Chapter 1 1
By the time the call comes in at 2:30 p.m., Mary Lou Kopas has already helped three women give birth.

The first was Monique, at 8:30 a.m. Aided by an anesthetic called an epidural, she pushed for a scant half hour after her water broke before delivering her second child into Kopas’s hands. The little girl needed a few puffs from a neonatal respirator to boost her breathing but now is nursing with gusto.

Next was Sofia, who had hoped for an unmedicated birth until three days of labor left her ragged and exhausted. She opted for an epidural, which allowed her to sleep for a few hours. The delivery went fine, but a bit of placenta refused to detach from the uterus. Kopas couldn’t dislodge it, nor could the obstetrician she called for assistance. Facing the risk of hemorrhage, the new mother was whisked to the operating room, where Kopas helped the surgeon perform a procedure to remove tissue from the uterus called a D&C: dilation and curettage.

Then came Nayantara. After four hours of labor, she delivered her first child, a boy, without pain medication. “That one was very nice,” Kopas says, smiling. “The baby just glided out.”

Back-to-back-to-back babies aren’t the normal order of business at University of Washington Medical Center–Northwest, where Kopas leads a team of six certified nurse-midwives. “I might get a day this busy once a year,” she says, plopping into a chair after the third birth—and just before the phone rings.

On the line is Amie-June Brumble, a thirty-seven-year-old law firm supervisor nearing the due date for her second child. She tells Kopas she’s been having sporadic contractions since early morning but isn’t sure whether they signal the start of active labor.

Kopas hasn’t eaten anything but a handful of hazelnuts since breakfast. She’s barely had time to pee. But as she chats with the expectant mother, her voice is unhurried and calm. There’s no hint of stress, no indication she has been running nonstop for nearly eight hours. “The patient doesn’t care how busy you are,” Kopas explains later. “Your job is to be there for her, to give her your full attention.”

In that way, midwifery has changed little from its ancient roots. Derived from Old English, the word midwife means “with woman.” Centuries later, that’s still how Kopas defines her basic commitment to patients: “It means being there with her no matter what happens.”

Following in the footsteps of midwives through the ages, Kopas helps women navigate the joys, terrors, and transformations of pregnancy and birth—experiences that rank among humanity’s most primal. But midwifery today is backed by the power of modern medicine. While midwives of old had no formal training and helped women deliver at home, nurse-midwives like Kopas are highly educated professionals who work mostly in hospitals. They offer their patients the personalized, holistic care that is the hallmark of midwifery—and the peace of mind that comes from knowing surgeons and state-of-the-art resources are close at hand if needed.

That’s why Brumble chose the UW midwives for both her pregnancies. She knew she didn’t want a typical hospital experience, with bright lights and medical staff rushing in and out and an obstetrician she might never have met before. She wanted to see if she could give birth naturally, with no pressure from busy doctors to speed up her labor or dull the pain with drugs.

“I didn’t want to be treated as a medical emergency,” Brumble explained during a prenatal checkup with Kopas two weeks earlier. “I felt that this was an experience that has been common to women, of women and for women throughout our species’ history, and I wanted to have a more personal connection with it.” But she also wanted quick access to medical care if anything went wrong.

Now, on the phone with Kopas, she describes contractions that started off mild and irregular but have been getting stronger and closer together. Before her first son’s birth three and a half years ago, Brumble and her husband packed a bag with fuzzy slippers, music, and snacks to help her through labor. But the baby came so fast they barely made it to the hospital in time. The bag sat in the car, forgotten, until long after the birth. Brumble doesn’t want to repeat that experience, but she’s wary of jumping the gun. And, she tells Kopas, she’s not sure her insurance will cover a hospital visit for a false alarm.

“Could you be at the clinic by three thirty?” Kopas asks. “I could buzz over there and check you out.”

The UW Medical Center–Northwest Midwives Clinic in North Seattle, a few blocks from the hospital, is where Kopas and her colleagues have their offices and conduct patient exams. Since she doesn’t have any more women in labor at the moment, Kopas has time to dash to the clinic, where there will be no question about insurance coverage.

But first, there’s record keeping to catch up on. Kopas clicks open a screen on her computer. Reading glasses perched on her nose, she quickly types in the details of Nayantara’s delivery, along with orders for a handful of drugs and other palliatives to ease postpartum discomfort: ibuprofen, laxatives, witch hazel pads to soothe tender tissues. “You always have to chart what you’re doing, and you can’t get too far behind,” she says.

Kopas is dressed in blue scrubs, her standard uniform for hospital shifts. Her graying hair is pulled up and clipped but keeps falling around her face. On her right forearm is a tattoo of a female elephant and calf. The matriarchal mammals, who tend each other’s births and rush to the aid of babies in distress, are a kind of totem for Kopas. At fifty-four, she’s approaching matriarch status herself as a leading advocate—and agitator—for women’s health in Washington State.

One of her inspirations was the badass midwife who helped her teenage sister through pregnancy and birth in the early 1980s, a time when out-of-wedlock babies were still considered scandalous by some—including Kopas’s Catholic parents. Her sister described the midwife striding down the hall of the small hospital in western Massachusetts wearing knee-high suede boots with tassels and drawing incredulous stares from doctors and nurses. “She was the rebel in the hospital,” Kopas recalls. “That’s what planted the seed for me.”

With her computer work done, Kopas checks her watch. There’s just enough time to grab a bite. She navigates the hospital cafeteria with the dexterity of a person used to eating on the fly, snatching a sandwich and hummus, then heading for her car. En route to the clinic, she points out a favorite cotton shopping bag in the back seat, decorated with a silhouette of jagged peaks, the phases of the moon, and the message “Menses Move Mountains.”

At the clinic, Kopas wolfs down the sandwich while conferring with a colleague about another patient. When Brumble and her husband, Tyler, arrive, the clinic nurse leads them to an exam room. Wearing a long gray skirt and a blue tee shirt, Brumble lumbers slowly down the hall, with Tyler at her elbow. The nurse straps a fetal heart monitor around the pregnant woman’s belly and helps her onto the table.

Kopas greets the couple and asks how they’re holding up. Lying on her side and holding Tyler’s hand, Brumble explains that her contractions got stronger and closer together during the ride to the clinic. Her wavy blond hair hangs loose around her shoulders. Tyler’s brown hair is equally long and twisted into a braid. Brumble grimaces and screws her eyes shut as a contraction pulses through her body. “Yes, yes, yes,” she chants under her breath, rocking and tightening her grip on her husband’s hand. When the pain passes, she opens her eyes and exhales.

Kopas examines the readout on the monitor. “The heart rate looks fine,” she says. “There’s nothing worrisome in there.”

Kopas pulls on surgical gloves and asks Brumble to scoot to the edge of the table. During the first stage of labor, the cervix, or neck of the uterus, thins and gradually opens to accommodate the baby’s passage. The extent of thinning—called effacement—and dilation are landmarks that map a woman’s progression toward delivery. Kopas can’t see the cervix, so she bridges the opening with two fingers and estimates. It’s a skill that takes time to master. Misjudging the size of the cervical opening is a typical rookie mistake for new midwives.

Brumble is at four centimeters, about the diameter of a Ritz cracker. That’s a little less than halfway to the all-systems-go maximum of ten centimeters, and wide enough to signal active labor.

Since Brumble’s first birth was a lightning-fast affair and second babies often come quicker, Kopas suggests the couple head for the hospital.

“You’re ready. You can do this,” she says. “My money is on sometime in the next few hours.”

No one takes the bet. If they had, Kopas would have won.

Soon after the couple settles into their birthing suite, Brumble’s contractions intensify. Now dressed in a green, open-backed gown, with her hair pulled away from her face and braided, she leans over the bed, squeezing a pillow and groaning. Her toes curl with each contraction. Kopas rubs her back, while Tyler fans her flushed neck.

Natural labor is a spontaneous process triggered by an interplay of signals from the mother, fetus, and placenta. Powerful and primordial, it commandeers a woman’s body and doesn’t let go until the birth is complete. For some women, contractions are not much worse than severe menstrual cramps. Others describe labor as the most agonizing experience of their lives. “I begged my hubby to throw me out of the car on the way to the hospital, it hurt so bad,” one woman writes. “I really thought my muscles were going to tear apart,” says another.

By the time Brumble got to the hospital for her first son’s birth, the pain was so overwhelming she briefly considered giving up on natural childbirth. But it was too late for an epidural, which is injected into the space around the spinal cord. This time, her early labor was light. She was able to work at home, taking care of chores and getting the house ready for the baby. As she arrived at the hospital, she was still chatting and joking. Now all she can do is lower her head and groan, a low, throaty sound like a rumbling bear.

When the contraction eases, she rises to pace the room. The next wave takes hold and Brumble leans against her husband. Head to head as if slow dancing, the couple sway to the internal rhythms moving their son closer to birth.

Kopas stands back, watchful but not intruding on the intimate moments.

She’s the medical authority in the room, the person who holds two lives in her hands and directs a team that includes a labor nurse and a neonatal nurse. It’s the same top-dog position the obstetrician occupies in most hospital births. Barring any complications that require a doctor’s assistance, Kopas will be the one in charge throughout, overseeing both Brumble’s care and the baby’s.

The bedrock tenet of midwifery is that birth is a natural process. It’s not a sickness. It’s not a pathological condition. Midwives intervene only when needed or wanted. Women are free to labor any way—and pretty much anywhere—they feel comfortable: in a tub, walking the halls, lying on the floor, or curled up in a chair. Every midwife has stories of babies born atop a toilet, or in a doorway or corridor.

Midwives often describe their job as “catching babies.” It’s a charming phrase that honors the mother for doing the hard work of delivery. But it doesn’t really reflect the complexity of the midwife’s role—which includes being constantly alert for trouble. During labor, Kopas needs to ensure that the forces roiling the mother’s body aren’t harming the baby. If the umbilical cord is compressed, it can strangle the oxygen supply. The placenta sometimes tears away from the uterine wall prematurely. Complications like that are rare and unlikely for a woman like Brumble with no risk factors. But Kopas doesn’t assume. She asks the labor nurse to periodically check the baby’s heart rate with a handheld ultrasound device called a Doppler. Pressed to Brumble’s belly, the instrument amplifies watery thumps that pound away at a robust 150 beats per minute.

Another key part of the midwife’s job is to gauge the level of support and encouragement each woman needs. For first-time moms climbing the walls with anxiety, Kopas does whatever seems to help—holding their hands, gazing into their eyes, helping them count and breathe and focus. Some women enter a Zen-like state and don’t want anything to break the spell. As Brumble’s pain builds, Kopas begins to murmur words of encouragement. The laboring woman is back on the bed, curled on her side. Kopas massages her back through a minute-long contraction. She presses a cool washcloth to Brumble’s neck and urges her to catch her breath and rest when the grip relaxes.

“I forgot why this was a good idea,” Brumble says, gasping.

“Because babies are so cute and cuddly,” Kopas says, rubbing her feet. “And when they come, labor is over.”

“Oh, God. Oh, God,” Brumble moans, almost sobbing. “I think I’m ready to start pushing.”

In most hospital births, this is the point when the lights are cranked up and the obstetrician—who usually isn’t present throughout labor—is called back into the room. She or he will maneuver the woman onto her back and into stirrups, then reach into her vagina to confirm that the cervix is fully dilated. If it is, the doctor will often start instructing the woman like a drill sergeant, telling her when to push and for how long.

Kopas does none of that. She and the nurses move quietly, making their final preparations. The labor nurse wheels in a cart of instruments covered with a blue drape. The neonatal nurse tests the respirator she will use if the baby has any trouble breathing. Kopas pulls on a pair of gloves and asks Brumble what position she prefers.

Hands and knees, Brumble replies.

The nurses wrestle a horseshoe-shaped pillow onto the bed and help Brumble turn so it supports her upper body.

Kopas leans in and pats Brumble’s hand. “You ready?” she asks. “Start taking deep breaths. Blow it out, all the way down to the baby.”

Brumble growls, then roars as she pushes into the next contraction. Standing next to the bed, Kopas presses down on her patient’s lower back to alleviate the pressure.

“Stay with it,” she urges.

Brumble grips the head of the bed and screams. Raw and wild, the sound pours out of her and fills the room. A gush of liquid floods the bed.

“Your bag of water just broke,” Kopas says. Brumble lets out a rush of air, half panting, half crying. Kopas positions herself between Brumble’s legs. “We’re getting so close now. Just listen to your body,” she urges.

Brumble groans and pushes and pushes and groans.

Kopas leans in again, her head next to Brumble’s. “Amie-June,” she says emphatically, to penetrate the fog. “You’re so close. You can do this. We’re all with you.”

“It hurts,” Brumble says, almost whispering.

“I know,” Kopas says, softly now. “You’re doing so well. You’re doing amazing. You got this.”

Kopas peers at Brumble’s bottom. She cups the vagina with her hand, feeling the bulge of the baby’s head.

“Can you see anything?” Brumble asks.

“No, but I can feel him.”

Another push, and the top of the head appears.

“Now I can see him,” Kopas says. “Little pushes! Little pushes!”

Then suddenly, another person is in the room.

Smeared and bloody, trailing a milky-blue cord, a tiny body fills Kopas’s hands. Only seconds old, the new human knows what to do. His mouth flies open. Pulling breath into lungs that have never before filled with air, he begins to cry.

“You did it, Amie-June!” Kopas exclaims. “So beautiful.”

Naked and trembling, Brumble tucks her legs beneath her and rocks onto her haunches.

“Here’s your baby,” Kopas says, passing the flailing bundle to his mother, who clasps him to her chest and gazes into his face.

“Oh,” she breathes. “Hi.”