A long overdue post...
Shortly after I found out that I was pregnant again at the end of April, I decided that really wanted to work with a midwife during the pregnancy and birth, and John agreed. Pregnancy had become so medicalized for us--charting, OPK's, clomid, prometrium, betas, monitoring of hormone levels. This was nothing like what I had anticipated or wanted pregnancy to be for me, being so measured, calculated, and monitored. After three miscarriages, I was beginning to lose faith in my body's ability to carry a baby and give birth. I felt broken and damaged. I thought that using a midwife would help me get back to experiencing pregnancy the way I had envisioned. I wanted to have faith again. I wanted to trust the process. I wanted to work with someone who would view me as healthy, capable, and whole.
John and I decided that we felt the most comfortable with a hospital birth (as opposed to a home birth or a birthing center). In Virginia, midwives cannot actually deliver a baby in the hospital, so, in addition to working with our midwife, we would be working in conjunction with an OB practice. The midwife had advised that we would have our first prenatal appointment in the OB's office, and that we could see either the OB or the nurse practitioner. Our first appointment would consist of a physical exam, blood work, and confirmation of the pregnancy through hearing the baby's heartbeat on the doppler or through ultrasound. About 4 weeks after our first prenatal visit at the OB's office, I would see the midwife at her private practice for the first time. At this time, we would talk about the rest of my care, including how often I would see her versus the OB. After our 7 week ultrasound where we saw our baby's heartbeat, the RE released us from his care, and I called to set up our first prenatal appointment. It was a significantly longer wait to see the OB, so I decided to go ahead and make our first appointment with the nurse practitioner.
On June 12th, John and I went for our appointment. I was 10 weeks pregnant. When I originally set up the appointment, I thought I would be going alone, as John had a work meeting that he didn't think he could reschedule. Thankfully, it worked out that he could be there with me, and for this, I am forever grateful. I can't imagine experiencing what came next alone.
We met at the office, and had to wait for what seemed like forever. I was getting impatient and irritable, and just wanted to go home and take a nap. Finally, it was our turn. We followed the nurse practitioner to the examining room. She asked me a few questions, and then I undressed for the physical exam. The exam was difficult and painful. She used the fingers of one hand inside my vagina as her other hand pressed firmly on my abdomen. She said that my uterus was tipped very far backwards--to the point where it was resting against my backbone, and that this made getting a measurement of my uterus very difficult. After applying even more pressure, she concluded that my uterus was hard, enlarged, and definitely pregnant. She explained that at this point, with me being 10 weeks along, they would normally try to find the baby's heartbeat using a doppler. Since my uterus was tipped so far backwards, she thought that we certainly would not hear the heartbeat, and she told us we would go ahead and get an ultrasound to take measurements of the pregnancy. I dressed and we waited in the exam room while the ultrasound machine warmed up.
After seeing the heartbeat at just over 7 weeks--a strong, quick heartbeat, and experiencing increasing pregnancy symptoms, I was starting to finally relax into this pregnancy. All of my other miscarriages had happened so much earlier. Having made it to 10 weeks, I really thought everything was fine. I was excited for the chance to see my baby again, to see how much he had grown in 3 weeks.
We came into the ultrasound room, and the nurse practitioner said that at 10 weeks it is generally possible to get a good view of things through an abdominal ultrasound. She warned us that the extreme retro-version of my uterus might make it more difficult to see the baby, but she though we could at least try. I was thrilled to transition away from vaginal ultrasounds, which were always extremely uncomfortable and even somewhat painful. I raised my shirt, rolled down my pants, and they rubbed the cold gel on my lower stomach. She did a quick scan of my belly, but then said that she didn't think we would be able to get a good view, and she said we would have to do the ultrasound vaginally.
I undressed from the waist down, still thinking that everything was fine. I was disappointed to have to have a vaginal ultrasound, but I was still excited to see that little heart thumping away. A few minutes later, a nurse came in and said that she would be performing the ultrasound. I thought this was a little odd, but she assured us that she had performed many, many pregnancy ultrasounds during her days. Looking back, it seems very strange that the nurse practitioner didn't come back in to perform the ultrasound. I think that there are two possible explanations: either she thought that everything would be fine and that it would be no problem for an experienced nurse to do the ultrasound, confirm the pregnancy was viable, and take measurements to determine my due date. OR that from the quick abdominal scan, she got a sense that something was wrong, and she went to call my RE's office for more information.
The nurse inserted the wand into my vagina, and positioned it to get a good view of my uterus and our baby. I was squeezing John's hand incredibly hard, but at this point, it was simply because of the discomfort of the wand's position. In this particular ultrasound room, there was a monitor next to the exam table, but there was also a television mounted to the wall directly in front of the table. I was staring hard at the screen in front of us. At first, everything looked fine. The baby was significantly bigger than he had been during our last ultrasound. She moved the wand around, silent. I was scanning the screen, looking for that little flicker of his heart beating. But I didn't see it. John and I exchanged concerned glances, and our grip on each other's hand became even stronger. In that moment, I think we both knew. We had so easily and quickly seen the heartbeat during our last ultrasound. There was no flicker on this screen. From the reading I had done, I knew that at this point, the baby should be moving around quite a bit, even though these movements are not felt by the mother for several more weeks. Our baby was quite still.
The nurse was still silent, and kept moving the want around, looking for a different angle. At this point, I said that I didn't see the heartbeat, and asked if I was missing it. In a sad voice, she said that she also did not see a heartbeat, that she had been looking for different angles in case she was missing it. I don't think she took her eyes off the screen to look at us. She took some measurements, and the baby measured 9 weeks, meaning that he had died about a week before. She pointed out a line on the screen that she said looked like was the placenta, and that it had separated from the uterine wall. The nurse said that she wanted to get the nurse practitioner to come and take a look. She removed the wand, and we waited for a few moments. At this point, the reality of what had just happened was really sitting in, and I became very upset.
The nurse practitioner entered the ultrasound room. The wand was inserted again. She took a quick look, and said that she too did not see a heartbeat. She told me to get dressed. I stumbled back into my clothes. She came back in a few minutes later and said that they had called my RE's office, and that they knew who I was right away, that everyone in his office loved me. It seemed like a bizarre thing to say. She then said that they could go ahead and schedule my D&C, or that I could come back in a couple of days for a repeat ultrasound. I was in shock. I said that I just wanted to leave. As John and I were leaving, they nurse practitioner called out to us, "Don't you want your pictures?" The first thoughts in my mind were, "Why would I want pictures of my dead baby?" John went back and got the ultrasound pictures. Later, I was very grateful to have them.
We had driven to the appointment separately, so John asked if I was okay to drive. I said that I thought I was, and we both left to make our way home alone. After pulling out of the parking lot, I immediately called my mother. She answered the phone, and from her "Hello," I could sense her excitement about receiving an update on her grandchild. I felt like I could barely speak, but I must have said something that made sense, because she said that she was on her way to our house.
John and I arrived home about the same time, and I collapsed on the bed, sobbing and incoherent. After a few minutes, we talked about what to do next. John suggested calling the RE's office. I told him that it was after hours, and that we would have to wait until morning. He suggested that we call anyway and speak to the doctor on call. So we did. The doctor called us back in a just a few minutes. I explained what had happened at the appointment. I can't remember exactly what he said, but it must have been the right thing, as this is how I remember it. I do remember that he told us to come into the office first thing the next morning, and that we would certainly see which ever doctor was available for a repeat ultrasound. The rest of the night is a blur of tears and confusion and anger. I called my boss to let her know what was going on and that I would not be coming in the next day.
The next morning, I called the clinic, and they told us to come right on in. Almost immediately, we were taken to the ultrasound room. My RE came in, and we told him about the visit the previous day. He looked at my file and at the pictures from our last ultrasound. He came over for the ultrasound, inserted the wand, and moved it into position. There was my uterus, our baby, but sadly, no heartbeat. He looked and looked, but the heartbeat was no where to be found. At some point, he commented that the baby had grown so much. In his words, I could hear genuine sadness and disappointment. I got dressed, and we met him in his office.
We told him again about the appointment the day before, and I told him what they had said about scheduling the D&C. He was upset that they had not encouraged me to get a second opinion. "You always get a second opinion," he said. He told us that he was glad we had called last night and that we had come in right away this morning. He said we did the right thing. We talked about what our options were. He said that he suspected that there was a chromosomal abnormality in the baby, that this was usually the case when there is a fetal death after observing a strong heartbeat. I asked about waiting for my body to miscarry on its own, and he said that he recommended a D&C for two reasons: 1) so that we could have a karyotype performed on the baby's chromosomes and 2) to hopefully save me from the long, drawn-out and painful miscarriage that was likely to occur after a late 1st trimester fetal death. John and I quickly decided to have the D&C done. The RE said that we could either have the doctor from the OB practice that we were in yesterday perform the D&C, or he could do it. There was no way I was having some doctor that I had never met perform the D&C, so I asked him to do it. I could tell that he really didn't want to. He even said something about the other doctor being "quite good at them." I again said that I wanted him to perform the procedure. You can read more about the D&C here.
Thinking back on this appointment, it seems even more bizarre than it did when we were living it. Did the nurse practitioner see something during that quick scan of my belly that gave her an indication of the state of my pregnancy? Why did the nurse perform the ultrasound? Why didn't they at least have the OB come and take a look? I feel angry for the way we were treated, angry that the nurse practitioner didn't even have the doctor come in for a second opinion. I feel angry and shocked that she offered to schedule a D&C on the spot.
I also feel really sad that our experience at this practice may prevent me from working with this particular midwife during my next pregnancy. The midwife doesn't work with any other OBs, and right now, I can't see myself going back into that office again. And, with us now having a higher chance of another baby with Down syndrome, I'm not sure who we will want to provide our prenatal care. I don't know what feels right anymore.