The Midwife of Black Hollow

Kayla Doss pushed for two hours and eleven minutes, and the baby came out gray and howling, which was exactly right.

"There he is," Mara said. "You hear that? That's the sound we want."

She had him up on his mother's chest before the cord quit pulsing, a warm towel over him and then a second one, drying him hard across the back and the crown of the head, because a wet newborn loses heat faster than anybody expects and a cold baby quits trying. He didn't need much from her. He was pink from the chest out inside a minute and yelling like he'd been cheated.

"Eight," Toya said behind her, marking it. "Feet are still blue."

"He'll get there."

Kayla was crying and laughing at the same time, that noise that isn't either one. Her boyfriend stood against the wall with his hands hanging at his sides like somebody had loaned them to him for the evening.

"Dustin. Come cut this."

He came. They always came, once you told them to. He held the scissors in the wrong grip and Mara turned his hand for him without saying anything about it, and he cut, and the crunch of it made him flinch, and then he laughed at himself, and Kayla said his name in a way that meant she loved him.

It was a good room. It stayed a good room for eight more minutes.

The oxytocin had been running since the anterior shoulder. Ten units in the bag, routine, dull, and the dullness is what keeps women alive. At eight minutes the cord lengthened and there was a small gush and Mara delivered the placenta with her left hand braced above the pubic bone and steady traction on the cord with her right. It came whole. She laid it in the basin and turned it over and ran the membranes through her fingers, counted the lobes, checked the vessels. Three. Nothing torn away. Nothing left behind. She said so out loud, because you say it out loud, so nobody has to argue later about what you knew and when.

Then she put her hand back on Kayla's belly and the uterus wasn't there.

It was there. It just wasn't hard. It should have come up under her palm like a grapefruit, tight and high and rising, and instead she found a wide soft place where the muscle had quit, and everything in her went very quiet, the way it does when the work turns over.

The collection pouch hanging off the drape had read two hundred and fifty milliliters at delivery. It was past six hundred now. While she looked at it, a fresh run of blood came down the pleat and pooled.

"Toya," she said, in the same voice she'd been using all night. "Cart. And a second line."

Toya was already moving. That was the good part about that hospital and Mara would have said it under oath. You said the word and people moved.

"Kayla. Look at me a second." She waited until the girl's eyes came around and stayed. "You're bleeding more than I want. The muscle's tired and it isn't clamping down the way it ought to, and until it does, it's going to keep on. I'm about to be rough with you. I'm going to say a lot of things out loud to this room and some of them are going to sound bad. Don't be scared of anything you hear me say. If I need you scared, I will tell you."

"Okay." Kayla's voice had gone small and about nine years old.

"Dustin, take him. Shirt open, on your chest. Nobody's carrying him anywhere, he just needs to be out of my way."

She got both hands on the fundus and kneaded, hard, harder than anybody who hasn't done it would believe is allowed. Kayla made a noise. Under Mara's palms the uterus firmed and gathered and then let go again, like a fist getting tired.

There are four reasons a woman bleeds after a birth, and Mara had been through all four in her head before she ever reached for the drape. The muscle. A tear. Something left inside. Blood that won't clot. She had the placenta in the basin and she'd checked it twice and there was no tear worth a fraction of this, and the girl was twenty-two years old and healthy as a horse.

So it was the muscle. That was the good news and it was also the whole problem, because a uterus that won't contract has a pair of arteries running into it that a person can empty out of in ten minutes.

"Straight cath her."

Three hundred and twenty milliliters came off the bladder, and that helped, and it wasn't enough. Mara opened the oxytocin wide.

"Pressure."

"One oh six over sixty-four."

"Methergine. Point two, IM."

The room filled up the way rooms do. A second nurse, then a third. The charge nurse in the doorway with her arms crossed, watching, ready, not saying a word, which is what a good charge nurse is for. Somebody paged Lindquist. Somebody started the clock on the wall. Mara kept her hands where they were and kept talking, low and steady, to a girl who had been laughing four minutes ago.

Blood is loud. Nobody tells you that. It slaps.

"Nine hundred," Toya said. Then, not long after, "Eleven hundred."

"Gram of TXA. Type and cross for two."

"Ordered."

Mara stripped her gloves and pulled on the long ones that go past the elbow.

"Kayla, this is the fastest thing I've got and it is going to hurt. I'm sorry about that. Hold his hand and cuss at me as much as you want."

She made a fist, and she went in, and she brought her other hand down onto the fundus through the belly wall, and she pressed the two together and held.

Then she just stood there. Bimanual compression, they call it, and what it actually is, is a woman standing in a bright room at eleven o'clock at night holding another woman's uterus in her two hands and squeezing it, while a monitor beeps and somebody's boyfriend cries very quietly against the wall with a brand-new son asleep on his chest.

"Time."

"Two minutes."

"Keep going."

Her forearms started to burn at three. At four, Kayla's pressure came back ninety-four over fifty with a heart rate of a hundred and twenty-two, and Mara said, with no change in her voice at all, "Liter of LR wide open, and where is my blood," and somebody said it was coming up from the lab.

At five minutes the muscle came back.

She felt it happen. It gathered under her fist and it hardened and it stayed hard, and she waited, because it will fool you. It will firm up just long enough to let you believe it and then let go the second you turn around. She held it two minutes longer than she needed to. The pouch quit filling. By the time Lindquist came through the door pulling on gloves there was nothing left in that room for him to do but sign things.

Final quantitative blood loss, one thousand six hundred and fifty milliliters. One unit of packed cells. A hemoglobin of seven point nine in the morning, and iron for three months, and a woman who would be exhausted until Christmas and then be fine.

Mara wrote her note standing up. She always wrote them standing up. Her right forearm had a fine tremor in it and she let it shake and typed one-handed until it stopped.

"You never raised your voice," Toya said.

"Raising your voice doesn't clamp anything down."

Toya laughed. Then she stopped laughing and put a hand flat on Mara's back for a second on her way out of the room, which was allowed, and which they never talked about.

Mara went back in at half past eleven with a warm blanket, because the shaking afterward is the worst part and nobody warns them about it either. Kayla was gray and shivering under two of them already and the baby was latched and working like he'd been at it for years.

"Am I going to die?" Kayla said.

Some of them ask. Most of them don't, and Mara had never once figured out what made the difference.

"No," she said. "You were closer than I'd have liked. You're not close now. You lost enough that you're going to feel like a bag of wet sand for a month and you're going to want to cry at commercials, and that's the blood, that's not you losing your mind. Eat red meat. Take the iron. Come see me in two weeks and I'll tell you how you're doing and I won't lie to you then either."

Kayla started crying. She held on to Mara's wrist with a grip that had a lot left in it.

"You were talking the whole time," she said. "You never quit talking."

"That's the job."

She had caught somewhere over a thousand babies. She'd stopped keeping count at a thousand, because a number like that starts to mean something to people, and she didn't want it meaning anything. It was work. It was the best work there was. You put your hands on a woman at the worst and best hour of her life and you told her the truth in an ordinary voice, and most of the time the truth was good.

Her mother had caught babies too, up in the hollow, in kitchens and back bedrooms and once in the bed of a truck, for the better part of thirty years. Mara had never once let herself think of it as the same job.

When people at work asked where she was from, she said East Tennessee. If they pushed, she said up toward the Kentucky line. If they pushed past that she gave them the county, and nobody had ever heard of the county, and that was the end of the conversation. Twenty years, and it had never failed.

She'd had a brother once. That was the sentence, on the rare occasion any sentence was called for. She'd had a brother once and he ran off at thirteen and nobody ever found him. It had gotten smooth from handling. You could pass it across a table and nobody cut themselves on it.

She had believed it for a while, that he ran off. Then she'd stopped believing it. Then she had built a life in which it never came up.

❦

It was twenty to midnight when she finally got to the break room. There was blood dried into the seam of her left clog. She poured a paper cup of coffee she had no intention of drinking and looked at her phone for the first time in six hours.

Three missed calls. A 423 number with no name on it, because she had never saved it, though she'd known whose it was for two decades. One voicemail, nine seconds long.

"It's June," it said. "Call me."

She took it out to the stairwell, where the reception was better and where nobody ever goes.

June picked up on the second ring, which meant she'd been sitting with the phone in her lap.

"You working?"

"I just came out of a birth."

"Well," June said. "That's you."

Twenty years in three words. Mara let it go past her.

"What's happened?"

"She's quit talking."

"Quit talking how?"

"How many ways is there? She don't talk." A chair creaked, and Mara could see the chair. She could see the whole kitchen around it, the yellow bulb over the sink, the calendar from the feed store, and she put her free hand flat against the cinder block to have something cold to hold on to. "Bonnie was out Friday. She says it's more of them little strokes. Says a person can have a dozen and not know it, and then one day the words are gone and they don't come back."

"Is she eating?"

"She'll take what you put in her mouth."

"Is she in pain?"

"How would I know that?" June said. "She can't say."

Three flights down somebody laughed and a door banged shut and the sound came up the stairwell and died.

"There's another thing," June said.

"All right."

"She's been getting in the cellar."

Mara didn't answer.

"She can't stand up," June said. "You understand what I'm telling you. She can't stand and she can't feed herself and she can't say my name, and I have found her twice now at the head of them cellar steps with her legs already over the edge. She got the hasp off with a spoon. A spoon, Mara. I don't know how long that took her and I don't want to know."

"With the vascular type they'll go looking for a place they felt safe. It's common. If she spent time down there when she was younger, it doesn't have to mean anything at all."

"Mara."

"What."

"She's not hiding," June said. "She's going down there like she's late."

The stairwell was cold. Overhead the ventilation kicked on and ran a while and shut off.

"How long has she got?"

"Bonnie won't say. She's got a way of not saying that's worse than saying."

"June."

"I'm not asking you to come," June said. "I'm telling you what's happening. Them's two different things and you never could hear the difference between them."

"I'll come. Tomorrow. I've got to clear my board and there's a woman at thirty-nine weeks I promised."

"Uh-huh."

"June."

"Come when you come," June said, and hung up.

❦

She sat in her car on the third level of the deck for eleven minutes with the key in her hand and the engine off.

She was still in her scrubs. There was a smear at her hip gone stiff and rust-colored, and blood under the nail of her left ring finger where the glove had rolled back, and if she went upstairs now she'd shower and eat crackers standing at the sink and sleep four hours.

She had not set foot in that root cellar in twenty years.

She could smell it anyway. Cold dirt. Vinegar off the jars. The sweetness of apples going soft in the crate in the corner. And under all of it, something else, something she'd never had a name for, and had not once let herself think about since she was sixteen years old.

She started the car.