My appointment with Dr. Patel was scheduled for 10:55 this morning.  I usually like to get there and sign in at least 10 minutes before the appointment time (because all of my previous doctors have taken for…evvv…errrr and the earlier you sign in, the better).  But today we rolled in at 11:00.  The waiting room was packed.  I signed in and barely got a chance to sit down before the lab tech called me back.  She did her tests and samples, etc and even though I had not seen her before, she had read my file and knew that I had had a loss.  It wasn’t that she was overly sympathetic or even particularly emotional at all.  But she knew what was up and she was concerned.  Then, instead of taking me to “sub-waiting” (like on usual visits), she took us straight back to an exam room.  We were skipped to the front of the line for the second time.  Dr. Patel was there within a few minutes.  She started out by just talking with us, asking us how we were coping, reassuring us that we had made the right choice given our situation.  Then she talked about our options for trying again.  I was so happy when she brought up the Transabdominal Cerclage.  She said that she would write us a referral to a high risk OB surgeon indicating that I qualify as a TAC candidate.  I know that a lot of doctors are unaware of the procedure at all, let alone confident enough to suggest it to a patient.  I asked her if she would be comfortable being my OB MD throughout a possible TAC pregnancy.  She insisted absolutely.  I told her that if we decided to move forward we would see her + someone within the local high risk group that we went to last time, but that we would like to get the cerclage placed by someone who is an expert at the procedure.  The 2 top guys in the country are Dr. Haney (Chicago) and Dr. Davis (NJ).  These are the Cadillacs of Transabdominal Cerclage and almost never fail.  Hopefully, one of them would be within my insurance network… if not, I could probably make a good enough case to justify it to them and maybe they’d make an exception.  Anyway, she would be my primary and she would deliver the baby.  She said that after recovery, there is no right or wrong time to TTC as long as we are emotionally ready – she would give me a referral to high-risk for a preconception appointment whenever I wanted.  She gave me a pelvic and said that my cervix had healed, but my uterus wasn’t done shrinking so I should still take it a little easy.  She prescribed new BC and sent us on our way.

And then, after taking a Xanax, I went to work… When I walked into the cafeteria there were only a few clusters of people.  Of them, only a few were knew me well enough to recognize and greet me.  A few girls from digital and a few from pre-press.  There was also the big boss and the HR people.  Everybody was really nice and nobody said anything stupid… yet. It’s a matter of time.  I spent about a half hour in my supervisor’s office getting welcomed back/updated on current projects.  I rearranged my workspace and my desktop and then we had a meeting.  My supervisor told us she would be out all next week and gave us some assignments.  I was just finishing my first book when I realized that it was 3:57 – almost time to go already.  ((*phew))  Throughout the day, in the hallways, I got a few hugs and a few “you’ve been in my prayers” and some “where have you been?”  Uhhh – “Out… but I’m back. (*smile)”  I think it’s almost worse for Tim.  He works at a bigger place with more people and the news hasn’t really spread yet.  He says at least 2 people a day come up to him and ask “How’s the baby?”

I got off work and ran some errands, paid 4 bills and packed the kids off to be with their mom for 2 weeks.  Tim & I had nice dinner with some old friends, drank some wine and watched TV.  The world is still out there & I might be able to pull off this “normal” facade for a while longer if I keep having OK days like this.

I’m sure it’s a serious and scary condition, but the term “incompetent cervix” is just inherently amusing. As Eric pointed out, it sounds like the kind of cervix you’d demote to a part-time position in the mailroom.

I can understand being uninformed – I was uninformed when I went into labor with Jacob at 24 weeks.  I never heard the term “Incompetent Cervix” until I was a high risk L&D patient, suffering from steady contractions for 4 days, fighting Nature herself to keep my baby inside my body.  Besides, it was a front. page. article.  She read it.  I’m sure there was plenty of information about the risks and losses associated with IC – not to mention the mother’s personal story and how she probably struggled to hang on to her pregnancy.  The author of the blog wasn’t misinformed by the time she wrote her entry. I don’t like the name either – after what we’ve been through, believe me:  I HATE it.  AND I’m all about free speech, blah, blah, blah… But to be so obtuse as to dedicate a whole blog entry to how funny you think the name of someone else’s serious condition (that you’ve never heard of before) sounds… And then hit “publish”?  C’mon, lady.  Go write dead baby jokes for South Park.  Stupid people make me so mad.

So, maybe I shouldn’t have left a shitty comment – and maybe I shouldn’t repost it here, but damnit, I feel like exercising my First Amendment rights on this Independence Day weekend.  Here’s me flying off the handle:

Inherently amusing?  Try devastating.  More and more babies are being born too early these days – last year 1 in 10 were born before 37 weeks (full term).  Many of these premature births are due to Incompetent Cervix – also know as Insufficient Cervix. The mother that you read about is very, very lucky that she delivered her baby only a month early – that baby is a miracle.  Most are not so fortunate.  IC usually occurs in the 2nd trimester or early in the 3rd trimester.  This is when the fetus is still forming major organs like their lungs.  When they are born too soon they die.  HILARIOUS!  The most insidious thing about IC is that you don’t know you have it until you lose at least one pregnancy.  I was terrified when I went into labor with my first pregnancy at 24 weeks.  That is the point of viability, but my baby still faced tremendous challenges.  He fought for his sweet little life 10 days in the NICU before he passed away.  His name was Jacob and he was beautiful.  I became pregnant again in January of this year.  Although my husband, myself and a team of experienced high risk OB MDs did everything we could, including surgery, bedrest and weekly progesterone injections, my water broke at 21 weeks.  We had to induce labor and my son Isaac was stillborn.  There are no words to describe the pain that these losses have caused me & my husband.  What did I do to deserve this?  What did my babies do?  Why did they have to die?  I struggle everyday with these questions while you read your paper and are “amused.”

So…  I set out to make a few friends &  the first thing I do is to pick a fight with a fellow unknown blogger.  Oops.  I asked my husband if he thought I was being excessively bitchy and he said that if what I read was in the public domain and if it offended me and if it were open to comments then I should go for it.  I can always count on him for moral support.  Was I out of line?  Tonight I don’t care.

With my first pregnancy, we proceeded as normal – I had no relative medical history and there were no indications that we were at risk for any complications. I saw a midwife (who worked along with a group of OB MDs) for monthly appointments – she wasn’t that great, a little flaky, but everything seemed to be progressing properly so I wasn’t worried. Out of the blue, at 24 weeks (04-20-2009), I began having strong contractions and began to bleed. I called the midwife who advised that I was having round ligament pain and I should lay on my left side for a half hour! Needless to say, my husband and I ignored her and rushed to the ER. She never even showed up at the hospital… ever. When I arrived at L&D triage, I was 4 cm dilated and in active labor. My water didn’t break (gush), but they think that I may have been leaking fluid. They slowed the contractions with magnesium sulfate, etc and administered steroids for the baby’s lungs which are the last of the major organs to develop. 24 weeks is the point of viability. Babies that come earlier just don’t have much of a chance of making it. 24-weekers have about a 50% chance of survival and of those, about 50% develop some sort of learning or behavioral problems, chronic bronchitis or more severe physical handicaps like Cerebral Palsy, blindness, etc. I was able to remain pregnant (with contractions) for 4 additional days before Jacob Scott Carmichael was born on 04-23-2009. The NICU MDs were on stand-by in the delivery room ready to jump in right away. Jacob cried a little kitten cry and peed on the doctor – I was so relieved that he had made it! I knew we wanted to do all we could to help save him. The doctors described him as “robust” and were pleased to see him working so hard. Tim & I tried to stay in the hospital as long as we could to be close to him but we were discharged after a couple days. It was so horrible to go home without him. I slept at home and spent as much time as possible each day by his incubator. I talked to him and sang him songs and told him how much I loved him. I got to help change his diapers and give him little sponge baths. He had a great first week in the NICU considering his gestational age. On day 8, a scan showed that he had developed a grade 3 brain hemorrhage. The MDs counseled us and revisited the risks of long term disabilities and reminded us that during our NICU stay, things would constantly change and we would always need to be ready to make tough decisions and revise our plan of treatment. She also reminded us that sometimes these things resolve themselves, the blood can be reabsorbed and some 24-weekers go on to lead perfectly normal lives. We prayed to God that we would not have to make such difficult decisions, that He would show us a way, that Jacob would show us what we should do. I just wanted my baby to be OK – Really OK. We got the call around 3:15 early in the morning on day 10 (05-02-2009) and they told us to come in right away. It seems that with no warning or distress, Jacob’s heart rate dropped so far and so fast that the doctors were not able to bring him back despite all of their rescue attempts. I met them in the hallway outside the NICU and I knew from their faces that he was gone. They were all shocked. His heart had always been so strong and steady. They had been more concerned with his lungs (because I delivered him so early when they were still developing) and with the bleeding in his brain. The decision was taken away from us. I was still reeling from the surprise of his early arrival and then, just a few days ago, I had been so thankful for Jacob’s steady progress and so unbelievably happy to be his mommy and now I was plunged so deeply into the darkest grief I had ever known. We will never know why or how or what might have been – it’s just the way that things happened. Maybe he knew better and decided it was time to go. I never got to see his little eyes open. The only time I was ever able to hold my baby was in the first moments after he passed away. He looked so much tinier and even sweeter without the tubes and tape and monitors that had sustained him. He was beautiful and free.

Eight months later, we were ready to try again – A new year, a new beginning. I became pregnant in January 2010. We went back to the midwife to get a confirmation and a referral to the high risk group (Dr. Torres with Regional Obstetric Consultants). I made sure we were square with them on our bills and requested my medical records to be transferred to a highly recommended OB who would be my new primary (Dr. Patel with Beacon Health) and who would work along with the high risk MDs. We were seen every two weeks by the high risk docs (where we had ultrasounds at each appointment) and every two weeks by my primary, staggering the appointments so that I would be seeing someone each week. Since we didn’t know why Jacob came early, we weren’t able to develop a real plan on how to treat this pregnancy. My labs looked great, my cervix looked great (more than 4 cm), the fluid levels looked great, the baby looked great with a strong and healthy heart rate. We did all the screenings for chromosomal abnormalities and other congenital birth defects – nothing there. We even went through genetic counseling to see if we could uncover any risks associated with heredity – no issues there either. At that point and for all we knew, losing Jacob could have been a tragic fluke. The only thing we could do is observe closely. We would watch the fluid levels and cervical length and plan on progesterone shots beginning around week 16. I welcomed the morning sickness and the fatigue – I was just so happy to have another chance to have a baby and bring him home with me. I worried over every little twinge and bubble and flutter, wondering if everything was normal. At our 14 week ultrasound my cervix was still around 4 cm and closed. Two weeks later, at our 16 week ultrasound, the transabdominal scan looked great – the baby was doing just what he was supposed to do. When the sonographer did the transvaginal ultrasound to check on the cervical length we could see his little feet moving around. Tim & I thought it was so cute to see him dancing around – We were clearly not experts at interpreting these images. She had already explained to us that the baby was getting bigger and the uterus had moved up out of the pelvis so that we would not see the him transvaginally. What we were looking at was not my womb, it was my cervix – or what was left of it! There shouldn’t be feet down there! The nurse brought in Dr. Torres and his colleague and they estimated the remaining length of the cervix to be around .5 cm. I couldn’t believe that so much had changed so quickly. They called the hospital and booked an OR. I would need to go in first thing in the morning to receive an operation to give me a TransVaginal cerclage (TVC) which is a suture that is stitched around the highest point of the cervix and tightened like a purse string. Now we knew what the problem is. I have what’s called IC – Incompetent Cervix or Insufficient Cervix. During the 2nd or 3rd trimester, the weight of the amniotic sac with the baby, placenta and fluid becomes too heavy for the cervix. The cervix is the “doorway” between the uterus and the vagina, or the birth canal. “Normally,” when a woman is full term and goes into labor the cervix thins out, or becomes shorter (effaces). It happens from the uterus side of the cervix (the internal OS), from the inside out. When it has shortened (or effaced), then you dilate and the cervix opens and contractions push the baby from the uterus through the birth canal. This was not “normally.” So… this is what must have happened with Jacob. This is why I had lost him. My body had betrayed us. And we were watching it all start again. Dr. Torres explained that this would be a rescue cerclage and that there was a chance that he would not be able to place the stitch in such a small area. On May 18th, we checked into the hospital and I got a spinal block which paralyzed me from the diaphragm down (*claustrophobia!) They performed an amniocentesis to drain off as much fluid as possible to reduce bulging and give them more room to work with. Dr. Torres later told me that the ultrasound had overestimated the length of the cervix so I actually had less than the .5 cm they had counted on. He said he could see the membranes of the sac pro-lapsing through the cervix. They tilted the table upside down so my head was way down and the doctor had to stand on his tip toes and push the sac back up into the uterus and then make the stitch. I was so happy to know that he was able to complete the procedure and that the cerclage had been a success. My recovery was fine and I was released later that day. I was placed on bed rest until delivery. At my follow-up appointment a week later, everything looked very promising. I already had recovered about a centimeter of functional cervix and the fluid levels were returning to normal. They started me on weekly progesterone shots to help trick my body into thinking it was still in early pregnancy. We would now get ultrasounds at both MDs so I would be getting one scan a week. During the next few weeks, on bed rest, I had days where I was a paranoid wreck and other days where I was positive that everything would come out perfectly. Mostly I just tried to stay distracted, but it’s hard not to dream about gazing into his eyes and laughing at his funny faces, hard not to imagine the nursery and the little outfits. I was so ready for the sleepless nights, the poopy diapers and the chaos a newborn would bring. Each week, the prognosis was better. I was strong, the baby was strong, the stitch was not only holding up, but now I had 1.65 cm of functional cervix length – everything appeared to be perfect. 4 weeks after the cerclage, we had our last appointment with Dr. Patel on Friday, 6-11. On Tuesday evening, 6-15, a little after dinner, I felt my water break. There was no doubt. It broke. I jumped up and stripped off my pants and started screaming and crying and cussing and praying. How could this be happening?! Tim threw everything together and I got myself (mostly) cleaned up and we were out the door within minutes. We called the “on call” number for both MDs to let them know we were on our way to triage. I was not having any pain or contractions or bleeding. They got us checked in, hooked up my IV and did an assessment exam to see what was going on. Dr. Torres showed up about 20 minutes later looking very serious, maybe even sad. He put his hand on my shoulder and said “I’m so sorry.” I wanted to evaporate. What happened? The cerclage itself did not “fail” but it had been an emergency surgery to rescue the baby after my cervix had already shortened so drastically. The amniotic sac may have become infected or weakened during surgery causing it to break too early. We were only 21 weeks – the baby would not be able to survive outside of the womb. Tim asked the doctor about our options, if this was the end of the road for us. Dr. Torres explained that we had reached a stopping point on the road and that we could take one of two paths. First, we could try to keep me pregnant in the hospital and see how far we could get (maybe a few more days, maybe a few more weeks), but there were a lot of risks to consider. This time the membranes had ruptured. Although the baby could make more amniotic fluid, there was no sac to hold the fluid so there would be no accumulation. The baby’s lungs would not be developed enough without the fluid, they would not have time to mature properly and he would not be able to breath when he was born. Not with a ventilator, not at all. Also, with the loss of fluid the baby would not be able to exercise his muscles. He would not be able to flex or extend his little arms and legs, fingers and toes. All this is IF we could remain pregnant, which was unlikely due to the high risk of developing an infection that could kill both me and the baby or cause permanent damage to my body. The other option: induce labor and understand our little boy would not survive birth. What kind of choice is that? There had to be another way… but there wasn’t. What could we do? This time the decision was ours alone. I had mourned for Jacob everyday since I lost him and I had not forgotten a moment of his struggles… I knew that this baby would have even worse odds and would face challenges that were virtually impossible to overcome. Even if I were able to stay pregnant in the hospital for 8 more weeks, he would not be healthy and he would not survive. They pumped me full of antibiotics and moved us to a “mother/baby” room. Tim and I spent a long night considering our options, crying and comforting one another the best we could, deciding what we would do when he was born. When the MDs made their rounds in the morning, we told them that we had decided to induce labor. It was the hardest thing that I have ever had to say out loud. After a while, we were moved to a Labor and Delivery room. They did an ultrasound and confirmed that there was ZERO fluid (which kind of confirmed we had made the right decision). They also saw that he was in breech position. I was beginning to freak out. I was already an emotional wreck and now my nerves were starting to get the best of me. They reviewed the risks of such an early induction, including the possibility of a D&C (*shudder). They had to go back in and remove the cerclage before I could deliver. They gave me a Valium to help me “relax” and gave me morphine and phenergan via IV. After the cerlage came out (with no complications) they gave me cytotech to induce labor (around 8 pm). They dosed me up and left us alone. We turned down the lights and decided to try to sleep before the contractions came. The nurse had said that everyone was different, but that it usually took a couple rounds of 2 pills every 4 hours to get things moving. I guess I was lucky in a way when I began to feel the horrible pressure and cramping within about 30 minutes. I figured this was just the beginning and that they would gradually increase in frequency and intensity. I was wrong. I felt like I was having one giant contraction for several hours. I finally had Tim call the nurse. I told her I thought he was coming any minute. They thought I might need more time and asked if I could hold on. I tried, but I really felt like I needed to push. The doctor and a few nurses returned to the room and within a few minutes Isaac Justus Carmichael was born (at 11:07 pm). He was not breathing and had no heartbeat. He was sleeping peacefully. Tim cut the cord and they took him away. We had decided not to see him or hold him. I’m still OK with that decision and I hope I don’t come to regret it. I saw Jacob alive and I saw him right after he passed. His frail little body was the saddest thing ever. He was not the same baby from the incubator. He was gone. I’m glad that I was there for him but sometimes I wish I did not have that one memory of him. At least I have other memories of Jacob when he was alive and squeezing my pinky or pulling on his ear. I did not want to have my ONLY image of my Isaac to be the same frail, motionless body – but even smaller. I know that he is a pure soul and that he understands. I hope he doesn’t think I rejected him. I hope he knows I love him and grieve for him every bit as much as Jacob. I know that he was as beautiful as his big brother had been and I know his bright little soul was shining beside me when I told him goodbye. Tim did see Isaac because he couldn’t really help it. He described him to me and answered my questions about how he looked, but he is glad that I didn’t see. I have to trust him on that. The contractions went away immediately, but the placenta had not come. They had to give me another round of the cytotech to bring on the contractions that would deliver the placenta. It came at 12:30 – I was so relieved not to need a D&C. I’m glad it was over quickly and that Isaac had not suffered. I’m glad that he passed without pain before officially joining this hateful world… but I would have done ANYTHING to carry him longer and to deliver him here healthy. It just wasn’t fair… again. They kept me there to observe my recovery andreleased us in the morning. We were leaving the hospital empty-handed… again.

It is not any easier the second time around. That being said, I learned a lot when I lost Jacob – at least I had been through it and maybe I created some internal resource to call upon. I had already had to consider what happens to babies who pass away. Do they grow up in heaven? Is my Grandma taking care of them? Will I get to see them as babies when I get there? Why does it have to happen? Did I do something to deserve this? What did I think about the God who gave them to me and then took them back so soon? I’m still not sure about most of it, but who can ever be? I’m trying to move on and adjust to the “new normal” – something I came up with last year. I’m blank and blah. I’m sad and angry. I don’t know what I think or how I feel, but I want to make my little angels proud of me. I’m so happy to see other people’s babies – I was afraid it would hurt too much, but it gives me comfort I can’t explain. I’m not jealous or spiteful. I don’t confuse them with MY babies. I am just… something.

The doctors insisted that we not give up. That there is hope for the future. Really? Haven’t we been through enough? Our cerlage was a rescue cerclage and rupture of membranes was one of the risks. They could place a preventive cerclage earlier in the pregnancy, higher up on the cervix before shortening begins and without the sac becoming exposed. An even more effective method (+95% in cases just like myself) is a TransAbdominal cerclage (TAC). It is placed through an incision in the abdomen (like a C-section) so it is a little more risky. The suture is on the uterus side of the cervix, right where they meet. These are placed either before or after conception and they are permanent. Any babies after a TAC are born via C-section. When we lost Jacob, it was a mystery. We only learned what caused it to happen because we watched Isaac so closely. Unfortunately, the best thing we could do for Isaac was to react to what we discovered – and it was not enough and too late. Dr. Torres says Isaac taught us all a lot. That he gave us a blueprint for next time. Next time? I don’t know if I could do it. I don’t think I’m strong enough for another loss. It will take a while to even consider – and if we do, then I swear I’m not telling anyone until I’m 32 weeks pregnant. I don’t want to become defined by my losses. I want to move forward in my life and be a positive force. I have the best husband in the world and two great step-kids to help raise. I also have a couple little angels to keep me company and they will never leave my side. I’m OK with that.