Placenta Praevia was aptly described by James Young Simpson as the condition which aroused more anxiety in the attendant and was of more danger to the mother than any other complication of childbirth.
-- Irvine Loudon, "Death in Childbirth," 1992
It's hard not to love the suspense of a good story, the puzzle of missing facts, the mystery coupled with the promise of resolution. Suspense satisfies us with its paradoxical aspects. It drives us forward through a narrative, revealing more and more at the same time that it continues to conceal. We enjoy not knowing, and we enjoy disclosure. We want to be in the midst of a compelling story even when we feel desperate to reach the end. We enjoy the gradual sharpening of our suspicions.
That's the way I felt during the calm, rotund final months of my first pregnancy. I wanted to meet the little person who would be my daughter, but I also wanted to relish the mystery -- and anxiety -- of not knowing. As long as my child was inside me, I knew where she was and had a sense from her pokes and prods and hiccups of how she was, even if I didn't yet know who she was. Pregnancy seemed to be one of the most satisfying stories, deeply suspenseful and hinting at every step of its own magnificent resolution. And when the pleasure of suspense threatened to deteriorate into worry, all I'd have to do was give a nudge or eat some penne arrabiata, and my little mystery would start bouncing around, assuring me that she was fine.
And so, pregnant with my second child, I looked forward to the same inspiring suspense, to the paradox of knowing and not knowing, to mystery and reassurance. But fate played one of its tricks, and at my 16th-week sonogram a problem was discovered. The fetus appeared to be developing normally, but the placenta was low-lying, directly over my cervix. All of a sudden I was promoted to the high-risk category of expectant mothers (goodbye to the trip to Italy we'd planned, goodbye to everyday pleasures, hello to "conservative management," as the doctors put it). The sweet, 40-week suspense of gestation became dark, strange, almost, at times, unbearable. Suspense was no longer a delight to me, and I found myself desperate to learn everything I could about my condition. I wanted to exchange uncertainty for absolute certainty. I wanted to know what was going to happen to me and my baby.
There is no place for routine vaginal examination in the diagnosis of placenta previa. This is because such examination may cause a torrential hemorrhage.
-- High Risk Pregnancy: Management Options, 1994
The afternoon of the day of the ultrasound, I went to my local library and checked out books about pregnancy. I was frustrated by the lack of information. Placenta previa tended to be briefly defined along with other high-risk indicators, including hyperemesis gravidarum, preeclampsia and spontaneous abortion. In contrast to such odd terms, placenta previa didn't sound so dangerous. But then again, I was 35 years old, of "advanced age" in obstetric terms. "The chances of a number of complications, such as Down's syndrome in the baby, preeclampsia, and poor labor pattern, increase with age," as the writers of "Pregnancy, Childbirth and the Newborn" put it. I was old. I was "high-risk." I was guilty. Not only was I guilty of risking pregnancy at an advanced age, but I was guilty of worrying and therefore compromising with my bad vibes the fetus growing inside me.
At that point, I could have recognized that the books were not reassuring me as I'd hoped they would and given up on my quest for information. I had an experienced group of physicians in charge of my care, and the hospital where I would deliver had one of those facilities for high-risk deliveries billed as "state of the art." But I was obsessed and becoming more obsessed. And so I turned from the layperson's guides to the medical textbooks and read on.
Prematurity: Cotton et al. reported a perinatal mortality of 100 percent at less than 27 weeks, 19.7 percent between 27 and 32 weeks, 6.4 percent between 33 and 36 weeks, and 2.6 percent after 36 weeks. The overall perinatal mortality has dropped from 126 per 1,000 to 42.81 with conservative management. -- High Risk Pregnancy: Management Options, 1994
I'd go to my prenatal appointments with the information churning in my head. "The perinatal morality drops to 19.7 percent at 27 weeks," I said to my doctor at my 26th week visit. I wanted him to tell me that the fetus was large enough to be considered 27 rather than 26 weeks old and so would have a better chance of survival, if she happened to be delivered by emergency C-section the next day. Even more, I wanted to be told that the baby would make it to the 36th week and so would have a 97.4 percent chance of survival. 97.4 percent? What if she happened to be in that 2.6 percentile? Of course the doctor could only reassure me that everything, so far, looked fine. I went home worried most about that 100 percent perinatal mortality rate at less than 27 weeks, and worried in a vague way about that 2.7 percent mortality rate at 36 weeks. I was unlucky enough to have a low-lying placenta -- the chances for this are about one in 200 pregnancies -- so 2.7 deaths out of 100 births seemed a precariously high number.
But this is the lie of statistics. My 10th-grade math teacher might have insisted that statistics are not predictions, but I couldn't read them without an awful feeling of foreboding. And still I kept searching for answers.
Intrauterine growth retardation: This may occur in up to 16 percent of cases. The incidence is higher in those with multiple episodes of antepartum hemorrhage.
Congenital malformations: The incidence of serious malformations is doubled in women with placenta previa. The most common are those of the central nervous, cardiovascular, respiratory, and gastrointestinal systems. -- High Risk Pregnancy: Management Options, 1994
Now, in retrospect, I wonder about this quest for information. Why did I think that facts and statistics would return to me the control over my body that I'd lost? In the hands of a talented writer, facts increase suspense rather than resolve it. The more we know about Miss Havisham in "Great Expectations," the less we really know about the true source of Pip's support. The vague discomfort we feel with Pip is created with information -- misleading information. Miss Havisham only pretends to be Pip's sponsor. And what a great pretender she is, we discover once the truth is revealed.
As my pregnancy continued and my placenta did not do what so many low-lying placentas do -- move up, away from the cervix -- and as the dangers of severe bleeding increased, so did my obsession. Instead of craving peaches and fresh orange juice, as I did in my first pregnancy, I craved information. I wanted as much information about placenta previa and high-risk pregnancy as I could get. And though I sensed that the information wasn't helping my mood, I couldn't stop. Whenever I had a free hour, I crept into the upper level stacks of the medical library as if I were heading toward some sort of illicit meeting. I greedily pored over medical textbooks and came away devastated. Besides the statistics there were phrases like "torrential hemorrhage" and "unexpected intrauterine death" that kept me shuddering all the way to the parking lot. I'd fall into a terrible gloom, and I'd go home to study the calendar: 10 more weeks to go, nine and a half, eight, seven and three days ...
Time was passing. I could hardly believe it. Some days time seemed to creep to a virtual standstill -- such was the effect of this cruel suspense. And with the pressure for resolution nearly overwhelming me, I couldn't be comforted by the natural increase in the baby's activity. The more jostling I felt within, the more I wanted to feel. A little nudge or wiggle was not enough, as it had been during my first pregnancy. I wanted to feel sure evidence of strength: a knockout jab, a gut-bruising kick. Meanwhile, I'd been instructed to stay in town and never to be alone. I was told to call the ambulance service and explain my condition to them. At any moment, I could start to gush bright red blood.
I figured that the medical library, since it was attached to the hospital, was a safe enough place for me. So I continued to go there, continued to read about other possibilities, other risks of this high-risk pregnancy. And then one day, worn out by more of my own anxiety, I took a detour from the regular stacks to the history of medicine reading room, a place I'd come to know a few years earlier when I'd been gathering material for some short stories. The books on the shelves in this room had given me a dependable pleasure -- they were full of anecdotes about strange medical procedures and grand mistakes, delusions and misconceptions, moral courage and scientific pride. These histories of medicine were great stories in themselves, and they had made science newly accessible to my own imagination.
So instead of reading about the probability of various outcomes of placenta previa, I took to reading about the history of placenta previa, about how in the 18th and l9th centuries it was sometimes treated by packing the vagina with cloth or inserting an inflatable bag in hopes of controlling the bleeding. More often, the physician or midwife would plunge a hand into the uterus, grab both legs of the baby and deliver it as a breech, since the pressure from the baby's buttocks helped to compress the bleeding in the uterine wall. Sometimes a cord was attached to the baby's leg and a weight attached to the cord and hung over the end of the bed.
I read about Lawson Tait of Birmingham, who suggested in 1890 that Caesarean sections be performed for cases of placenta previa. I read about Murdoch Cameron of Glasgow, who said that Lawson Tait's suggestion was nothing but a "bad joke."
My biggest discovery in that reading room was that the books, the histories -- so many of them about strange and sometimes tragic medical mistakes -- were still illuminating. This was information that I wanted to know, contextual information about what passes as information in the medical world. This was information that revived the old feeling of suspense, filling me with healthy suspicion. These were stories that enacted the mystery of pregnancy rather than pretended to resolve it.
Information ... Often it is no more exact than the intelligence of earlier centuries was. But while the latter was inclined to borrow from the miraculous, it is indispensable for information to sound plausible. -- Walter Benjamin, "The Storyteller" (translated by Harry Zohn), first published in Orient und Okzident in 1936
The information laid out so plainly in textbooks and journals appears at first to be without personality and therefore untainted by human mistakes. But this is the grand illusion of style, of statistics and charts, of affectless instructions and sometimes insensitive phrases. Without medical training and instructors there to help me interpret information, I'm obviously not the ideal reader for medical textbooks. The ideal reader is a doctor who reads the textbooks as he or she might read a novel -- questioning the information, reflecting upon the language used and continuously wondering about the peculiar material that might be hidden behind the facts. The language of medicine, like the language of a novel, conceals even as it tries to lay out everything known about its subject. But a textbook is far more confident than any novel and rarely admits its own uncertainties. Mystery, surprise, suspense, the stories that can be told about any experience -- these belong to the clinical side of medicine. The other side, where information is standardized and committed to print, pretends to have no secrets. Even case histories, strange and nerve-wracking as they might be to both patient and doctor in real life, tend to be offered as no more than proof to substantiate research.
The main secret concealed by medicine is death. Of course, physicians in training learn firsthand about death and so can match experience to phrases like "perinatal mortality." Yet I wonder if medical researchers and editors could afford to leave "traces of the storyteller" on their words. This is what distinguishes information from stories, according to Benjamin in his essay "The Storyteller." The "new form of communication is information," he wrote, and information must seem "immediately verifiable." Stories supposedly get in the way of truth. Measurements, observations and statistics want no narrative design.
A century from now the language of our current medical textbooks will seem as archaic as the language of a mid-19th century lecture on placenta previa seems to us now. Time will give us the silhouette of the style and show us how what passed as medical research was influenced, ever so subtly, by opinion and bias. So why shouldn't the textbooks and journals tip their cards now and put more of the storyteller back into medical discourse? More stories -- and more skepticism -- might make it a little easier for the individual physician to apply the current facts to the extraordinary variations in life.
I started asking questions again once I'd read about the bizarre treatments that had passed as medicine in the past. I wondered about other women and their specific situations. I started gathering information in other ways -- by watching faces in the supermarket, by talking to friends and searching through the self-help and sentimental slop of magazines for the incredible stories women have to tell.The outcome of my own high-risk pregnancy was a happy one. My second daughter was born at term, healthy and alert ("She's so loud," were my first foggy words at her birth), and in hindsight I can admit that I was unduly alarmed by the diagnosis of placenta previa. But because of those months of worry I had to learn how to give myself up to the dizzying mystery of gestation, a mystery intensified by a little bit of knowledge.
When I was in the delivery room -- the theater, as the British rightly call it -- for my elective C-section and was swooning from an epidural, I happened to see my primary obstetrician out of the corner of my eye. He was sitting in a chair by the wall, waiting for his turn to come at me with the knife. He was reading. What, I wondered hazily, was he reading? I didn't ask him. Thinking back to that moment, I can say that I wouldn't have minded if he'd been reading the latest journal article on placenta previa or updating himself with my medical file. No, I wouldn't have minded that at all. But I would have been delighted if he'd already finished with the information and was sitting there reading "Great Expectations."