Martha and Jim Swaffield saw the first photograph of their baby three and a half months before it was born. A technician at Palomar Hospital in Escondido had aimed an ultrasound machine at Martha’s growing belly, and from the ultra high frequencies a black-and-white print had been produced. It showed a perfect-looking embryo, wide-flung legs revealing his masculinity. When Martha and Jim first stared at the photo, chills of excitement danced up their spines. Later, they found it hard to refrain from showing off their ripening son’s image to friends. As the due date approached, they felt they’d already met Jason Peter, and they were ready for him to enter their lives.
Before she had gotten pregnant, Martha had felt the normal nervousness about childbirth, but as her body had swollen, her fears had subsided. As the due date had approached, she felt more than ready, even impatient. When she had taken Jim to visit the San Diego Birth Center and showed him the cozy room where their child would be delivered, Martha almost yearned to climb into one of the beds and end the waiting then. But the due date had passed, the days had melted away, and still Jason slept peacefully within her.
Then all day Sunday, Jim had fell anxious and apprehensive. He hadn’t slept well the night before, and when this sense of uneasiness gripped him, he paced back and forth in his living room. He worried about driving to Long Beach for his company in the morning, and mentally, he ran through his careful preparations, calculating over and over how quickly he could return to San Diego.
About 10:30 p.m., Martha interrupted his reveries. She announced that her amniotic fluid appeared to be leaking and the first contraction had begun. The two grinned at each other and grabbed for the phone to call the birth center and Martha’s relatives.
Then they waited. At first Martha welcomed the pains like long-awaited friends; they felt merely like strong menstrual cramps. Jim talked to her, urging her to relax and concentrate as the two of them had practiced. Then he dozed on the couch for a while, assured that Martha felt in control.
As her contractions quickened, however, so did Martha’s curiosity. Each time her muscles tightened, she was more eager to know how many millimeters her cervix had stretched; she felt like a laborer toiling at some frustratingly hidden task. Around two a.m., her worries about false labor finally receded. With contractions five minutes apart, she roused Jim and they drove away from Poway, as thrilled as children going to a birthday party.
Outside, a piercing chill accompanied the darkness, and cold beams from the full moon made the night seem frostier, rather than brighter. Fragmented clouds scudded across the luminous sky, and beneath it, the freeways stretched silent, deserted. The Swaffields arrived at Washington and First streets in Hillcrest more quickly than they ever had before. Jim parked, then helped Martha to the doorway under the “San Diego Birth Center” lettering.
The warm offices within were familiar. Martha had been coming here throughout her entire pregnancy; in fact. Dr. Bob Gordon had confirmed her condition here nine months ago, except that then Martha had figured she would deliver her child in a hospital, like everyone else. On that first visit a nurse had mentioned that Gordon also delivered babies at the birth center (which is actually just one section of the gynecological offices), but the comment “just didn’t register,” Martha recalled. Later she wondered about it and inquired. Once informed, she and Jim didn't take long to decide they liked the birth center alternative.
That alternative — of having one’s baby in a comfortable, homey facility, rather than the cold and forbidding hospital delivery room — recently has taken hold in San Diego. Before this past year, if you and your mate lived around here and were expecting a child, you had two choices: you could join the die-hard iconoclasts and plan your baby’s birth at home, accepting the risk that comes with not having emergency medical aid immediately at hand, or you could choose from among the local obstetrical wards, places often frozen into inflexible and cumbersome tradition. In other cities, birth centers have been touted as a happy compromise, but for a long time San Diego had none. Then the San Diego Birth Center opened in March. “Alternative birth centers” also have opened within Scripps, Sharp, Mercy, University, and Paradise Valley hospitals in the past twelve months.
Details vary from one to another. “Nurse-midwives,” for example, deliver the babies at University Hospital’s birth center (unlike the others, where physicians still run the show). Paradise Valley’s birth center requires a minimum stay of twelve hours after delivery, in contrast to a mere six-hour minimum stay at most other centers. The degree of “naturalness” at each center seems to depend upon how much the attending physician believes in it.
Yet the birth centers claim more similarities than differences. All stress a return to greater naturalism as a fundamental reason for their existence. Costs range from $825 on up for the total package, a price many couples find attractive ($1500 for a more traditional birth is common). The birth centers even look alike. Dominating the rooms are comfortable double beds, surrounded by rocking chairs, bassinets, plants, other domestic touches; they look like extraordinarily cozy hotel rooms. Above all, they don’t look like hospital rooms, a calculated deception. And in this regard, the San Diego Birth Center stands out. Since it isn’t a hospital, it doesn't have to contrive an atmosphere.
When Martha and Jim arrive, an expectant hush envelops the offices. Mary Foley, one of the obstetrical nurses who’s arrived a few moments earlier, ushers them into the softly lit private waiting room. Martha heads straight for one of the four birth rooms, however, where she changes into a well-worn nightgown she’s brought with her. .She then shivers and settles under several layers of white blankets. Jim also shucks his clothes and dons a set of surgical greens, required by the center to minimize the chance of infection. He perches next to Martha, holding a gold pocket watch, a family antique, which he uses to time each contraction.
3:05 a.m. — Mary examines Martha for the first time. Using an oversized stethoscope, she listens to the baby’s heart and manually gauges the progress of Martha’s contractions. Martha’s cervix, the narrow outer end of the uterus through which the baby must emerge before entering the birth canal, has expanded from its normal closed state to a diameter of between four and five centimeters. Still, this is less than half what is necessary. Before Martha's labor ends, her cervix will have to expand to ten centimeters.
The pregnant woman trembles from the chill, snuggling under the blankets again and leaning back on two fluffy pillows. Her legs stretch out stiffly in front of her, the impossibly massive belly towering over them. Under the covers, the skin of her stomach looks mottled and angry, stretched like an overripe fruit to the bursting point.
“Contraction,” Martha says a trifle breathlessly. At her side, Jim automatically reaches for the watch and notepaper.
“Now just relax. Breathe. You’re doin’ fine.” His words come softly but Martha doesn’t react to them. She looks like a doll, her body mysteriously ballooned at the middle, her face as tranquil and motionless as a mask. The shallow, even breaths passing through her lips don’t even move her chest. Then she pulls in a deep breath and her eyelids flutter; this contraction is over.
Martha and Jim are using LaMaze breathing and relaxation techniques; the couple just two weeks ago completed the eight-week course which explains the physiology of childbirth. Learning it is one of the requirements of the San Diego Birth Center, part of the commitment to undergo labor and delivery without drugs. To deliver her baby here, Martha also met other requirements. At twenty-three, she possesses excellent health, for one thing, and no risk factors have complicated her pregnancy. (She wouldn’t have been accepted into this or any other birth center, for example, if she had had hypertension, diabetes, a previous Caesarean section, twins, or other risky conditions.) The San Diego Birth Center also provides a series of prenatal classes, but Martha wasn't able to attend them since she had worked (as an X-ray technician at Palomar Hospital) until just ten days before her baby was due.
“Are you going to stay home with the baby, Martha?” asks Mary, the nurse, curled up in the polished wooden rocking chair at the foot of the bed.
Martha shakes her head ruefully. “It’s kind of hard to make enough to survive if both of you don’t work.”
“Yeah,” the nurse sympathizes. “With one salary you can usually make enough to get by, but nothing more.”
Martha and Jim look strained. “No, we couldn’t even get by on just one,” they chime in simultaneously, laughing. Martha explains how buying a house and a van and getting pregnant all converged unexpectedly, and now the financial pressure weighs upon them.
Martha's attention snaps back to her bulging belly.
“Contraction,” she whispers, inhaling a cleansing breath. When the pain finally ebbs, she explains that the contractions now are claiming her immediately, then declining from a peak of intensity. Suddenly, she begins trembling violently, and Jim massages her legs, laying another blanket over her. Chill still permeates the room and Mary fiddles with the heating controls.
Mary, a petite brunette with three children of her own, quietly answers a question about how Martha’s experience differs from what it would be in a traditional hospital setting. There, Martha would be confined to a narrow hospital bed with high sides, and liquids now would be dripping into her body intravenously. The tubes naturally would restrict any movement. In contrast, the nurse points out that some mothers laboring at this birth center feel most comfortable walking up and down the halls, even out into the main lobby where regular patients await appointments. At the moment, however, the cool of the night discourages Martha from doing so; moving from one position to another under the covers, she feels warm and secure.
The nurse chafes a little at comparisons between the hospital and the birth center. In addition to working here part-time, she also still works part-time in Mercy Hospital’s regular obstetrical ward, and “I don’t like to see either one put down,” she says. “We feel that probably the most optimal situation is to avoid invasion [into the natural birth process] as much as possible, but there are many situations when the anesthetic and the other procedures are really good.” Some women run high risks and can’t qualify for the birth center, plus “Many women really need that structure. They want to be taken care of. They don’t want to be that involved with the responsibility. But when you do get a couple that’s really enthusiastic about this type of setting, that's probably best.”
5:01 a.m. — The nurse examines Martha again. Now her cervix has stretched to five and a half centimeters.
“Contraction.” Martha sucks in a breath. Her face now looks a little more set. and concentration grips it more noticeably. As she sits upright, ankles crossed and silently counting her breath, she resembles a feminine Buddha, somber and Western. Jim caresses her back and arms. “Keep your concentration on your focal point,” he reminds her. Inches away from her, he whispers “I love you” with tender urgency. “I love you, too,” she murmurs back, distracted.
Now the contractions are coming every four minutes; a little earlier they lagged to seven minutes. Martha comments that they’re strengthening in intensity, with the pain pressing her for longer before receding. The unevenness of the contraction intervals reminds everyone of another pit-fall of first pregnancies — uterine muscles, unfamiliar with the demands of birth, can take twelve, eighteen, even twenty-four hours to push the baby downward. Time seems to be passing more slowly, Martha notes. “Maybe I’m starting to get tired. Earlier I was amazed at how fast it seemed to be going.”
Indeed, the small space of this quiet room seems to be warping time for everyone. The hours and minutes which Jim faithfully lists in growing columns now seem meaningless, irrelevant; all that counts is the imminent contraction. And during the wait, expectation builds and mingles with a slight hint of fear. The tension drones on as faintly and persistently as the distant hum of the heater in the silent room, and unspoken questions shape the suspense — how wide does Martha’s cervix measure now? Will the contractions build quickly; stop altogether? Will Martha and her baby make it through the birth safely? Despite Jim’s proximity, Martha seems removed and very alone, like a solitary piece of driftwood on a wide beach, caught up in and at the mercy of pounding, inexorable waves.
Jim leaves the room for a moment, adjourning to the brightly lit birth center kitchen. He sits at the formica table and nervously smokes a Marlboro, occasionally hugging his arms close to his body. “I’m anxious, really anxious,” he says steadily. At the moment he feels so attuned to Martha that it almost seems as if he’s in labor, too. “I don’t know what it is, but Martha and I have something going,” he says. “Many times I’ll walk in the door and say, 'Let’s go out to Filippi's,’ and she’ll already have called and ordered a pizza.” Stubbing out the cigarette, he returns to the room, where through the window, the darkness can be seen giving way to shades of gray. Martha doesn’t even have to tell him a contraction is starting; he senses it, grabbing for the watch and paper.
7:02 a.m. — A new sound interrupts the quiet, as if Martha were catching her breath, only steadily and gently. A few moments later she declares that she keeps feeling close to panic, “like I want to scream.”
“Don’t worry Martha,” says Mary. “You’re doing real fine.”
7:50 a.m. — The office Muzak suddenly kicks on, as strange and intrusive as a brass band in someone’s bedroom. Other noises also are stirring; office workers have begun to arrive. Mary declares that she probably won’t examine Martha again, since the doctor should arrive momentarily. Although the four doctors who operate this birth center make an effort to each deliver their own patients, chance has dictated otherwise in this case. Dr. Gordon has left town for a short vacation, and Martha’s will be the first delivery he has missed at the center. Before leaving, however, he introduced the Swaffields to Dr. Benjamin Fiorica, who instead will assist with the birth. While she waits, Martha adds a puffing blow to the other types of breathing. She looks like she’s blowing out bubbles and Jim helps her by calling off a sequence. Despite her fears, Martha still exudes discipline. But her eyes have reddened. Her face looks worn.
9:07 a.m. — The air inside this room has grown warm and humid, and Martha’s heavy body has pressed wrinkles into the white sheets. Outside, the fully lit sky is an unbroken gray. When Fiorica finally examines her, he brings frustrating news: Martha's cervix as yet has dilated only seven centimeters, about the diameter of an orange.
An hour later, he reports that it has widened by less than a centimeter, but the baby’s head has started to descend a bit more. Martha lies on her side, fighting off a nausea that has troubled her now for several hours. She extends only a wan greeting when her mother arrives from El Centro.
10:20 a.m. — Martha moans for the first time. “Oh, that really hurts!” she cries. She asks for a pan to choke up more stomach fluid. Her belly still looks massive and immobile, and it’s hard to believe that within it, a human baby could be journeying downward. Martha’s mother sits in the rocking chair, big-eyed and subdued, but nervousness soon drives her into the hallway. She bites her lip and whispers plaintively, “If I could do it for her, I would.”
11:25 a.m. — Fiorica says the cervix has now dilated by eight to nine centimeters. The baby’s head is facing Martha’s side instead of downward, he reports, but it should slip into the proper position soon. “It should speed things up, once it turns,” he promises.
11:40 a.m. — Another contraction hits hard, and Martha at last seems to be losing some of her self-control. “Relax!” Jim insists to her, forcefully. Martha groans, but she compels herself to loosen up.
"Get your focal point,” Jim whispers, as another contraction rolls over her. “Concentrate on it. Just keep concentrating. Just keep concentrating. Relax. You’re all right. Keep relaxing.” Jim ignores the sweat which bathes his own brow as he sponges off his wife’s.
It seems this can’t continue much longer, and at last Fiorica announces good news. When he checks Martha a little after noon, he reports that her cervix is now fully open. A minor aberration intrudes: the doctor wants to administer liquids to her with an intravenous needle, something which the vast majority of women laboring here do without. But Martha has lost a lot of fluids through perspiration and vomiting, and she needs more energy, Fiorica decides.
Quickly, the nurses tape the needle to the back of Martha’s hand and stand the hanging bottle next to the bed where a plant had hung a little earlier. Now the baby is poised at the top of the birth canal and Martha must use her muscles to push it down toward the extended cervix. Calm lingers in the room for a moment, then Martha sucks in her breath.
“Got one?” Jim asks, and she nods abruptly.
She drags in a huge lungful of air and slides her feet up close to her buttocks, then she grabs her kneecaps. Simultaneously, Jim pushes her back forward and supports her in the sitting/squatting compromise.
“Ready?” he nearly yells. “One. Two. Three. Four. Five. Six. Seven. Eight. Nine. Ten!” Martha expels the breath explosively but immediately gasps for air and makes the effort again. All the muscles in her face bulge with effort as she strains and Jim shouts out the count. She inhales convulsively once again and then pushes one last time, collapsing onto her pillow at the end of the contraction. Jim slides her legs down to rest and praises her lavishly.
The break is short-lived. Martha must push with each contraction, but the contractions are coming every two to four minutes now. At first, the pain seems to fade away while Martha yields to the overpowering instinct to bear down, but then the sensation suddenly changes. Pain grips her continuously.
“Oh God, that hurts. It hurts,” she mutters, but Jim and the nurses urge her on, and the urgency in her husband’s voice is contagious.
“Pu-u-u-sh!” he grunts when she signals the start of a contraction. Throwing his shoulder behind her weighty back, he seems to be pushing as ferociously as Martha. Martha’s hands on her knees start to tremble convulsively. Each time she pushes, the violence of her effort cracks the room like a gunshot. Her face is blood-red,‘contorted with force. “That was a good push. Good push. That was really a good push,” Jim babbles between efforts, holding her.
The tension in the room has completely dissipated, swept away in the periodic brute force of Martha’s pushing. Martha seems even more removed now, limp and almost exhausted, yet with each contraction she rouses herself back to the furious effort. ‘‘Remember how we pushed when the dog had her pups?” Martha’s mother asks her white-faced daughter quietly. By this time, every adult in the room is pushing along with the woman as she strains to squeeze her child out of her body.
1:56 p.m. — Fiorica enters, examining Martha again, and just as he starts to check her, a contraction commences.
“Push against my fingers,” he orders her sharply. ‘‘Come on now, hard!”
At Martha’s side, another obstetrical nurse has relieved Mary Foley, “Push. Push. Push. Push. Push!” she coaxes.
“Don’t grunt now, honey,” Fiorica says.
“No noises now,” adds the nurse. “Don’t take away any of that energy from the pushing.” Then she shouts excitedly, “We can see the baby's head!”
“Push again if you’ve got the contraction,” Fiorica urges Martha.
“It’s got dark hair! What do you think about that!” the nurse says when the contraction subsides.
The description of her child revitalizes Martha, and she pushes with renewed vigor the next few times. But the fatigue reclaims her soon, and still the baby lodges inches away from escape.
At 2:30, Fiorica returns, looking a trifle somber. “Martha, I think we may want to deviate from our normal procedure a little,” he tells her. He recommends moving her in a few moments to the gleaming minor-surgery room just down the hall. “It should be a little easier to push on the table in there,” Fiorica says. “Also, if any minor complications arise, we can take care of them better in there. I’m not saying they’re going to develop,” he adds. “This is just in case.”
Martha has been warned, months in advance, that she will be transferred to Mercy Hospital, five minutes away, in case of any major complications. All San Diego Birth Center patients have double records — one at the center and one at the hospital — in case of such contingencies. Yet the birth center doctors say such transfers are rare, and no one has yet delivered in the minor-surgery room.
Martha and Jim assent to Fiorica’s suggestion readily; by now both of them simply yearn for respite. But ironically, Martha’s next two pushes noticeably improve the baby’s progress. Fiorica returns and changes his mind. "If you’re doing well here, we'll let you stay here,” he explains. "I just didn't expect you to crown that well here.”
The nurses are checking the baby’s heart rate every few minutes now, and it continues to remain steady, about 136 beats a minute. At long last the room throbs with building activity. Fiorica re-enters, dressed in his surgical greens, and the nurses distribute face masks to everyone present. One of the nurses spreads out a plastic sheet at the bottom of the bed, while the second woman slides a hard, narrow board under Martha, for added support. At 3:05, everyone in the room slips a face mask on. Fiorica begins to sponge off Martha’s vulva with a dark-colored antiseptic, while one of the nurses slips a | heavy plastic sheet under her bottom. Jim sits by Martha’s side and his voice practically breaks with excitement. "Oh great. ” he yells, as she pushes desperately. "Great push! Keep it up, babe, C’mon, Jason Peter.” he cheers. “You're doing great!”
Then suddenly, the baby’s head finally presses against Martha's vaginal opening. The gray skull, covered with dark hair, looks crumpled and wet. With another contraction, the skull bulges against the narrow opening. "God, the episiotomy is going to feel good after this, ” Martha cries as Fiorica administers a local anesthetic. “I feel like I’m going to tear apart!” Fiorica grabs the elastic-looking panel of Martha’s flesh below where the baby’s head shows, and deftly, he snips downward, enlarging the opening. Blood streams onto the sheet, but the next moment overshadows it. The round dome of the baby's head now is protruding out of the opening, ready to emerge.
An electric calm settles on the room for just an instant; then Martha feels the start of a contraction, like a person cresting the highest hill on a roller coaster.
“Okay Martha, now PUSH!” her attendants chorus, and as she does so, her child's head suddenly pops out.
“Now wait. Wait. Wait. Wait. Take it easy, Martha,” the nurses warn her. At the same instant, the doctor feverishly grabs a rubber bulb syringe and jams the end into, the infant’s tiny mouth. He extracts a white, thick-looking mucus, and the baby suddenly coughs. The doctor clears the infant’s nostrils, and Martha is ready to push again.
The contraction grips her and she bears down savagely. For a moment, the baby’s shoulders hesitate at the orifice, looking too impossibly broad to make it through the opening. Then magically, they slip through, and despite the cautions of the nurses for restraint, the rest of the sturdy body plops out, slippery as a fish. It is a big baby, and for a few seconds it lies on the bed. still tied to the placenta within its mother’s body. Pinkish gray, it suddenly emits a shattering high-pitched yell, and Fiorica swiftly cuts and clamps the cord.
Immediately, one of the nurses scoops up the baby and dries it off in the bassinet, cooing as the infant screams with rage. Then she quickly bundles the newborn in a blanket and places it on Martha's chest. Instantly, the crying ceases, but Jim and Martha choke up, dissolving in the emotional force of the moment. “How about that! How about that!” is all that either can say. “Just look at him!” Martha’s eyes are riveted on her child.
The wonder of the baby insulates them from the final details of the birth, and they play with their son as he rests in front of Martha’s still-raised knees. Sitting on the foot of the bed, Fiorica quickly delivers the placenta and orders a hormone to restrict some of the heavy uterine bleeding. Then he apologizes for Martha’s discomfort as he stitches up the flaps of skin sliced apart by the episiotomy. A few moments later, Martha’s body is repaired and covered again, and the well-wishers stream through the door.
The nurse temporarily removes the baby, settling him on the scale just outside the door. “Nine pounds, three ounces,” she announces. “Nine pounds, three ounces! How did we do it?” Martha cries happily. Then Fiorica returns with a bottle of champagne and the room resounds with a noisy toast. One of the nurses brandishes a Polaroid, and Martha and Jim pose with Jason Peter, reigning over the chaos from the head of the bed. The pain and struggle seem incredibly distant, like the memory of a childhood dream.
7:00 p.m. — Quiet has finally returned to the room. All but one of the nurses has left, and Martha’s mother has departed for Martha’s sister’s home in Clairemont. The pediatrician has come and gone, certifying Jason’s health, and Martha has showered in the bathroom outside the bedroom. Now Martha and Jim doze together, Jason in the bassinet next to them, resting as the twilight deepens. Around nine, they will rouse themselves and climb from the now familiar bed, then sleepily, they will bundle their few possessions together and don their coats. They will hold their son very close to their warm bodies as they leave the birth center and climb into the van for the long drive home.