Friday, April 23, 2010

Miscarriage, Act III: There Will be Blood

Tuesday evening, three weeks to the day after the disappointing ultrasound, the miscarriage began in earnest.  And when I say "earnest," try to picture that scene in The Shining with the elevator doors.  In retrospect, now that I'm home from the hospital, I know that what was happening was not just surprisingly heavy flow, but a hemorrhage.

I called my OB's office and got juggled by incompetents at their answering service for a while, finally got a call back from the on-call doctor, who wasn't a member of the practice.  He prescribed Methergine, a hormone, to slow the bleeding.  Andy went and got it, and I took the first dose at 9:30 PM.

It was a scary night, and one of the worst things was having to make the judgment call myself.  The standard is soaking through a pad an hour; more than that, and you're supposed to go the ER.  But that's an extra-tough call to make when going to the ER involves waking your sleeping toddler and hauling him off with you.  After the Methergine kicked in, the bleeding slowed, but I was still soaking more than a pad an hour, and I was passing some pretty horrifying clots.  Tissue (normal) or clots (if large, worrisome)?  How was I supposed to know?  The trend was positive -- I was definitely bleeding less.  So I stuck it out, and after the second dose of the hormone, around 2:00 AM, the bleeding slowed significantly, and I was able to sleep until 6:30.

In the morning, everything seemed fine.  Bleeding like a normal period.  I called the OB's office, and they said I should come in and get checked, which I did at 11:30.  Andy took the day off work.  I saw the midwife, she did a pelvic exam, and everything looked normal.  In her opinion, I'd just had an all-at-once miscarriage, and though she could still see some blood and clots, she expected that I wouldn't bleed heavily again, and probably not for long.  So, good!  Hurray for that.  Such relief.

We got home around 1:00, and the heavy bleeding started again.  I called the office, and by the time the midwife called me back, I was beginning to feel light-headed.  I should have mentioned it, but it didn't seem significant, especially since I'd hardly eaten all day, and I'm prone to feeling light-headed when underfed.  She told me to take the Methergine again, but if I was still soaking a pad an hour after four hours to go to the ER.  I took the Methergine at 2:30 and went upstairs to try to nap.  I slept some, but mostly I just lay in bed and bled and worried.  When I got up at around 5:00, I had to sit down at the bottom of the stairs because I felt like I was about to black out. 

So we went to the ER.

The admitting doctor was a putz.  He asked me how long my OB would "let me" continue bleeding.  I told him what the midwife had said about four hours post-Methergine, and he started arguing with me in way I didn't entirely understand.  I explained that I expected -- and I assumed my OB practice expected -- that going to the ER meant I would get a D&C at the hospital.  The doctor said no, the ER would refer me back to the OB.  That seemed crazy, but I wasn't about to argue with him, since I figured either another doctor would be less stupid or someone would call my OB.

They wheeled me into the inner section of the ER, and Ben became blessedly absorbed by Cars and Trucks and Things That Go.  Eventually another doctor came in, who began by asking me how I knew I was pregnant, which flummoxed me completely.  Uh, because I know how to pee on a stick?  So he got the whole history and concluded that I needed an ultrasound before they could determine any course of treatment, which seemed entirely sensible to me.  By the time they wheeled me out for the ultrasound, the bleeding had mostly stopped.  That was around 7:30.

Another doctor joined in the fun.  He said based on the ultrasound, which showed a small amount of tissue remaining, and the fact that the bleeding had stopped, we had two options: send me home with the caveat that if heavy bleeding started again, I was to come right back, and if not, go to the OB in the morning; or transfer me to Bellevue (the sister hospital a couple of miles away that handles all the OB/Gyn stuff for the hospital system) where they could keep a closer eye on me and possibly give me the D&C as soon as that night.  They wanted to take my vital signs again and consult with someone from my OB practice before making the call.  The vitals were what clinched it: they took them lying down, sitting up, and standing, and my heart rate was somewhere in the realm of crazy-cuckoo when I stood up, so no going home for me.  Which was fine.  The last thing in the world I wanted was to go home and start bleeding and have to haul the poor toddler out of bed and start this whole nonsense over again, but at some charming hour like 2:00 AM.

So Ben and Andy went home.  And let me take a moment here to sing the praises of my mellow and largely unflappable toddler, who sat quite happily in a chair looking at books and crashing toy cars together and watching Seinfeld and eating crackers and charming nurses until nearly three hours after his bedtime.  And Andy, for whom patience and calm do not come easily, who smoothly distracted Ben out of every possible turn into crabbiness and held my hand and didn't freak out even a little.  At around 9:30, they went home, and I waited for the ambulance.

The next few hours were kind of hard.  From the time we got to the ER, I felt enormously relieved that, whatever happened from that point, at least I wouldn't be the one making judgment calls, and if the crazy bleeding kept up or started up again, someone would know what to do.  But when Andy left, I felt alone, and sad to be alone.  I have lovely friends here who I'm sure would have jumped in the car if I'd called, but it didn't seem a dire enough emergency, my desire for further company and hand-holding, to get other mothers of babies and toddlers out of their beds at 10:30.  I'd have called my mom if she weren't three hours away.  I'd have called older friends with whom I have deeper credit, if they lived nearby.  Maybe.  It's hard to ask for help, even when you want it.

When the EMTs wheeled me into my room at Bellevue, I could hear a newborn crying.  The room was just down the hall from where I'd stayed when Ben was born.  I've never felt, throughout the loss of this pregnancy, that I was mourning a lost baby -- but ending this journey in that place was hard.  The doctor on call couldn't come talk to me because he was delivering babies.  I asked, when I woke up the following morning, how many babies they'd delivered that night.  The nurse said five, and I'm not even sure why I asked, because of course it made me cry.

No one knew whether I'd be getting a D&C that night, or in the morning, or not at all.  Which was fine, but it meant that I wasn't allowed to eat or drink, which sucked.  I was substantially dehydrated from all the blood loss, and I'd been getting IV fluids since arriving at the ER, but it didn't make me less thirsty.  They let me have a sip of water to take the Ambien which it was someone's excellent idea to give me around midnight, and handing that cup back demanded the kind of willpower I don't generally admit I'm capable of.  I wasn't hungry until morning, and then I had to start changing channels when food ads came on.

In the morning, I had another ultrasound and another blood draw.  The doctor (this time someone from my own OB practice) came in around 11:00, 12 hours since I'd been admitted and the first time I'd spoken to an actual MD, and said if I hadn't already lost so much blood, he'd be tempted to send me home to let the rest of the tissue pass normally, but he didn't want to run the risk that I'd start bleeding again, so he wanted to give me a D&C.  Which, duh.  I mean, I think I'd have burst into tears if he'd tried to send me home again.

They put me under for the surgery, bless them.  Not on-a-ventilator under, just knocked out and with a local.  So the surgery, so far as I'm concerned, was a total breeze.  I came to, dozed for a while in recovery, then got wheeled back to my room.  Most of my focus was on when could I eat something and might there be crackers and I have crackers in my bag if there aren't crackers here and can I eat crackers yet?  The nurse brought me saltines and ginger ale, and never have such things tasted so good.

Andy and Ben had come for a visit in the morning between breakfast (theirs, of course) and nap time, and I'd requested -- for my sake and Ben's, not so much Andy's -- that they not come back until I was about ready to be released, since I preferred to rest and watch something on TV other than Dora or Dinosaur Train.  After I gorged myself on crackers and further demonstrated my ability to function extra-hospitally by peeing, the nurse said it was just a matter of some paperwork (translation: maybe two hours) before I'd be free to go.  That was around 3:30.  I called Andy, and he and Ben came back.  I was home by 5:00.

The bleeding started Tuesday night.  I spent Tuesday night bleeding and freaking out, Wednesday night in two hospitals, and Thursday night sleeping soundly in my own bed.  Today is Friday.

In terms of the surgery itself, I feel absolutely fine.  I had some very mild cramping last night, wholly solved with ibuprofen.  No pain whatsoever today.  But I'm still feeling weak from the blood loss.  The doctor told me to take iron supplements, and I should have thought to buy some on the way home, but I didn't, and I don't think I should drive, so Andy's going to stop by the pharmacy on his way home from work.  Not feeling 100% up to kid-wrangling this morning with Andy back at work, I called in the cavalry, and two marvelous friends turned up to take Ben to the playground and wear him out. 

No sex for four weeks.  No attempting to conceive until after my next period, which will probably be in four to seven weeks.  If I'd had the D&C three weeks ago, of course, I'd be three weeks ahead of this schedule.  I think it's the timing I find most frustrating.  We would have started trying to get pregnant this past fall, but I needed several dental procedures that were best done before conceiving, and what with scheduling and waiting for pre-approval from insurance, that ran us into January.  I got pregnant in February, the first cycle trying, but it turned into a bit of a catastrophe, and now we can't even start trying again until the end of May at the latest, and probably more like the middle of June.  I'm 37.  The clock is ticking.

In the short term, right now, I'm feeling kind of traumatized.  My bathrooms freak me out.  Having always enjoyed rude good health, having my only experience of pregnancy before this an entirely by-the-book gestation and delivery, I'm finding myself pretty shaken, especially given my age, by the idea of the next pregnancy and all the things that can go wrong.  A miscarriage, even one that goes as badly as this one, is really the least of my worries.  It's like, once the possibility of this bad outcome was made manifest, the floodgates opened, and now all the bad outcomes seem far more plausible, far more threatening, far more real.

Wednesday, April 14, 2010

Fifteen Days

Two weeks ago yesterday was the ultrasound.  That was a bad day, but the days since have been fine.

Like I said in my first post about the miscarriage, the fact that this pregnancy never made an embryo was significant to me, and has really meant that I haven't mourned the loss the way I would have had a proto-person ever developed.  And I certainly don't mean to minimize the grief experienced by other women in the same situation.  I feel pretty strongly that you don't get to choose how you feel about something, and there's a big range of valid reactions to any experience, and it's just the luck of the draw that I don't happen to have been made very sad by this one.

It has been a bit of a roller-coaster, though.  When I still wasn't bleeding after a week, the NP became concerned that my hCG levels weren't dropping the way she'd expect, so I had to go for more bloodwork and schedule another ultrasound.  It was possible that I was still pregnant, but my dates were way off, or I might have had an ectopic pregnancy.  The former possibility seemed so remote to me that I honestly didn't really even consider it.  My cycles have never been irregular.  I tested positive the day before my period was due, and then again about a week later, and the likelihood of two false positives is so close to zero that it might as well be zero.  The latter possibility, though, was pretty terrifying.  I drew some comfort from the fact that it seemed implausible that I'd have gotten to nine weeks with an ectopic pregnancy without feeling any pain.  In any case, when the results of the second blood draw showed that my hormone levels had dropped significantly, I was relieved -- way, way, way more relieved than disappointed.  I canceled the ultrasound and turned down another shot at a D&C.

Another week passed, still no bleeding.  I had the next weekly blood draw yesterday morning and checked in with the NP in the afternoon.  My hCG levels are now below half of what they were at the first test.  She wasn't concerned yet about the possibility of necrotic tissue causing an infection and was totally on board with my continuing to wait for things to work out on their own.  Which is still and will remain, until it seems like any kind of threat to my health, my preference.

And it kind of blows to be two weeks out and still with no end in sight, unable to move on, wearing pads when I leave the house because who knows when the bleeding will start.

Too graphic, too intimate?  I'm erring on the side of over-sharing because it seems to me that we're all a little too delicate about stuff like this, and the result is that every woman who has a miscarriage has to learn it all herself, rather than benefitting from other people's experiences well before the event.  It's too common an experience to be so shrouded in mystery.

Friday, April 9, 2010

Shillin' Like a Villain

Heaven help me, I signed up to be an Amazon Associate.  With my shall-we-say-modest readership, I don't expect to start sleeping on piles of cash anytime soon, but what the heck?  I pepper my posts with Amazon links anyway, so I might as well have a shot at getting paid for it.

So.  Here are some of Ben's and Andy's and my favorite picture books:

Anansi the Spider: A Tale from the Ashanti
adapted and illustrated by Gerald McDermott
Caldecott Honor, 1973

The illustrations in this book will cause you physical discomfort if you have astigmatism.  Seriously.  But that shouldn't stop you, bcause it is a goofy, goofy tale told in a voice that's inordinate fun to read aloud.  Ben liked it immediately, and it's remained among his top most-requested.  It took Andy and me a longer time to warm up to it, but it's earned a firm place in the household canon. 

All the World
by Liz Garton Scanlon, illustrated by Marla Frazee
Caldecott Honor, 2010

I'd be lying if I said the latte-liberal fantasy element of this book didn't make me a little queasy, though I'm about as latte liberal as it gets.  The farmers' market!  The happy plump lesbians on their tandem bike!  The baby in an Ergo!  All the World indeed -- if all the world were only such a quiet and carbon-neutral resort town!  Also, there's something facile about the lists of things with no active verbs -- they make for nice rhymes, but they don't go anywhere or do anything.  Still.  I can't actually read more than three pages without choking up, and the illustrations are so beautiful and intricate, the little town with its geography and genealogy fully imagined, each page referring to all the others.  My head thinks this book is very, very silly, but my heart loves it very, very much.  Ben likes all the dogs and trucks.

Ox-Cart Man
by Donald Hall, illustrated by Barbara Cooney
Caldecott Winner, 1980

If I had to pick a single favorite book, I think it might be this one.  The illustrations are reminiscent of Grandma-Moses-y folk art, and they suit the story perfectly.  The story follows one of my favorite themes for children's books: the work and produce of the seasons.  It also speaks to my Yankee roots with its New Hampshire setting (rolling hills, little hamlets with tidy white churches) and message of hard work and thrift.  Andy likes the woodworking, and I like the fiber craft.  In fact, I don't think there's anything about this book I don't like.  Ben likes pointing out the cheese in the shop and the lights in the window of the farm when the Ox-Cart Man returns home.

Let's Make Rabbits
by Leo Lionni

I love a little postmodern meta: so sue me.  This is a sweet little tale about rabbits.  It's also a bit of a meditation on the construction of reality.  The hardcover version we have (a gift from C. -- thanks, C.!), which I hope is the same one I've linked you to, is a tactile pleasure in itself, a small volume perfect for little hands and a novelty for adult ones.  It's also very pretty.  I'm not sure what Ben likes about this one, but he demands it regularly.

At the Top of My Voice
by Felice Holman, illustrated by Edward Gorey

This one's out of print, I'm afraid, but it's not hard to get a decent used copy from, oh, let's say Amazon.  I grew up with this book, and it's in my blood the way lines of liturgy run in the veins of someone raised to church.  On tiptoe I'm taller, and taller I'm older.  And I'm not Nan, I'm a dancer.  And City asleep, city asleep, a carnival on the garbage heap.  The poems are great, and the illustrations are great, and little kids should grow up with good poetry so they learn to love it before they can learn to fear it.  Ben likes the squirrel, the birds, and the lion.

Wednesday, April 7, 2010

Beating It*

I should probably leave well enough alone, but I went to bed last night still thinking about the anti-circ petition and what I'd said about it, unable to let it go, and convinced I'd become bogged down in nitpicking the text instead of making the bigger points that were really under my skin. (Ew, how did I end up with lice metaphors?)

So, allow me to beat this dead horse.

I don't think opposition to routine circumcision is wrong -- generally I find it reasonable and justified, and though I chose to circumcise my son, I consider myself an opponent of routine circumcision. But this petition obliterates any respect I might ever have had for the sense of anyone involved with it because it A) seeks to shut down debate rather than encourage it, and B) shows no respect whatsoever for science or expertise.

If you have taken a position based on a reasonable interpretation of factual evidence, you should never be afraid to hear new evidence that tests your position. If you're correct, new evidence will bear you out. If you're incorrect, why would you want to maintain your position? Similarly, you shouldn't be afraid to argue the point, especially with an expert in the field. Opposition to routine circumcision isn't an irrational position and has considerable foundation in medical science, so of all the responses available to a potential challenge, why on earth choose the one that boils down to SHUT UP SHUT UP SHUT UP LALALALALA WE CAN'T HEAR YOU?

I can't fathom what motive the authors and supporters of the petition ascribe to the CDC for doing something so unethical and counter to its mission as ignoring -- not insufficiently weighing, but ignoring -- the risks of a procedure it is considering recommending. The CDC is not some crazy bunch of penis-mutilating yahoos. It is a body of public health experts. Being human, of course, they are fallible and certainly have biases of their own. It is foolish to take their word as gospel, but it is equally foolish not to accord them the respect their expertise deserves. If we could all conduct research and draw appropriate conclusions, we wouldn't need scientists, but the fact is that we're all a little busy doing other things, and many of us plumb ain't smart enough, and few of us have the talent or training, honed over a lifetime, to conduct or interpret the kind of medical research that the CDC is reviewing before making its recommendations. Skepticism is fine -- it's admirable even -- but when it crosses the line into anti-intellectualism, into opposition to science itself, it deserves a smackdown.

Though I chose to circumcise my son, I do not support routine circumcision. But if the CDC is considering recommending it, I'm certainly interested to hear why. What research, what interpretation of the research, could support such a radical position? I look forward to the opportunity to re-evaluate my own position in light of new evidence or new argument. I look forward to hearing the opposition's response -- if it's rational, if it's based, as the CDC's certainly will be, on evidence and informed interpretation.

I definitely look forward to any chance to improve public health. If it turns out that the research demonstrates that routine circumcision actually does provide a significant protection against deadly STDs, against cancer, wouldn't that be good news?

*I'm so sorry. I'm 12, and I can't write two whole blog posts about penises without a single bad pun.

Tuesday, April 6, 2010


Mothering magazine and Intact America (a non-profit advocacy group opposing circumcision) are calling for signatures on a petition to stop the Centers for Disease Control (CDC) recommending routine infant male circumcision.

Circumcision is not a big issue for me, though of course I'm aware that it's one of those parenting third rails, like breastfeeding and vaccination. I did a lot of reading about it before Ben was born, and the most I could muster was a mild bias against, based on a general principle of avoiding all non-crucial surgery. At the time, there was some not-extraordinarily-significant research supporting circumcision as plausibly prophylactic against certain STDs, and the combination of that, Andy's more-than-mild-but-not-very-strong bias for, and the extreme discomfort and embarrassment of a family friend who had to be circumcised for medical reasons in his 70s added up to a Yes. There's also in there somewhere, in a way I can't possibly justify, a weird little family-cultural / atheist-but-CYA adherence to the covenant. Or comfort in the tradition. Or notion of tribal belonging. Or something.

Anyway, like I said, it's not something I can work up a lot of strong feelings for or against, and it's one of those things, like whether you use a baby carrier or stroller, that I have a hard time understanding why some people are excited enough about to advocate publicly rather than simply decide for themselves. But I do feel strongly about this petition, strongly enough to have broken my own very sensible rule about not picking fights on Facebook.

Here's some of what Mothering says:
Based on flawed studies that ignore the risks and ethical concerns of infant circumcision, the CDC may recommend this unnecessary surgery for our baby boys. We know that safe sexual practices and abstinence – not circumcision – prevent sexually transmitted diseases. And we know that there is NO link between infant circumcision and better health.

We will be delivering our petitions to CDC headquarters in April with the hopes of convincing them to make the right decision.

Mothering doesn't specify which studies it considers flawed and what those flaws might be. Unlike the CDC, it doesn't cite references. The CDC's fact sheet on male circumcision contains a useful paragraph, helpfully titled "Risks Associated with Male Circumcision," which includes no fewer than eight cites to studies that explicitly did not ignore the risks of the procedure. Mothering doesn't state its ethical objections, but I'm guessing they have something to do with the fact that an infant can't consent. And that's not something to dismiss out of hand, but we make decisions for our children every day, and that kind of ethical hairsplitting simply can't weigh heavily against substantive evidence (should there prove to be any) that performing the procedure would be a significant benefit to public health.

Mothering knows some stuff. Again, they don't cite references for how they know circumcision doesn't prevent transmission of STDs or how they know "there is NO link between infant circumcision and better health." And this kind of arrogant ignorance professing knowledge just honks me off. Take the claim that there's NO link between infant circumcision and "better" (as if that's even a meaningful or specific term) health: the American Medical Association says in this report, "there is little doubt that the uncircumcised infant is at higher risk for urinary tract infection." Smaller risk of UTIs = "better health"! But that's hardly the point, is it? The question isn't whether circumcision has any health benefits whatsoever (the most cursory review of current research makes it clear that it does); the question is whether the benefits are significant, whether they outweigh the risks and justify the costs. The ability to make that kind of essential distinction is only one of the reasons we trust the CDC before Mothering magazine to advise us about public health issues.

Mothering claims to want to convince the CDC to make the right decision. But to convince someone of something, you need to present an argument -- ideally with some evidence to back it up. A petition is not an argument. It's political pressure. It's a more or less polite way of ganging up. And I think we should all think very carefully about whether applying political pressure to the CDC is something we'd want to put our names to, or something we seriously think a group like the CDC should allow itself to be persuaded by.

It would be one thing if the petition advocated further specific study, if it made specific criticisms of the evidence, if it provided, in other words, an evidence-based argument to which it could then legitimately claim the CDC wasn't giving enough credence. But that's not what the petition advocates. Here's the text of the introduction:

No medical society in the world recommends male circumcision – yet newborn male circumcision is the most common surgical procedure in the U.S. This painful and risky procedure deprives more than a million boys each year of healthy, functional tissue – without their consent – while increasing medical costs by an average of $678 per baby.

The Centers for Disease Control (CDC) is developing public health recommendations for the U.S. on male circumcision that could ignore the serious risks of this non-therapeutic surgery. As the foremost expert on public health in our country, the CDC has a responsibility to share the truth about infant circumcision.

We need just a few more signatures to help us reach our 25,000 goal before the end of March. Sign our petition to the CDC below and demand a truthful statement on the risks and harms of newborn male circumcision.

So, if the CDC's recommendations don't ignore the risks of the procedure and do present a truthful assessment of said risks, but conclude that the benefits outweigh the risks, Intact America will support the recommendations?

Here's the text of the petition itself:
As the foremost expert on public health in our country, the Centers for Disease Control (CDC) has a responsibility to share the truth about public health issues that can affect millions of Americans.

Newborn male circumcision is the most common surgical procedure in the U.S. - yet this painful and unnecessary surgery carries serious risks, including hemorrhage, infection, surgical mishap, and death.
The role of circumcision in preventing sexually transmitted diseases (STDs) and other health claims has been investigated by public health researchers and remains highly debatable. Only safe sexual practices, such as the use of condoms and abstinence, can prevent STDs, including HIV/AIDS. Circumcision cannot be responsibly recommended as a way of preventing disease.
If the CDC chooses to promote newborn male circumcision, it is supporting a procedure called "non-therapeutic" by the American Medical Association - in favor of inconclusive and highly debatable research.

I ask that the CDC not recommend circumcision as a means of preventing HIV/AIDS and formally recognize the risks and harms of the procedure and the right of every child to bodily integrity.
Though Intact America makes no wild claims about what they know about circumcision, they throw the word "debatable" around as if it means "worthless." But they fail to mention what standard of proof they would find conclusive, and indeed fail to cite a single reference, most notably for their claims of the associated risks. They demand that the CDC admit the truth, implying of course that the CDC has failed to do so or is likely to fail to do so, but there is no evidence presented that suggests any kind of obfuscation or dishonesty.

What I can't understand is, if they accept that the CDC is the foremost expert on public health in the US, that the CDC has a duty to present the truth to the American people, and that there is debatable evidence about whether routine circumcision is beneficial to the public health, why on earth they can't just get the hell out of the way and let the CDC examine the evidence and make its conclusions?

The evidence is debatable, so for pity's sake, let's debate it! Let's hear it, all of it, including what the CDC -- the acknowledged experts -- think we should do. Let's open our minds to the possibility that while there might not have been significant evidence to support recommending routine circumcision five years ago, or last year, perhaps there is now. And if there isn't this year, perhaps there will be five years from now. Let's keep asking the questions whose answers might save or improve lives, and let's listen to the people who can speak about those questions with informed intelligence before we start arguing with them. Let's not dig so deep into the trenches we make of our personal decisions that we can't occasionally climb out and take a look at what a new day's sun might have revealed.