diaries and get up in the middle of the night and stomp around in white bloodstained gumboots, those things happen to the penis-less among us. This is not a coincidence.  To disguise the details is also problematic.   It is in the exact details that the horrors are fully revealed.

Agatha Christie once said that it is a curious thing what one remembers.   You never know what is going to be permanent.   If my head were made of paper mache, the births I’ve attended would be posted like bills in a gallery of their own inside it.  There are many of them so it’s crowded, and they get papered over under layers of other births.   I remember the ones that soak and bleed through like wounds that cannot be staunched, no amount of plastering and bandages are enough.

I have presided over some deaths, and there they are, scenes of tragedies, in the obituary section.  A recent addition is a couple who came in last week.   I see them clearly, their heads bent together making a little drawbridge over their grief.   My colleague and I are taking turns operating the ultrasound.   It takes seconds to find a beating fetal heart with a scanner in a full term baby.   It takes a couple seconds more to break a mother’s heart when you can’t find it.   A few extra seconds of scanning: a lifetime of grief.

Over here, in the same week’s catch, another baby-shaped void, but she’s not dead, only missing.  This one’s been uplifted, there’s a misnomer, it’s the word they use when babies are taken off their mothers.  Mothers who are bad, or mad, or addicted to drugs, or in this case, all three.  This mother’s eyes look back at me like two deep wells when she asks me where her baby is when I visit on rounds the next day.  In those wells there is a sadness that surpasses understanding, a deep tissue sadness that no drug can penetrate.

In my brain there is a dark lit gallery where these portraits hang, portraits of mothers who lose their babies, lose their minds, and have had their minds fucked over, purposely.  “Don’t you want what is best?”

It is depressing, and I don’t mean for you to feel that way.  When one becomes depressed, it is because one realizes that life has no purpose. Patients sometimes say an obstetrician’s job must be so fun.  We know our speciality is often full of sadness. Patients know this too, if they think about it for a moment. The psychologist Jordan Peterson said “Everyone knows that life is tragic.  Everyone knows that to exist is to suffer.  And one logical and appropriate response to this is to be grateful in spite of your suffering and attempt to make the best of it.”   I am not going to do this.  I will not be grateful in the patriarchy.  But here I must tell you the all-purpose cure for depression:  the one and only cure that doesn’t involve denial or repression.   It is this:  to try if we can to alleviate the suffering in others.  And when we cannot, it is to bear witness, to be in solidarity, to say, yes, it happened to me too.   I add to my gallery every day.

The most beautiful section in my gallery is the exhibition of the births of my own children. They are on the innermost layer of paper mache, but visible at all times to my inner eye.  Like all mothers, it doesn’t matter how long ago it was.  The images don’t fade.  My oldest son’s birth was painted there by Michelangelo.   There, in the Sistine Chapel of my brain, he is dancing out of my body.    He spins upwards like a baby dolphin, dark wet, and slippery, breaching the surface of the universe.   He is half an infant god, and I am the goddess mother to whom he needed to return.   My arms fling outward to receive him.  And his arms fling upward to reach mine.   Our fingertips almost meet.     It is an exact copy of Michelangelo’s painting in the Sistine Chapel, where God’s fingertip reaches out towards Adam.   Divine sparks are flying from our outstretched beseeching palms.

This must be a multimedia exhibit, because I hear myself saying to the doctor, “Please, can you give him to me right away?”    But at that precise moment, the sacred moment of my son’s birth, an anaesthetist walked into the room.  In that moment of dithering my doctor stops, she hesitates, she is confused for a moment, and then she gives my baby to this higher power instead of giving him to me.   I had no need of anaesthetic.  My son had no need of neonatal care.   But later I find out that in the Canadian medical system, if that anaesthetist gets your baby he can do something you, the mother, cannot do.  He can bill the government for resuscitation.

Where exactly do these men, those anaesthetists, the alpha males in charge, that swagger with their male privilege into our spaces, those of the small and large penises and untrimmed toenails and unhearing hair-filled ears, where do they think they started out?  Do they not know they hang in a gallery in some other woman’s brain?  Were they not little boys at one time in their lives?  When did they become such assholes?  Isabel Allende says that misogyny trickles down.  There is always some woman to be abused.  But where is the wellspring?   Let’s shut it down.

St Augustine, before he became a saint, wrote a manual called the City of God, in which he touched on the woman problem. The latest Pope has solved the dogs-going-to-heaven issue, back then Augustine grappled with the question of the female immortal soul.  Men, self-evidently, were created superior from the get-go.   In my view you could count them as the first draft.  The shitty first draft, Anne Lamott might say.   Not so the wise men of that era.   Augustine wrote that, by virtue of women’s inferior shitty second-class draft status, no matter what godly deeds they did in their life on earth, they could never be the equal, let alone superior, to any living man.  Fortunately, there was hope in the afterlife.  Once women were actually admitted past the pearly gates, like cripples and the blind, we’d be restored to a perfect state.  In the case of women, it means that we will get a penis.  If we are good and virtuous in this misogynistic life, it is meant to be no small measure of comfort that we will get a penis of our very own.

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I am on call, and a woman comes in bleeding, 30ish weeks pregnant.  She is haemorrhaging badly.  We rush her to the operating room.   Her partner, the one with the swastika tattoo, is anxious and pacing.  There is a letter in the notes about domestic violence and the police.   His last baby was born by c-section, (to a different partner, he’s on his fifth or sixth now), he’s an expert, he mansplains what I’m going to do.   But those babies weren’t premature and this is different.  He is not cutting the cord, there will be no skin to skin.  It’s not on purpose, we want these fathers, all fathers, to attach, to bond.  So they don’t kill their babies or their partners for starters.   The woman is unstable, and the anaesthetist needs to give her a general anaesthetic, and this means he’s not allowed into the operating room. When he’s told the plan, he loses it.  The aggression and verbal abuse escalates.  We have no time to cross match blood, no time to deal with years of trauma, no time to dismantle systemic racism and misogyny.  I try reason:  it doesn’t work.  That chills me, because it almost always does.  I’m nice.  Really nice.  It scares me when scary people don’t respond to reason and to genuine kindness.

 “How dare you goddam bitches keep me away from the birth of my child?”   He raises his voice, his face is too close to mine, he knows what this is about, “You fucking cunt.  I know my rights.  You are discriminating against me!    All because I have a dick”.

“No”, I hear one of the staff say, moving her body like a shield between us. “It is not because you have a dick, it is because you are acting like one”.

I flee to the scrub room.  In a few minutes, I find myself in a company of women, surrounding this mother, our heads bowed, a scalpel in my hand.

 

This Post is Not About My Workplace

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The other day, the front page of my city’s local newspaper had an article in it called Big Brother Is Watching.  The hospital that I work at featured prominently.  The communications people there (and there’s a misnomer for you) are monitoring our communications, and if we say unfavourable things about them, we are to be disciplined.

So.

 

I read this thing once that said the only way you can write something approximating the real truth is by writing fiction. I read memoirs, and the only ones that are any good are brutally honest, and the only ones that are brutally honest are when the narrator is the sole survivor of some horrific thing.  Everyone else is dead, or it’s a scandal of epic proportions and the person has been stripped of all dignity.  She has nothing at all to lose since everyone knows the public details of the shame right down to the brand of stain remover she used to try to remove the semen stain from her dress.

The heroes in these memoirs are divorced, widowed, fired or wrongfully imprisoned.  Most importantly they are usually unemployed, if not unemployable.  Horrific things make for gripping reading, but that’s not the only reason these memoirs grip you.    It’s because they are free to be true.  It is the pure raw truth of it that holds you in its thrall.  You could make someone’s ordinary life a best seller too, if only you had some way of making it that truthful.  But you can’t, because you need the witnesses dead, so you can speak ill of them.  If they aren’t actually dead they will soon be dead to you if you are writing anything awful about them.    And you will be writing awful things because it’s the truth.  Everyone has an awful side to them.   They don’t call it the awful truth for nothing.

I like to read mom memoirs too.  But there’s a reason why all those mommy blogs are about toddlers.  They have to stop writing as soon as their kids can read.  There’s this huge gap in the momoir genre.  Unless something horrific happens, like, say your kid is in one of those schools for criminally insane children in Utah, and even then, you don’t dare write a word, because they might get out one day.  You hope they will.  If, say, they are trafficked out into a polygamous cult and meet a tragic and sticky end, well, then you can write away.  You don’t hope for that.  So, you can’t write about your own real life.

The main barriers to writing the truth come in the form of witnesses.  If the writer-to-be is the actual perpetrator, they, of course, have almost no incentive to reveal themselves.   If the writer-to-be is a victim, they are often afraid of retaliation. So a great many awful things carry on happening in plain sight of many people.   It is The Emperor Has No Clothes On and He is Now in Charge of the Maternity System.   No one can speak of it, unless you want to be divorced, exiled or never employed by anyone ever.

In his book Feral, author George Monbiot writes that we have been conditioned to have a benign view of farming because of the stories and rhymes of our childhood.   Remember those story book farms with exactly one pig, one horse, one cow and one duckie swimming in a little pond?   The horrors of the slaughterhouse, the cruelty of factory farming; those things were never depicted in those books.   Later, we put two and two together:  Farmer Brown’s friends were in those the meat packs in the supermarket.  The farmers in turn, point their finger of shut-the-hell-up shame at us to distract us from the pile of entrails in the corner over there.  They don’t want us to be vegans.

We’ve probably been conditioned to have a kinder regard of medicine than it deserves too.  A similar set of circumstances conspires to shape our early views of it. The play doctor kits, storybooks and soap operas are practically developmentally staged favourable views of the medical profession.  Later, it’s self-interest and self-preservation that keeps you from examining things too closely.   We give up the best years of our lives for medicine and to find out it is based on any word of a lie is painful.

There’s something else that prevents us from truthfulness.  People can get hurt by lies but they can also be hurt by the truth.  Mothers know this.  They have fed a great many mother’s day breakfasts, lovingly prepared, to the family dog.  I read this thing about how people with Asperger’s do actually read the things that you write on the internet about people with Asperger’s.  Patients read what we write and I like my patients.  Colleagues read what we write and I like my colleagues.  Flawed and twisted they may be, I like them a lot.  They are a pain in the neck to work with just like people with Asperger’s are a pain to live with.  But then, people, in general, are a pain to live with.   It makes sense that they are a pain to work with too.  And a pain to look after as patients.  Life is a pain.

You can take painkillers, or antidepressants, alcohol, and, if you can get it, a smidgen of cocaine, for that.  But life in general has no medical cure.  We all know how it ends.  Palliative care for life comes in the form of reading poetry and literature and in writing things down.  I have done this almost my whole life but I only found out recently that this is a thing.   There are actual prescription books, “novel cures”, and emergency poetry….things you read for the treatment of actual conditions.  You can have bibliotherapy, which is exactly like chemotherapy, without the side effects.

If I was talented enough to write fiction, I’d write about a middle aged obstetrician, who has a disabled son.  She’d have hair greying in an attractive way, which she wouldn’t dye because she’s paradoxically quite crunchy.   Just to be clear, she’s not me, you can tell because she weighs five kilograms less, she’s a little taller, and has better teeth. She would have more energy than I have too.  In the night, when not on call, instead of lying in a state of sweaty anxious exhaustion, she’d be doing research, at the university, trying to find help for her son, which is to say, help for herself, which is to say, the meaning of life.

She is failing on every count.  It is ever thus, half-finished projects litter her life.  She needs to pick one cause but there are too many things of too much importance and she is paralyzed.  In addition to the above mentioned tasks, she wants to dismantle the system that conspires against mothers, but she finds that it’s snowballing out of control from its own weight.   It has scooped her up, surrounding her in deep swathes of snow, her arms and legs are soon the only things sticking out as it rolls down, down, down, dead leaves and twigs stick to the surface like medicalization and iatrogenisis stick to the practice of obstetrics.

Like so many problems, the trouble is in the naming.  The trouble is that good people stand by and say nothing, while so many emperors remain unclothed. In obstetrics, in workplaces everywhere, it’s no wonder.  Have you ever tried to speak with your mouth stuffed with snow?   We are trapped and silenced.  We cannot speak the truth.  She, our hero, especially, cannot.

She can’t lose her job because her disabled son will depend on her for his whole life.

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I am a first year resident.  My job is to assist, to write the post op orders, and to dictate the notes.  Today, I am assisting one of the staff doctors at a caesarean section for breech presentation.   The surgeon makes the first cut, parting the skin over the fat and underlying fibrous rectus sheath and so he begins the decent down to the uterus from the abdominal wall.  He reflects the bladder, and cuts into the uterine muscle.   But what’s this?  We are supposed to be seeing the baby’s bottom, this is what they call the “indication” for surgery, as if it’s a signal, a sign, a pointing finger, the marching orders to the operating room.  You draw that breech card and you are not passing go.  You are not collecting 200 dollars.  The baby is head first.  The surgery has been done for nothing.   The doctor swears, just loudly enough for me to hear.  The rest of the surgery proceeds in silence.  At the end of the case, he says “I’ll dictate this”.   I wonder what he is going to say.

I read the note later.

Pre op diagnosis: Unstable lie tending to breech

At least the lying part was true.

#notallobstetricians

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In Tolkein’s classic Lord of the Rings, Arwen Evenstar gives up her immortality for the love of a mortal man, Aragorn. Arwen’s father is against the match. He’s got nothing against Aragorn, it’s just that he understands the full weight of her choice. But Arwen won’t be dissuaded. We often do things that are crazy in the state of temporary insanity induced by love. Like having children. It’d make a great story if I could say that’s why I did obstetrics too. For the love of it. But looking back, it might have been for hate.

My son Colin, the philosopher, tells me that our decisions go back to the big bang if we go back far enough. By this he means that there’s a certain inevitability to our choices. That if we look backwards at our lives, everything that happens nudges us in a certain direction, and we find ourselves falling down a particular pathway under the influence of these unseen forces. That hateful obstetrician who I met the day I attended my first ever birth might have tripped me up a little, but I might have been heading in that direction too.

I like to think that the reason I became an obstetrician was that when I saw that doctor pull that baby out with forceps for no apparent reason, it made me think that I could do better. That I could cancel out some of the abuses that I saw were happening to women. The trouble is that some of those things I did to cancel out the wrongs have been acts of responsible subversion. Because they maintain the status quo, responsible subversion is somewhat irresponsible. And also, since people don’t know about my good deeds, one day history might judge me in the same light as those evil obstetricians. History might think I was one of them. But history lies sometimes. Like, just because I once owned a gold lame pantsuit, it doesn’t mean I was a disco queen. Disco music gave me a migraine in my ear.

I’ve written about Mary Rose McCall’s book The Birth Wars before. In it, she compares the philosophical disagreements between midwives and obstetricians (birth as natural: birth as dangerous) to a war in which women and babies are the collateral damage. I’m aware that one day my grandchildren might well ask me what side of the war I was on. If you read the obstetric history books it would appear that all my predecessors were monsters and maybe they were but more likely they were just human beings trying to do the best they could with the material they had to work with: the lowest human life forms on the planet –mothers and babies. Who knows, maybe Joseph Delee himself, he of forceps = gentle / vagina = skull-crusher fame may have been a closet feminist.

The poet and philosopher Criss Jami wrote “When good people consider you the bad guy, you develop a heart to help the bad ones. You try understand them.” And he’s right. In trying to understand the field of obstetrics we must consider the patriarchy, and the fact that birth must not go quietly into the service of those dark knights.

In the world of obstetrics, there are too many bad guys. #notallobstetricians, that’s for sure, but far too many. The sad explanation is that we do not value motherhood, which is a nice way of saying that our culture (still) hates women. I know many people won’t believe that: they will say they love women, but they only love good women, thin women, beautiful young women, they don’t love women on welfare, women who smoke and who eat junk food, women with rotten teeth and rolls of fat, women who have had too many babies to too many different men.
When I had my first baby one of the first things I felt was a deep connection to all of the other women who had babies before me. This feeling surprised me. I think part of the reason it surprised me was, in truth, that I had been a snob. Before I became a mother myself I hadn’t appreciated the profundity of the act. After all, even stupid women become mothers. Women with rotten teeth, and rolls of fat, who eat too much junk food. These women are often, too often, some might say, mothers too. If ordinary, regular women could do this thing– become mothers— like I just had, then perhaps there was more to them then met the eye. Maybe there were other things I’d overlooked. It wouldn’t be the first time I’d judged someone harshly and then come to find things out about them that shattered my image not only of them but also of myself as a fair minded and reasonable person.

What all women have in common is that they when they become mothers they deserve the best of care. Let that sink in. That woman with the tattoos and badly dyed hair who got addicted and had a baby with a gang member deserves the best of care. Yes, we have a duty to protect the baby from abuse from her own flawed mother. But the best way of doing that is to make the world a better place so that good mothering can emerge from flawed women.  
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The Lord of the Rings trilogy has a long appendix, so maybe you haven’t read it. In it we find out what happens to Arwen in the end. As it gets closer to that day of reckoning, when Aragorn ages and eventually dies, Arwen comes to regret her decision. The reality of a mortal life is before her. It is in the end, looking back, where choices can be regretted. When we suffer, ourselves, for taking what stances we took in our lives. Where what seems like a good idea at the time doesn’t seem like such a great idea after all. Part of this is just what always happens when we have lived a while in the actual life we chose, with all of its disappointments. The road we didn’t take often seems so much better, because it’s always a fantasy. We don’t imagine alternative careers to be boring, alternative spouses to be abusive, alternative children that won’t brush their teeth when asked.

Imagine Arwen sitting at the coffee table with her best friend. There are things even best friends don’t talk about, for example, their choice of partner, especially when it’s a done deal like that. My dearest friends have ended up with some surprising choices. I know left wing beauties married to right wing uglies; down-to-earth earth mothers hitched to conservative snobs; friends who divorced weirdos and remarried idiots. You can’t account for it other than thinking that Cupid is pretty random. We might not comment but we certainly think it, what they hell did she see in him and she could have done so much better. Behind her back Arwen’s friends might have said that Aragorn was pretty hot in the day and a King and all, but seriously, I’m sure she coulda had any pick of the elves AND kept her immortality. To paraphrase my grandmother, “it’s just as easy to marry a mortal man as it is to marry an immortal one”.

We tell ourselves it’s for just and worthy cause, this diminishment of power. But there is no reward for love in the patriarchy. Most women become lesser beings there, in the service of men. We tell ourselves its okay, we’ve done it for a noble cause: because we love them. And we are punished, because they—the ones that write the rules that govern how women are abused and oppressed —-they hate us most of all.

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I am leaving the hospital after a difficult night which stretched well into the next day. A colleague has called in sick, and I have stayed far beyond the rest of my shift. When I get to my car, I realize that in my haste to arrive in a crushing emergency, I have parked in the space reserved for the paediatrician on call. My driver’s side window is plastered with a sticker warning me that I will be towed if this transgression ever happens again. The sticker obstructs my vision and I can’t remove it. I cheer myself up by indulging in a fantasy about what happens if I am killed in a car accident on my way home. The CEO of the hospital attends my funeral, the jerk who is a member of the hospital board, and wait, here is a particular manager who has previously made my life miserable; they all say how great I was. It makes at least page three of the Times. The dream sequence fades into nightmare when a man approaches. I think he’s going to offer me sympathy for a moment; he is looking at the sticker, so I get a shock, because he’s nasty. He strides towards me menacingly. How dare I park in this spot, he (An Important Man!) had An Important Meeting!! in the morning and was Running Late!!! I try to explain about the emergency c section that turned into a postpartum haemorrhage and the foetal distress that followed in the room next door, and the same time and to top it off there was a woman with an intrauterine death who I have just left and how one thing lead to the other and that I didn’t mean it, I try to engender some sympathy, you see, while I appreciate the importance of the meeting there were lives truly at stake, except for that woman with the dead baby which wasn’t an physical emergency but it was an emotional one, but I realize he doesn’t care. All I manage to say, hanging my head, is that I was on call. He knows what it’s like to be on call, he’s done it himself for years, as he (raising his voice)—- don’t I know—, is a Consultant Paediatrician. It doesn’t dawn on me until later when I am at home, that, because of my crappy car, and my crappy clothes, and maybe the mascara tracks on my face from the dead baby, he treats me that way because he doesn’t see me as a peer.

He thinks I am a midwife.

Lessons from giving birth: A letter to my friend Wendy

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Dear Wendy

 

When I was in labour with Olivia, you were there, and I hated you.  Don’t take it personally, I hated everyone.  I was in pain, and not having fun. I felt sick to my stomach, and shaky, and in pain, and those feelings mixed up together in a hot and cold mess of misery. The nausea shakes and pains came at me in disorderly unpredictable waves, I couldn’t brace myself against them.  At that point, I was mad at the world.

For a price, you can employ other people to do most unpleasant things in life.    You can pay someone to wash your windows, to scrub your toilet, to clean your stove.  Some things you can avoid doing entirely, a favourite technique of mine.  This makes sense because according to a quiz I took on the internet I’m an anxious avoidant on the attachment scale. My oven cleaning strategy illustrates this perfectly.  Normally, I just don’t clean my oven. Things merely burn off as they crust over and reach a critical mass.  Pregnancy and birth don’t work that way.  You can’t get a stand-in for the unpleasant parts.  

In my case though, the pain brought important lessons.   First, I’m really good at birth though no one could say I enjoy it.  I know women who do: I shake and vomit on the floor, like I’ve had too much too fast to drink at a party, like I’m having a bad acid trip.  The hangover part is missing though. Instead, I get this grand afterglow, the kind of buzz addicts everywhere search for endlessly.  The kind of feeling you might expect to have when you’ve died and actually gone to heaven.  Complete with angels.  One anyway:  a plump, pink and juicy freshly squeezed angel baby that plops out of your vagina.  It’s ridiculous, hysterical, and also true. 

The second lesson was this. I’m getting serious now.  When I had Olivia, there was a point where that intense feeling of hating you and everyone else because you all were enjoying your lives and not in pain—so unfair – there was a point where this feeling suddenly gave way and I realized something:  I was alone. With my baby yet to be born, I was alone.  With a room full of supporters, I was alone.   No one could birth the baby for me.  The labour was mine and mine alone.  It would continue inextricably as death follows life.  

The Jesuit priest Henry Nouwen wrote in his book The Wounded Healer that “the painful experience of loneliness is an invitation to transcend our limitations and look beyond the boundaries of our existence”.  He wasn’t kidding.   My painful experience of loneliness just happened to coincide with the pain of labour, but the transcending bit was exactly the same.  This was a gift, filled with promise. I looked at the boundaries of my existence and found the space it enclosed to be empty.

Nouwen writes that we spend our lives trying to fill this emptiness, to meet the right person who will complete us, to have a job that makes us feel powerful and special, to read a book that will have all of the answers.  Or we drink, or become addicted, or shop.  We are depressed, sad, anxious, unhappy.  It is all everyone else’s fault.   There I was, in a blue cotton hospital gown that did up the back, in a room full of people, alone with my pain. And like Nouwen said, I too have tried to fill this emptiness.

How many of us really ever come to know the mind of any other?  We read of suicides, of murders,  of murder-suicides,  the neighbours say during interviews on TV “I had no idea”.  I think it’s because we keep the worst of ourselves, the empty space we all have– mostly hidden from each other’s view.

 

There’s a quote that says that having a baby is to forever know what it’s like to have your heart walking outside your body.   This is true.  But it’s true when we have any meaningful relationship. Real relationships have real meaning only if we put ourselves on the line:  we let them have a piece of our heart to carry with them, to do with what they will.  We give away a lump of our own myocardium and we risk that others will not value or cherish it.  Sometimes they can’t even hang on to it; they let it die for lack of caring.   Meaningful life is a willingness to be vulnerable with our true unvarnished secret self, the self that approaches –but can never truly banish—the truth of our isolated existence.

 

 

Time has passed since that birth, but I remember it all so clearly and I always will. We had the same due date, you and I.  But I went into labour before you, so I came to your birth a few days later with my daughter, the first birth she has ever attended.   You sang in labour, like you always did.  Each note held, clear and beautiful, moving higher and higher up the scale.  You are a true soprano. I imagine you filled your empty space with song.  Your son is a musician now and my daughter is studying to be a midwife and I don’t know if that means anything.  

What I do know is this.  We all get here- one way or the other- from the body of a solitary woman (results may vary).   There is always blood.  There is almost always pain.  There are sometimes drugs; forceps, surgery, prematurity, inductions, stitches.  Sometimes, the pain is not understood or comprehensible.  Sometimes no one cares.  Sometimes it’s really ugly.  Sometimes it leaves scars.  Sometimes it’s nothing that fabulous or transcendental. Sometimes it’s ordinary, straightforward, routine.  But maybe birth could have something valuable to teach you about yourself.  

 

 

You can listen to my friend Wendy’s heart walking outside her body here: 

 

http://keenanreimerwatts.bandcamp.com/album/thoughtful-music-and-other-music

Or here on youtube: https://www.youtube.com/watch?v=95i20vcago8

On the penalties you pay for believing in women

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On the first day of my first obstetrics rotation as a medical student, I got to attend a birth.  I was assigned to shadow one of the staff obstetricians. We waltzed in unannounced to the room of a labouring woman, who was pushing, feebly, ineffectively, with her feet in stirrups, legs encased in drapes.  The doctor turned to me and rolling his eyes said, “At this rate, we could be here all day.  Nurse, get me a pair of forceps.” And then, for what seemed to be no reason at all, other than impatience, he pulled the baby out.    It was awful and I remember feeling terrible for everyone….the mother and her baby, the nurse who had to “obey” and for myself for having to bear witness to this thing. 

 What did I do with those feelings?  Did I report this behaviour to the proper authorities?  No, I certainly did not.  It was clear to me that this was how it was going to be, that shocking things like this were – shockingly – forbidden to be viewed as shocking at all.  The way everyone else around me was acting it seemed to be the expected norm.  The staff doctor was my boss, and he was at least in part responsible for my grade during that rotation.  I was in no position to complain.   

To be fair to the obstetrician, as a student, I didn’t understand everything that was going on.  It could have been that there was some other reason to deliver the baby that way that I didn’t fully appreciate.  Maybe the fetal heart rate tracing wasn’t optimal.  Still.  I’ve had many other experiences of the same kind in my training and beyond, enough to know that this kind of casual approach to violent events is commonplace.

By looking at me and speaking to me in that way, including me as a sort of a peer… “we could be here all day” ….. I was being asked to take sides.  It was as if I was being groomed for something.   Grooming can be quite flattering.  You don’t want to speak out because you are afraid of being humiliated.  This doesn’t change the fact that you are complying with the abuse of women. But you are complicit in an act of oppression for the same reasons everyone complies with oppression, because you are weighing the risks and the benefits of non-compliance.   You are performing complex calculations in your head, below the level of your cerebral cortex.  Who would have known the brainstem can do this kind of math? 

It’s a survival mechanism though.   We need to suppress this information from our conscious selves to function in this system.   We are helped to suppress our empathy in so many ways.  In the hospital setting we make the patient seem “other” than ourselves.  The patient gets a hospital gown and an arm bracelet to segregate and anonymize her. The patient I described in that story above didn’t even have a name.

We do these things in part because at times we have to do horrible things to people in the name of helping them….for example, most days I’m cutting into the flesh of women which could—perhaps even should– be repulsive and frightening but I have learned not to think about it in that way. It is easier to think you are cutting into a piece of some sort of material and not, you know, an actual woman.   

The problems happen sometimes when the patient seems too much like us.   As long as the patient comes from some sort of difference:  age or race or socioeconomic class, it’s okay*, but then, someone comes along and bam—-all of a sudden we have trouble.  For example, I once had a lot of problems staying out of grief with a dying woman who –though not related to me—happened to have the same last name, and children around the same age as mine.  (For the record, staying connected to her as she died was a transformative event in my medical life, which is to say, my actual life.)

And then there are the very scary things that happen.   Like when patients bleed to death and babies die.   After half a dozen or so of these sentinel events as they are called, we start maybe exhibiting some of the signs of post traumatic stress disorder.  We shut off even more.  We abuse patients, for better or worse, we are perpetrators.  We become that obstetrician that I followed on the first day of my obstetric rotation.

Not much is written about the perpetrators of violent crimes. They aren’t usually the ones seeking therapy.   I read a book recently called The Birth Wars by Mary-Rose MacColl, which highlights the terrible relationship – the war – between midwives and doctors in Australia where tragic outcomes for women and babies have become a sort of collateral damage.  She doesn’t offer us any solutions but it seemed to me, since she called it a war, we can maybe learn something from the studies of soldiers who have been in combat.  I think the comparison is apt because they are both perpetrators and victims.

Judith Herman, who wrote the book Trauma and Recovery about the survivors of violence, political terror and sexual abuse, writes that every soldier has a threshold of resilience that can be exceeded fairly quickly:  most “tours of duty” exceed this threshold.  And given a horrific enough event,   no one is immune from the consequences of traumatization.   Judith points out that the trauma of combat takes on greater force when the soldier can no longer rationalize it in terms of some higher value or meaning.   Doctors like me feel a little bit this way when we question the evidence behind our practice.

There is a solution.  Herman also writes about the healing power of connection.  And so it is the connection that provides the recovery. It is disconnection, in some cases perhaps a merciful act of the brain to minimize memory of horrific events, which becomes the problem.  

Therapists say that when we make connections, whether it is in our relationships or in our professional lives, we can talk about anything.  What they don’t seem to talk about is the cost of connection.   Each of us needs to weigh in that cost.   If you disconnect, it seems that you will probably pay later: depression, anxiety, PTSD.   With connection, you pay now:  anger at everyone who makes the system suck for women. Anger at yourself for not being able to change it.

For me, one of the penalties in believing in women is to live alone in a world of wounds.  The choice is to harden my shell, or to make believe that the consequences of intervention and obstetric “scare” are none of my business[i].   I can’t seem to do either one.

 

*******

I am in the operating room, about to do a caesarean section.  The baby is exceedingly premature.

A paediatrician stands waiting to take him away.   The baby is breathing on his own, and very vigorous, and so, I say to the mother, go on, reach up and touch him, it is really important; they may not let you hold him for a while.  She reaches up and grabs his little foot in her hand, and afterwards I am sewing up her skin she is still looking at her hand and marvelling at the warmth of him, and how wonderful his skin felt. “He was hot as, cuz he came from inside me, and his skin was so freaky, soft,” she is saying.   But the anaesthetic technician has just noticed her fingers are covered in blood and amniotic fluid.  Frowning at me over the top of the drape, he hastily puts on gloves, and gets a bunch of tissues to wipe it away.  

 

 


[i] Aldo Leopold described this wounding from the view of an ecologist living a world of exploitation of the land, in his book, A Sand County Almanac  Oxford University Press 1949

*(of course, this is NOT even remotely okay)

“The women aren’t here for us.”

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I was in a meeting after some horror show had played out in the birthing unit. It featured a ruptured uterus, a dead baby and multiple units of blood, and the STAFF were traumatized. We were planning a debriefing session: the venue, the time, the invitee list. One of the managers thought we were taking things a little too far. She said, “We have to remember, the women aren’t here for us”.

Are the women here for us? Not exactly. But care is not a one way street, and we need to talk about that.

I listened to Dan Ariely’s TED talk “Our buggy moral code.” Dan spent months; stretching into years, in the hospital after third degree burns affected most of his body. During that time he had to have many painful wound dressing changes. You may have heard that having burn wounds attended to is one of the most painful things imaginable. Dan said that the nurses would rip off the dressings quickly. And, they would start cleaning the most painful parts and work their way towards the least painful. They would rush through the work as quickly as possible. He would beg them to do it slower, give him a rest, save the worst parts for last, but they said “No, its better this way. It would be much more traumatic, if we did it the way you suggest”.

Once Dan got well he started doing research into whether what people believed about pain was true. He did a number of experiments using small electric shocks, plunging ice baths, vice grips on fingers, things like that. He rigorously measured the responses to the degree of pain his subjects experienced. Dan found that the average overall pain that people experienced was much reduced if things were taken slowly. His work revealed that many of the things that health care workers did to burn patients as a matter of their intuition were wrong and should be changed.

There are two powerful messages in Dan’s story. The first is the message that the patient is often right. We should listen to our patients much more than we do.

But I’d like to deal with the second message, made very clear went Dan went back to the hospital and spoke to the staff who looked after him. He explained his results to his favourite nurse. She said that there was one very important thing that Dan didn’t measure. He hadn’t looked at how the treatment made the nurses feel:

She said, “Of course, you know, it was very painful for you. But think about me as a nurse, taking, removing the bandages of somebody I liked, and had to do it repeatedly over a long period of time. Creating so much torture was not something that was good for me, too.”

In obstetrics we are the creators of torture. We often are witness to suffering, many times we, like the nurses who looked after Dan, are the ones inflicting it. We are regular bystanders, harbingers, creators of pain: we are victims of vicarious traumatisation and perpetrators of violent acts. It is true that sometimes we save lives in the process. But these uglier views of typical clinical events must be faced and examined carefully.

It is not good for staff to come to work and harm patients in the course of their care: intentionally or unintentionally. But the nurses did hurt Dan, they felt they had to, as part of their job. The pain they inflicted affected them so deeply they could not listen to what Dan was saying. Some part of their selves disengaged.

The day of the horror show, a mother was hurt and a baby died. I’m not getting into the fault of it. The thing is we were the audience and the cast of a tragedy. We need to review that play and not only to find out what scenes might have been better acted.

I think that when the manager said “the women aren’t here for us” she was extorting us to remember our non-starring role: the women aren’t here for our entertainment. She felt we should keep this professional distance, keep our emotions in check, toughen up and get back to work. The implication was there that if we didn’t, there was something wrong with us. But there is something more wrong when we don’t take the time to consider not only what happened, but how we feel about what happened.

There are times, I get called in to look at a tracing, or to give some advice, to births I have no other business being at, and when I get there, I realize that my services are not required. The woman is being supported, the midwife and family are there, and whatever they called me to do was a false alarm. Still, it is very hard to leave. I mean, it’s easy to leave a place where you are not wanted….but in this case, there’s a feeling of going out into the cold rain from a warm hearth, and you would like to linger, you would like to be invited to stay. But I don’t. That women wasn’t there for me. It’s enough for me to know that the warm hearth exists.

Instead, I’ve got a permanent invite to the parties that no one wants to attend. There’s a rush of adrenaline with all the drama of a five alarm fire. There’s a ruptured uterus, a dead baby and multiple units of blood. Like they say, it’s a crazy job but someone’s got to do it. Turns out that women want that someone to be a person who cares deeply about them.