Midwives

  "No," my mother said, "she isn't really."

  "That's awfully big of you, Sibyl. You're with family and friends here; you don't need to be noble," Stephen told her, and he seemed as angry as when the judge had called the recess fifteen minutes earlier.

  "I'm not. Anne's just ... she's young, and she's gotten herself in too deep."

  "Well, then," Stephen said, "she's about to drown. It will be short and sweet, but we're about to take her down for the third time."

  "Miss Austin, you will focus solely on the question Mr. Hastings is asking, and Mr. Hastings, you will allow her to answer each question fully. Do we have an understanding?" Judge Dorset asked when we had reconvened.

  Stephen nodded, and moved out from behind his table and began pacing the room as he had with most other witnesses. He asked the court reporter to read back the last question he had asked, the one about first- or second- or even third-hand experience.

  "That's right," Anne answered. Her eyes were red from crying, and her words were no longer draped in poise.

  "But nevertheless, when Sibyl made the first incision, you decided Charlotte Bedford was alive."

  "When I saw the blood, yes."

  "Did the body show any other signs of life as the incision was made--or, for that matter, after?"

  "Like what?"

  Stephen shrugged. "Did the woman cry out with pain?"

  "No, she was unconscious."

  "Did the body ... shudder?"

  "I didn't see that."

  "You didn't see it shudder?"

  "No."

  "It didn't move at all, did it?"

  "Not that I saw."

  "Does that mean that the only indication you had that the woman might have been alive was the blood?"

  "Yes."

  "But that was enough to alarm you?"

  "It was."

  "So what did you do when you were alarmed? Did you try to stop Sibyl from proceeding?"

  "No."

  "Did you say to her, 'Don't do this, Sibyl, she's alive'?"

  "No."

  "Did you try and take the knife out of Sibyl's hand and--"

  "Objection. This is just badgering," Tanner said.

  "Overruled."

  "Did you try and take the knife out of Sibyl's hand?"

  "No."

  Stephen nodded, and walked the length of the jury box. "So despite your contention later on that Charlotte Bedford was alive before the incision, you did absolutely nothing to try and save the woman's life. Did you, at the very least, share your fear with the father while the two of you were still in the room?"

  "No. Not then, I didn't."

  "You testified earlier that you were surprised Sibyl never checked for a fetal heartbeat. Did you suggest to the midwife that perhaps she should?"

  "No."

  "So am I correct in saying that despite your claim after the fact that Charlotte Bedford had been alive before the incision, you did absolutely nothing at the time to try and prevent the surgery?"

  "I just didn't know what--"

  "Miss Austin--"

  "I just didn't--"

  "Your Honor--"

  Judge Dorset rapped his gavel on the dark wood before him and then surprised me--probably surprised us all--by throwing the young woman a life preserver and thereby preventing her from going under a final time. "Counsel," he reminded Stephen, "I asked you to allow the witness the time to answer each question fully. Go ahead, Miss Austin."

  She took a deep breath and dabbed her eyes with a tissue. Finally, in a voice that quavered slightly, she said, "I just didn't have the confidence at the time to stop her, I just didn't know enough. Like you said, I hadn't been through anything like that before. But I saw the blood pumping and pumping and I knew something was wrong, and it was only a few hours later that I decided I had a ... a moral responsibility to tell someone what I'd seen. I didn't want to, I really didn't want to. But I had to. That's the thing: I had to do it."

  Perhaps because of the phone call I'd overheard one night between my mother and Stephen--a conversation that seemed steeped to me in flirtatious innuendo--I made a point of being home when he came by our house one afternoon in the week before the trial began. I hovered in the kitchen, pretending to do homework while they met in her office. When he finally left, as my mother walked him to his car, I went to an open window to watch them through the screen. They assumed I had stayed in the kitchen.

  Instead of strolling to the car, however, they wandered to my mother's flower garden, stopping somewhere amidst the sunflowers--taller than they by far that date in September, but just about ready to die--in a spot I couldn't see. And so I went back to the kitchen and then out into our backyard through the sliding glass doors. Pressed flat against the side wall of our house, I still couldn't see them, but I could hear parts of their exchange.

  I don't know if Stephen had actually tried to kiss my mother before I got outside: In my mind, I can see him taking her hands in his the way he once had by his car, and lowering his lips to hers. But I never saw him do such a thing.

  Nevertheless, I've always understood why a lawyer has faith in logical inference, the idea that one doesn't need to hear or see it rain overnight to know in the morning that it did rain if the cars and the ground and the trees are all wet.

  And so I believe Stephen may have tried to kiss my mother by the way I heard her saying to him, "No, it's not just the place. It's everything. If I sent you those signals, I'm sorry. I'm really and truly sorry."

  Before I became a doctor, I couldn't imagine why anyone would become a coroner. I assumed that anyone willing to spend that much time around corpses was inordinately fixated on death or--at best--had never outgrown a nine-year-old boy's interest in vampires and mummies and ghouls. Only after I'd started medical school did the fascinations of that job become apparent to me, and the reasons why so many profoundly--at least outwardly--normal people choose it as their life's work. It's like being a detective. And once you're past your first cadaver, human tissue loses its ability to shock, and organs and bones become routine.

  When I was fourteen, however, I imagined a coroner had to be a very sick person. And so I was unprepared for the medical examiner for the state of Vermont when a bailiff escorted him between the two rows of packed benches in the courtroom mid-Friday afternoon, and led him to the witness stand. Terry Tierney looked like any one of the fathers I knew in Reddington who coached Little League baseball in the spring and Pop Warner football in the fall: energetic but patient in carriage, and downright unexceptional in appearance. He was a good decade older than my parents, with a black beard that was graying and eyeglasses very much like Stephen's.

  He smiled when Bill Tanner greeted him, and--at Tanner's prodding--explained for the jury his litany of degrees and accomplishments. The two were so chummy that for a few moments I almost expected them to start discussing the deer hunting they could expect later that fall.

  When they finally got around to the scene that had greeted Tierney when he walked into the Bedfords' bedroom back in March, however, all of that changed, and Tierney grew serious. He described the way my mother had stitched the exterior incision she'd made and then pulled the woman's nightgown back down over her torso.

  "Did Mrs. Danforth tell you how Charlotte Bedford had died?" Bill Tanner asked.

  "She said the lady had had a stroke."

  "What did you think?"

  "I thought it was possible. Anything's possible in a home birth."

  "Objection!" Stephen said, shooting up from his seat, and the judge sustained it.

  "When did you conduct the autopsy?" Tanner continued, as if there had never been an interruption.

  "Later that morning."

  "Did you find any indication that the woman had had a stroke?"

  "No."

  "If Charlotte Bedford had had a stroke, would you have been able to determine that from an autopsy?"

  "Definitely. Absolutely."

  "Why?"

  Dr. Tierney s
ighed and gathered his thoughts. Looking back, I believe he was merely pausing to frame his answer in a way that would convey the details of postmortem dissection without sickening the jury. But at the time I thought his hesitation was driven by sadness.

  "When I examined the brain, I would have found significant changes. I would have seen hemorrhaging--bleeding. The tissue would have softened; it would have gotten almost spongy."

  "And you saw none of that--no bleeding, no softening--when you were examining Charlotte Bedford's brain?"

  "No, I did not."

  Tanner returned to his table, and his deputy handed him what I assumed were his notes.

  "Did you examine Charlotte Bedford's abdominal area?"

  "Yes."

  "Beginning with the incision?"

  "That's right."

  "Including her reproductive organs?"

  "Of course."

  "You mentioned Mrs. Danforth had sewn up the skin where she had cut Charlotte open. Did she sew up her internal organs as well?"

  "No."

  "She didn't sew up the uterus?"

  "No."

  "Why not?"

  "Objection," Stephen said. "Calls for speculation."

  "Sustained."

  "So you found the uterus had not been repaired," Tanner continued.

  "No, it had not."

  "Could you tell where in the birth canal the baby had been when Mrs. Danforth pulled him from his mother?"

  "No."

  "Could you tell if the baby had descended at all in all those hours Mrs. Danforth forced Charlotte to push?"

  "Objection, no one forced anyone to do anything."

  "Sustained."

  Tanner smiled for the jury's benefit, a grin more mischievous than chastened.

  "Could you tell if the baby had descended at all in all those hours Charlotte was pushing?"

  "No, I could not tell."

  "Could you tell if there had been a placental abruption?"

  "Yes, definitely. There were areas of hemorrhage."

  "Was that the cause of death?"

  "No. As it occasionally does, it had clotted over. Started to heal itself."

  "Was it a factor in Charlotte Bedford's death?"

  "It would become one indirectly."

  Tanner glanced at his notes and grew quiet. Finally: "How so?"

  "The woman had lost some blood during that event. Given the cesarean that would be performed a few hours later, it's impossible to gauge how much. But it was probably a significant amount."

  "Meaning?"

  "Her body was weaker. She wasn't as strong."

  "Why might that matter?"

  "As any mother knows, labor's hard work. Incredibly hard work. A woman needs all the strength she can muster, especially if something ... something unforeseen occurs."

  "Did something unforeseen occur in this case?"

  "I assume you mean other than the poor woman dying."

  "Right."

  "Then yes, clearly something unforeseen happened."

  "Based on the autopsy you performed, and all of the subsequent laboratory work, what do you think that something was?"

  As if he were recalling an event as common as a drive home on slick roads in a blizzard--hazardous, perhaps, but an endeavor everyone in that courtroom had endured and could discuss comfortably at a dinner table--he said, "Well, although there was no medical evidence of a stroke, there were eyewitnesses who saw what apparently looked like a stroke to someone who wasn't a doctor. The woman twitched or spasmed, and then blacked out. The father saw it, the young lady--the apprentice--saw it, and of course Mrs. Danforth saw it. But I don't believe it was an aneurysm that caused the spasm."

  "Do you have an opinion as to its cause?"

  "Yes."

  "Would you tell us what that is?"

  "To use Dr. Lang's expression, I think the woman 'vagaled.'"

  "Would you elaborate?"

  "Right here, in the small of the back of our heads," Tierney said, motioning to the spot on his own head with his hand, "there is a pair of cranial nerves filled with motor and sensory fibers. Those are the vagus nerves. They innervate a variety of organs and muscles--the larynx, for example, and many thoracic and abdominal viscera."

  "What does that mean in layman's terms?"

  Tierney offered the jury a small, self-deprecating smile. "They communicate between the brain and the heart. They help to carry the information from the brain to the heart about how fast or slow it's supposed to beat. Now, like everything else in the body, the brain needs oxygen. And oxygen is carried to the brain in the blood--blood pumped, of course, by the heart. If the brain isn't getting enough oxygen--if it becomes what we call hypoxic--it doesn't function properly. Or at all. Obviously, there are lots of things that can cause a brain to become hypoxic, including even a planned medical event like general anesthesia. But another cause may be labor, and the way a woman has to push. You take in these very deep breaths, work very hard, and then you exhale at once. And you do this for hours. Suddenly, before you know it, your brain is going hypoxic."

  "Is this dangerous?"

  "Absolutely. If you strain enough and become sufficiently hypoxic, your heart can slow down or even stop. It's a sort of reflex mediated by the vagus nerve. Your heart stops and you pass out. As some doctors say, you vagal out."

  "Can you die?"

  "Oh yes, indeed one can. But women in labor almost never do, because a delivery room nurse or an ob-gyn knows exactly what the early symptoms look like, exactly what the first signs are. And it's very easy to treat: You simply have the laboring woman relax for a bit or--in an extreme case--you administer oxygen."

  "What makes you think Charlotte vagaled?"

  "First of all, she evidenced the symptoms of a person going hypoxic: She had a seizure, lost consciousness, and her heart stopped. That's what the eyewitnesses may have seen. Then, when we were looking for injuries to brain cells in the hippocampus, we saw significant evidence of hypoxia."

  "What does that look like?"

  "The nucleus of the cell becomes pycnotic--shrunken and dark and really rather unattractive. Meanwhile the cytoplasm of the cell body becomes a deep red, and looks almost glassy."

  "So you're saying Charlotte Bedford was forced ... you're saying Charlotte Bedford pushed for so long she went hypoxic. She vagaled."

  "Yes."

  "In your opinion, was that the cause of death?"

  "Well, that's the thing, I don't think so."

  "Why not?"

  "This is going to sound pretty ironic, given the reason we've all assembled here, but I believe Mrs. Danforth saved her life after she vagaled. I'm convinced that the CPR Mrs. Danforth performed--all those cycles--actually brought the woman back."

  Dr. Tierney's opinion was not a surprise to our family, and my mother barely moved when he spoke. But it was a revelation to most of the crowd, and one of the mothers in the back row must have moved with such suddenness or gasped just loud enough that she woke her infant. We all heard a moment of crying, followed by the rustling we'd all become used to, as the infant's mother worked her way down the thin space between benches and then out of the courtroom.

  "What makes you think so?" Tanner asked when the room had settled.

  "The amount of blood in the peritoneal cavity--the abdomen. I mean, there were close to seven hundred and fifty milliliters in there."

  "Over two pints?"

  "Roughly. Plus there was all the blood outside of the wound: Around the incision. On the bedding. And, of course, on that pillow Mrs. Danforth had used to soak some up so she could see what she was doing. Find the uterus, I guess. In my opinion, there would not have been that much blood in the deceased's abdomen and around the bedding if the woman had been dead when Mrs. Danforth tried to perform a cesarean section."

  "And so you believe Charlotte Bedford was alive when Mrs. Danforth performed the cesarean?"

  "That's correct."

  "In that case, what was the cause of death? How did Cha
rlotte Bedford die?"

  Dr. Tierney sighed and then looked right at the jury. "As I myself typed on the death certificate--the final one--she died of hemorrhagic shock caused by the cesarean section. In my opinion, it was Mrs. Danforth's C-section that killed her."