The Blue Cotton Gown

  To midwife: To be with women, at childbirth and for life.

  AUTHOR’s NOTE

  The Blue Cotton Gown is based on my experiences and stories told to me by my patients. All names, identifiable characteristics, details of time, and names of places have been changed for the sake of preserving confidentiality. Several patients, professionals, and staff are composites. The events and conversations described are how I remember them.

  Heartfelt thanks to every precious woman who has shared her story with me in her thin blue cotton exam gown, and to every health-care provider who has persisted in his or her calling despite personal and professional obstacles. We each have our own story. This is mine.

  Patricia Harman, CNM

  Spring

  CHAPTER 1

  Confessional

  I have insomnia … and I drink a little. I might as well tell you. In the middle of the night, I drink scotch when I can’t sleep. Actually, I can’t sleep most nights; actually, every night. Even before I stopped delivering babies, I wanted to write about the women. Now I have time.

  It’s 2:00 a.m., and I pull my white terry bathrobe closer, thinking about the patients whose stories I hear. There’s something about the exam room that’s like a confessional. It’s not dim and secret the way I imagine a confessional is in a Catholic church, the way I’ve seen them in movies. I peer at the clock. It’s now 2:06.

  The exam room where these stories are shared is brightly illuminated with recessed lighting. The walls are painted off-white and have a wallpaper border of soft leaves and berries. There are framed photographs of babies and flowers and trees, pictures I took myself and hung to make the space seem less clinical, and a bulletin board with handouts on stress reduction, wellness, and calcium.

  The room is not big. It’s the usual size. If I had to guess, I’d say eight feet by ten feet. The countertop under the tall white cupboard is hunter green, and there’s a small stainless-steel sink in the corner. Other than a guest chair, my rolling stool, and a small trash can with a lid, there’s just the exam table, angled away from the wall, with a flowered pillow and rose vinyl upholstery. On it lies a folded white sheet and a blue cotton gown with two strings for a tie. The exam table dominates everything.

  I don’t drink for fun. I don’t even like scotch. It’s for the sleep. I can’t work if I can’t sleep. The scotch is my sleep medicine and I want it to taste like medicine. The little jam jar with the black line at three ounces sits in the bathroom cupboard. My husband fills it for me, then locks the bottle in the closet. I ask him to do that. When you have as many alcoholics in your family as I do, you don’t take chances. On nights when I’m restless, I drink it down sip by sip, making a bad face after each swallow. Then in an hour, I go back to bed.

  I stand now at the window listening to the song of the spring frogs and thinking of the stories the women tell me, and then, in the stillest part of the deep night, I sit down to write. I need to sleep … but I need to tell the stories. The stories need to be told because they are from the hearts of women; the tender, angry hearts; the broken, beautiful hearts of women.

  HEATHER

  It’s Monday morning and I’m late again. Waving to the receptionists, I rush through the waiting room. They turn to greet me in their aqua checked scrubs but keep on with their work. I know they keep track of how often I’m tardy.

  “Hi, Donna,” I say as I pull open the heavy cherry door to the clinical area. Donna, at the checkout desk, looks over her sleek horn-rim glasses and gives me a smile. The phone is tucked under her ear and she’s clacking away at her computer.

  Around the corner and down the hall is my office. It’s small, just enough room for a desk, a file cabinet, two bookcases, and a guest chair. The cream walls are lined with my photographs: the highland forest in full autumn color, a pregnant woman stepping out of the shower, and our barn with the red roof next to our cottage in Canada. On the window ledge are purple African violets rooted in a green pot that Tom threw on the wheel in his studio and a framed photo of the five of us last Christmas. I toss my briefcase into the corner.

  In the picture, three mostly grown boys, Mica, Orion, and Zen, clown in front of the slightly crooked spruce tree. That’s me in the back, with round pink cheeks, short straight brown hair streaked with gray, and wide blue eyes; a tall, girlish, middle-aged woman. Tom, stocky, slightly balding, with wire-rim glasses and short gray hair, stands with his arms around me. He’s laughing too. It would take a miracle drug to get us all looking normal in front of a camera.

  The Women’s Health Clinic is located in Torrington, home of Torrington State University, on the fifth floor of the Family Health Center. Our private practice is composed of Tom Harman, ob-gyn; our two nurse-practitioners; and a staff of seven nurses and secretaries, all women. The suite, which we designed ourselves, is arranged in a rectangle with nine exam rooms, five offices, a lab, and a conference room. There’s also a small kitchen, the waiting room, and the large secretaries’ area up front. On two sides, windows run the length of the office. I wanted the staff and the patients to be able to look out at the sky.

  Five minutes after I arrive, I’m standing in the exam room holding out my hand to a skinny young woman who stares at it as if she’s just been offered something she’d rather not touch, a dead fish or rotten banana. She has short curly red hair, a beautiful girl, but she holds her head down like she doesn’t know it. An eyebrow ring mars her perfect face. I pull my hand back and try again. “I’m Patsy Harman, nurse-midwife, you must be …”—glancing at the new chart—“Heather Moffett.”

  Heather doesn’t say hello or anything else. There’s also an older woman and a young man in the room, so I start talking to them, turning first to the older lady who’s sitting in the guest chair, clutching her large white pocketbook. “And you are … family?” The grim-faced, gray-haired woman nods once. She inspects me through her glasses, clear plastic frames with rhinestones at the corners.

  I was hoping she would introduce herself. “Heather’s mother or aunt …?” I prompt. It’s always better to flatter than insult, though the woman appears to be in her seventies.

  “I’m her grandma.”

  This is not a cordial group, and I’m wondering what kind of conversation they were having before I came in. The air feels like cement just beginning to harden. “And you?” I turn to the young man.

  “T.J.,” he responds sullenly. That’s all he says.

  Heather is sitting hunched over on the small built-in bench in the dressing corner of the exam room, her arms tucked into her blue exam gown. T.J. swivels back and forth on my stool. The grandmother is perched on the one gray guest chair, so there’s nowhere left for me to sit except the exam table, and that isn’t going to happen.

  “Before we get started, let’s rearrange things,” I say energetically. “Heather, you sit up here on the exam table. T.J., you sit where she was, and I’ll take the stool.” We all trade places and when the young man stands I realize he’s over six feet tall. His hair reaches past his shoulders and he’s good-looking, like a heavy-metal star in the eighties, thin and sensuous with flat gray-blue eyes. No one says anything. They just move to where I point.

  “So.” I start up once more. “It looks like you’re going to have a baby, Heather. Were you trying, or did it just happen?” I ask it like this, not wanting to assume every teenage pregnancy is an accident. Heather shrugs and glances at T.J.

  I try again. “So are you excited, or still in shock?”

  “Excited, I guess,” Heather says, not sounding like she is.

  “Well, that’s nice, then,” I respond. The grandmother rolls her pale, watery blue eyes and crosses her ankles, which look purple and sore.

  “Let me go over w
hat you’ve written in your history, and then I’ll ask you more questions. Today what we need to do is an exam and some lab work—” I don’t get to finish.

  “I got to puke,” says Heather, standing up with her hand over her mouth and searching wildly around. The grandmother and I stand up too. The older woman opens her bag and comes up with some tissues. I take Heather’s slender arm and lead her to the small stainless-steel sink. T.J. stays where he is. This doesn’t involve him. Heather gags.

  “Do you have time to get to the bathroom?” I ask. The patient stands still, her head down, her red hair hanging around her face. I pull the curls back, holding them out of the way. Nothing comes up.

  “I’m okay … I think,” Heather whispers.

  “Has she been vomiting a lot, Mrs. … ?”

  “It’s Gresko, Mrs. Gresko. A fair ’mount, yes. Three, four times a day, seems like, maybe more.”

  I take the girl’s pulse. It’s rapid, and when I pinch the pale skin on her forearm, it tents, a sign of dehydration. “Are you keeping anything down?”

  “Some,” says the grandmother. “She’s bleeding too.” Our eyes meet, and when I look over, I see blood dripping down Heather’s legs.

  “When did this start?”

  “Yesterday. That’s why we called ’round for an appointment. I don’t want nothin’ to happen to this baby.”

  So much for taking a detailed, organized history. “You know, Heather, I’ve changed my mind. I’ll read what you wrote on the OB form and ask you questions next visit. Since you’re feeling so sick, I’d just like to get you a prescription for the vomiting and—”

  “What about the blood?” T.J. challenges. “That isn’t good, is it?”

  “No, it isn’t. It isn’t a good sign, but it doesn’t always mean something bad. How much blood is there?”

  Heather looks at her grandmother.

  “’Bout like her monthly,” Mrs. Gresko says.

  “Can you tell me when your last real period was?”

  Heather shrugs.

  “We can’t be sure,” says Grandma. “I tell her to write down her time but she don’t.”

  Great, I think. “Well, why don’t you lie back on the exam table and I’ll feel your belly to see if I can get an idea.” My hands palpate Heather’s lower abdomen. There’s a bulge halfway between her jeweled belly-button ring and the pubic bone, about right for fourteen weeks. Could the girl really be that far along?

  “Give me a minute. I want to see if my husband, Dr. Harman, is available for an ultrasound.” I leave, shaking my head, and trot down the hall. Looking through the window in the nurses’ station, I see storm clouds have come in from the west.

  Tom’s two exam rooms are on the opposite side of the clinic, and both doors are closed, indicating there are patients inside. Behind one, I can hear voices, and I knock softly, nervous about interrupting him.

  No one answers, and I tap again, louder, hoping he’s not in the middle of a pelvic exam. Finally he opens the door. “What’s up?” He’s wearing a red checked shirt with a Beatles tie and black Dockers. His white lab coat is reserved for the hospital. He would wear jeans and a corduroy shirt to the office if I let him.

  “I have a new OB that’s spotting; can you do an ultrasound for viability and dating?” I ask. “Do you have time?”

  Tom glances at his watch and shakes his head. “I have three patients to see before I go to the OR. Is she bleeding heavily? Can we do it tomorrow?”

  I shrug. “It’s not like she’s hemorrhaging. But it’s not good either, and they’re anxious.”

  “Get her here in the morning, I’ll squeeze her in.” A middle-aged woman sitting on the exam table glares at me through aviator glasses. Tom closes the door, and I head down the hall, trying to decide what to say.

  I could scan Heather myself, but even if I can find the heartbeat she’ll need a second ultrasound to get an accurate gestational age. And if it is a miscarriage, I want Tom to be there to confirm it. The family won’t like having to return, but tomorrow is best.

  When I reenter the exam room I find the small group standing in a knot next to the sink. They quickly sit down. “She threw up,” says Mrs. Gresko, as if it’s my fault.

  “What about the ultrasound?” demands T.J.

  “I’m sorry,” whispers the girl, looking down.

  I go to the sink. They’ve cleaned it, but it still smells like vomit. The nurses will have to spray with disinfectant. “We’ll have to do the ultrasound tomorrow. I’m sorry. If the bleeding gets worse tonight, come to the ER. I know you’re worried, but you have to understand that if a miscarriage is going to happen, nothing can stop it. Just rest, get some ginger ale for hydration, and come in around ten. I’ll write you a script for medicine that might help with the nausea, and you could try some peppermint tea. I have a feeling everything’s going to be all right …” I’m not sure why I say this.

  Mrs. Gresko shifts in her seat and sighs with irritation. T.J. crosses his long legs in disgust. Heather studies her stubby blue fingernails.

  So far she’s uttered all of four sentences, and that’s all I’m going to get.

  Blood

  When I got up to pee in the white enamel commode, it was dark and I couldn’t see the blood dripping down my legs. I didn’t bother to light the kerosene lamp. This was downstairs in the log cabin, back in the commune days.

  Because my first pregnancy with Mica had gone without a hitch, miscarriage was the last thing I had on my mind. When I saw the brown streak in my underwear that morning, I didn’t even know what it was. It didn’t occur to me that the streak was old blood, and I didn’t bother to call my doctor. Then again, I couldn’t have, since we didn’t have a phone; not that there was anything a doctor could have done anyway.

  By afternoon I began to bleed in earnest. I wasn’t a midwife yet, but I understood. Tom and I cried together. In the night, the fire in the woodstove went out, but we had thick quilts and were used to the cold.

  Most women don’t have more than menstrual cramps when they miscarry, but for me the pain came like labor contractions. If I could have gotten up and walked around, it would have been easier. I might have built up the fire or asked my husband to, but I just stayed under the covers.

  With a towel between my legs, I lay doing my childbirth breathing. Mica slept curled in his little homemade bed across the room. Tom adjusted the pillow under his bad shoulder. He knew what was happening but he wasn’t a physician then, hadn’t even thought of becoming one. He asked if I needed anything. I didn’t. What could he do?

  When I got up at dawn I was dizzy. In the gray light I saw the sheets covered in red. I lay back down in the warm blood and stared out the window. During the night, it had snowed. The oaks and maples on our West Virginia ridge were covered in white; the pine trees, the cedars, everything.

  NILA

  Nila speaks first. “So, I guess you’re surprised to see me.” The five-foot-tall dishwater blonde leans back on the exam table, swinging her bare legs like a girl. The blue cotton exam gown is three sizes too big.

  “No, not surprised to see you, just surprised to see you pregnant. I thought Gibby was going to get a vasectomy. Did he change his mind?”

  “Nah, he never got it.” Nila pauses. “I’ve been living in Independence, South Dakota, for over a year.”

  “Did the receptionist tell you we stopped delivering babies?”

  “That’s what I heard; they said you gave up births a few months ago, but I don’t have any money and I haven’t been to the health department to get a medical card. I figured you’d see me anyway.”

  She gives me a smile, and she’s right. At our clinic, we see new OBs even if they aren’t established patients, regardless of payer status. We try to help them get medical cards, back-billing if they qualify, setting up payment plans if they don’t. Tom and I were poorer than poor when we lived on the farm. We know how it is.

  “It was the cost of malpractice insurance. Last year the practice pre
miums for obstetrics went from seventy thousand dollars a year to a hundred and ten thousand. We just couldn’t do it. A hundred and ten thousand a year! You could buy a pretty good house in West Virginia for a hundred and ten thousand dollars, a new one every twelve months.” The patient nods sympathetically. I tell all the new OB patients why we gave up deliveries. I give them the numbers, hoping they’ll understand.

  Nila is a “grand multip,” meaning she’s had more than five babies. In all her pregnancies she’s never had a miscarriage, a C-section, or a stillbirth. She smokes, has poor nutrition, and when not pregnant weighs about a hundred pounds. I delivered babies five, six, and seven. Most people think the more babies a mother has, the easier it gets, but that’s not true. After baby five, it gets harder. By that time, the uterus is so stretched, it doesn’t contract well. Malpresentations (breech, transverse, face), prolonged labor, and hemorrhage are common. Nila’s seventh one was the worst.

  I can still see Nila lying in the birthing bed, thin, flat-chested, with smooth tan skin. She has the high cheekbones and small chin of a lot of Appalachian women, and when she smiles, her two front teeth gap a little, but not badly. The petite thirty-eight-year-old was fully dilated, her epidural topped off, and she was as comfortable as a breast-fed baby, but she wouldn’t push.

  “Come on, Nila,” I pleaded. “Come on. You can do it! Two or three more pushes and it’ll all be over. Then you can rest.”

  “I’m tired; I want to rest now.”

  Nila’s labor had been long. It started at two in the morning. At four in the afternoon, she’d been given Phenergan IV for her nausea.

  Now sunset, the baby is poised at the opening of the vagina, ready to be born, but the mother’s half drunk from the medicine and won’t cooperate.

  “Please, Nila. Just grab my hand and push hard.” I nod at her husband, Gibby, indicating he should say something.

  “Yeah, come on, honey …” Not much enthusiasm. He’s tired too.