It required a year to get this post written for a variety of reasons. I felt strongly about getting this story out there, as difficult as it was to tell.  

Cattle, Chickens, Hogs

During the 2012 election season, a Georgia politician spoke in favor of a bill, that would outlaw pregnancy termination after 20 weeks gestation, even if the woman is known to be carrying a stillborn fetus or the baby is otherwise not expected to live to term. Representative Terry England then recalled his time working on the farm:

"Life gives us many experiences...I've had the experience of delivering calves, dead and alive. Delivering pigs, dead or alive. It breaks our hearts to see those animals not make it."

The comparison of myself and my daughter and all other women to livestock gave me pause, but it was not the cause of my true horror. No, this scenario is one I have lived.

Our First Choice

With the development of the oral contraceptive pill and other highly effective methods of birth control in the 1960's, childbearing truly became a choice rather than a random event. This freedom from pregnancy helped power the feminist movement of the era, advancing the achievement of women in many career fields. In medicine, women comprised about 10% of graduates from US medical colleges in 1970. By the time I graduated in 1985, women made up approximately 25% of graduates.

Getting that MD degree no longer gets you a job.  License requirements vary from state-to-state, but most of the US requires a minimum of 1 year of post-graduate training to be a general practitioner physician. To really practice, one must become eligible for a specialty board exam. This status requires at least 3 years of residency, even to provide general primary care in family medicine, pediatrics, or internal medicine. Some specialties, such as neurosurgery, require as much as 12 years of post-graduate training.

Let's do some math. College and medical school will take 6 to 8 years at a minimum to complete, plus at least 3 years of post-graduate training. A typical fledgling physician will start a "real job" at the age of 29. Female fertility declines after the age of 27, and more substantially after 35. The most fertile period of a woman's life occurs when childbirth is least convenient in the context of physician training.

My spouse and I married in 1983. At first, I had no interest in parenting, but I kept my options open. By the fall of 1986, I wanted a baby. Our peers were becoming parents, and nothing would satisfy this desire except a burping, crying, pooping bundle of joy. My husband also suffered from "nesting fever." We decided the most convenient time to give birth would be right at the end of residency training, in the spring or early summer of 1988. All our friends had taken at least 6 months to get pregnant after stopping oral contraceptives. I took my last pill in November of 1986, and we hoped for a March or April baby in 1988.

Conception after Oral Contraceptive Pills

Birth control pills work by inhibiting ovulation. The neuroendocrine systems regulating this process may take several months to normalize after discontinuing the pill. A recent literature review shows that this delay in conception is variable, but typically only 6 months at most. The 12 month conception rate following pill discontinuation (72-94%) is similar to that seen following cessation of other reversible methods: intrauterine device (71-92%); condom (91%); and natural family planning (92%).

Our First Pregnancy

The 1980s were not encumbered by pesky work hour limits for residents. A typical schedule involved staying overnight every fourth night. We generally had to stay at work until call started the next evening. If a two-resident couple got their call schedules out-of-sync, it was hell on their sex life. Most of the women in my residency class had also married doctors of the same age, and we were averaging sex once each month. In December 1986, that night was our third wedding anniversary. We had a romantic date night.

A couple of weeks later, I felt incredibly tired. We could not just pick up a kit at the drug store; over-the-counter pregnancy tests were still a couple of years away. After a few days of denial, we got a blue plus sign in our hospital clinic. I dug out the dating wheel from my obstetrics rotation. The "conception" arrow fell on our anniversary, and the due date mark landed in September of 1987.

So much for those plans we made.

After visiting the doctor, we called both sets of parents to let them know. I was about 7 weeks along when I had my fellowship interviews. I managed to get through them without mentioning my health status, although the last person I saw at one center probably still wonders why I had so much trouble staying awake at 4 in the afternoon. I made up some of my calls for my leave before delivery by taking the overnight shift every other night. That was actually a lot easier than some of my nights as a parent.

All couples come up with something to call their impending kid. As a fan of alliteration, we christened Festus the Fetus. My husband conversed with the baby via my belly button (I do not understand that route of communication either), frequently reading box scores for the St. Louis Cardinals.

Once a woman becomes obviously pregnant, she essentially transforms into public property. No one would ask strangers missing an eye or a limb questions about their condition or medical history during a brief elevator encounter, but they will cheerfully question a pregnant woman about her gravid state. I have never heard that touching the baby bump brings luck analogous to rubbing Buddha’s belly, but this must be a pervasive idea given the number of people who felt mine.

A generally uneventful 41 week pregnancy ended with the birth of our daughter. After 6 weeks at home with her, I went back to residency so I could finish on time. Her father had a research fellowship year. Every fourth night he spent alone with the baby. I highly recommend this strategy to all families; it really gets dad involved.

The Next Choice

Nine months passes much faster with an infant than while pregnant. Soon it was time to load our child and our stuff and head to a colder climate for fellowship training. The first year was rough, with the first 6 months on non-stop call. Some days I would not see my daughter awake; other days we would have to hand her off in the parking lot so we could both get our work done.

Time marched on, and our child grew. While our days revolved around science and statistics, our nights featured books with pictures, number games, and an endless stream of Disney characters. Every day she became less of a baby and more of a person.

We wanted a second child. The most sensible advice I received on spacing pregnancies came from my mother who recommended a minimum 4-year gap. Not only would that mean only one child in diapers at a time, but also only paying one college tuition bill at a time. Having the next child toward the end of fellowship would also let me start my new job after a long, generous time off. Six weeks was not enough!

With these plans in mind, we started trying to conceive in the summer of 1990. Despite much more opportunity, nothing took the first month. With the next cycle, things went long: 28, 29, 30 days. We then did a home test and saw the blue plus. I scheduled an appointment with my doctor.

During my initial exam, she asked when the spotting had started. What spotting? I had not experienced any spotting. The next day, I had a transvaginal ultrasound. The procedure was annoying but not painful. Unfortunately, it did not show any evidence of a pregnancy. Over the next 48 hours intermittent spotting became heavier bleeding. Eventually a beige sac about the size of a marshmallow passed.

We had not shared any information about the pregnancy with our daughter, so no difficult discussion was required. I went to work after my ultrasound. I had some cramps, but nothing worse than a usual cycle. I felt sad that I was not pregnant, but not much more than the month before when I had failed to conceive.

Miscarriage

Doctors define miscarriage, also called spontaneous abortion, as pregnancy loss prior to 20 weeks after conception. Clinically recognized pregnancies, when the woman knows of her condition, carry a 10-25% risk of miscarriage, especially in the early weeks. The exact risk of miscarriage is unknown, since many women may miscarry before they suspect that they are pregnant. Some estimate that up to 75% of conceptions may end with early embryonic loss. Risk factors for miscarriage include advanced maternal age, smoking, drug use, and other maternal health issues.

If at First You Don’t Succeed…

Two months after the miscarriage, we got the blue plus sign again. Things proceeded as expected, with no complications. I felt uneasy throughout the pregnancy for some reason, probably because of the prior miscarriage. I also got exposed to cytomegalovirus, a congenital infection that can lead to brain damage in the fetus.

Once I felt the baby moving, it became clear that Festus II wanted to rock and roll. Vigorous movement would wake me up at times. I did not bother with formal kick-counts because this kid thrashed all the time.

Around 32 weeks of gestation, I started having some regular contractions. This led to a visit for some monitoring one evening. The contractions came every five minutes, but they never got intense. After a few hours of rest, they stopped. I relaxed again.

On an unseasonably warm day in May I had reached 36 weeks. My obstetrician agreed that everything looked good. If those contractions began again, we were far enough along to let the baby come. I mentally sighed with relief. As a pediatrician, I knew we were at a good stage, beyond the gestational age for many complications of prematurity.

The next morning our daughter awoke with a sore throat. Strep had been going around her daycare, so we got the antibiotics started. I lounged around at home with her. After a few hours I noticed that Festus II, previously a whirling dervish, was very, very quiet. I had felt no movement since arising that morning. I ate some lunch and took a warm bath, both activities that usually made it feel like the fetus was about to ram its way out through my abdominal wall.

Nothing. All still as the grave in my pelvis.

I called my doctor who sent me to the hospital. After I dropped my daughter off with her sitter, I went to the labor deck. They attached a fetal heart monitor and found nothing. My husband arrived about the same time as the ultrasound technician. We held hands and wept as images of a 36-week fetus with no cardiac activity filled the moitor.

Festus II was dead.

By now it was early evening. My doctor recommended inducing delivery in the morning when there would be a fully staffed labor area. We went home to rest.

Of course, the idea that I would get sleep that night was just crazy. I do not remember much except sitting in my rocker sobbing. I would never hold this child in my arms in this chair, trying to sooth it to sleep.

The next morning we appeared at the hospital at 7. My parents drove all night to be there with me. After prostaglandins and oxytocin and time, my second daughter was born.

At that moment I truly understood the term "stillborn." When my first daughter came into the world, there were cheers and congratulations and lusty crying from the baby. This time the doctor softly told us the gender while the rest of us shed tears. The room was so quiet, so still.

Festus II looked perfect except for the knot in her umbilical cord.

Cord Knot Science

A true umbilical cord knot is just what it sounds like. As the fetus kicks about in the amniotic fluid, the cord becomes knotted. The cord provides a vital connection between the mother and fetus, with two arteries to bring oxygen and nutrients into the offspring. A single vein carries blood back to the placenta. Wharton jelly, a soft gel of connective tissue, surrounds and cushions the vessels. This biological bubble-wrap likely prevents true cord knots from being universally deadly.

One single center study of 69,139 anatomically-normal singleton pregnancies showed an incidence of 1.2% of true cord knots. On multivariate analysis, knots associated with grand multiparity (more than 5 prior pregnancies carried to term), gestational diabetes, maternal hypertension, excess amniotic fluid, genetic amniocentesis during the pregnancy, and male gender of the fetus.  A true umbilical knot doubled the risk of fetal distress from 3.6% to 7%, while quadrupling the risk of intrauterine fetal death from 0.5% to 1.9%.

We had no risk factors for umbilical cord knot. We were just incredibly unlucky.

The Worst Day of My Life

We named our daughter Erin Festus Lane, although we left the middle name as merely an initial during the funeral. We took photos and let our daughter hold her sister. We signed the forms for autopsy and cornea donation.

My husband and parents went to get our vehicles. I got dressed, kissed her one last time, and then did the hardest thing I have ever done; I left her behind in the crib to confront the rest of my life.

We needed to do something to acknowledge the birth and death of this child, even though she had no birth or death certificate. A wonderful chaplain intern at the hospital held a "service" for our family and a few friends. He told a story about a family of rabbits who dealt with the loss of a child, something to help our daughter through the next few weeks at home with me.

You would be surprised at some of the things people say after you lose a child. Many tell you how brave you are; they would not be able to live after such an event. You manage not to slap them silly. You do live on, especially if you have a living child. You have to deal with your circumstances and face the future. You have very little choice in the matter.

Livestock revisited

When I hear Terry England saying that women should carry dead fetuses to term, I shudder. I know how public our pregnancies become in those last weeks. I could not have functioned when people asked me about my due date or rubbed my bulging belly full of deadness. A gravid cow or pig may have a stillborn offspring, but do they know it? Are they aware that the life growing within them is gone? Do other animals treat them as public property the way humans do, asking if they know the gender of their fetus?

Women are not livestock. We should not be thought of nor treated in the same manner as cattle and pigs.

Moving On

Fellowship completed, we moved on to our first real jobs. I took July and August off as planned; new baby time became unpacking time. My daughter and I found the grocery store, the hardware store, and all of the other necessities in our new neighborhood. Soon I started my job, seeing patients and gearing up my own lab. My daughter picked out a kitten for her birthday.

In February I began to feel sick. I managed to sneak the pregnancy test into the house and test my urine the next morning. Once again, the blue plus appeared on the stick. I went to my office and made a very special valentine for my husband, advising him that October could be a busy month.

About a month later I had an episode of spotting. My obstetrician put me on rest, so I spent a weekend relaxing with March Madness on the television and my feet up on the ottoman. After that, the pregnancy proceeded as it should. One morning the Little Flipper (as we named this fetus) did not wake up and start kicking while I showered. As I lay down to do a kick-count, a wave of panic spread over me. It took 20 minutes for the kid to move.

I had to answer a call during that period of fear; I should apologize to that family for my abrupt manner that day.

On our due date we induced labor to preserve my sanity. After several hours my son entered the world, screaming and kicking and anything but still.

Epilogue

Twenty-two years have passed since Erin died. Her loss still makes me sad, but time does dull the pain. I did cry when I read about Terry England's statements, remembering that day, the hardest of my life. I cannot imagine stretching that pain out over days or weeks, waiting for my uterus to expel its lifeless contents spontaneously.

No woman should be forced to carry a fetus that cannot survive outside the womb. Some women may make that choice; women and their doctors should determine the best strategy for such a bad situation. After all, women are people, not livestock. We are quite capable of making a rational decision.