miscarriage

A typical first antenatal visit. A high school English teacher. I like her. We talk about the books her classes are studying while I fill in the repetitive forms. A medical student is sitting in the consulting room with us. Her husband is on a job, driving his truck, and her first child is with a babysitter. The questions finished, tests ordered, we go into the examination room to check the progress of the pregnancy, at eleven weeks gestation according to an ultrasound scan three weeks earlier.She lies on the examination couch. I squeeze gel onto her lower abdomen and place the probe on her skin. It takes a few seconds to orientate the scan picture but an embryo is quickly seen.

The embryo is the right shape but seems faded. Perhaps the settings are turned down. A quick check shows normal settings and the embryo seems under developed for eleven weeks. Perhaps the dates are wrong, but they shouldn't be if she had an ultrasound only three weeks ago. I pass the scanner back and forth over the image of the embryo as these thoughts rapidly coalesce. I hope its not a miscarriage. No heartbeat can be seen. Maybe I'm wrong. The colour Doppler probe cannot demonstrate any blood flow either. I haven't said anything yet. She must be starting to wonder if there is a problem. I keep scanning in the increasingly unlikely hope that a heartbeat will be found. I have to tell her. 


I summon my courage for the coming ordeal and say without inflection, " I can't find a heartbeat." Instantly, her face turns pale as she asks me what I mean. I have to say that the hoped-for baby is dead. I have to find words to say something that will ruin her day, her year, her happiness, her confidence; to say something so devastating that she will probably remember it in full emotional detail for the rest of her life. I have to find a way to be kind while offering no hope at all, because she needs to be sure.

"I'm sorry. You've had a miscarriage...probably two or three weeks ago."

Now her cheeks flush as though  with shame or embarrassment and, without crying, tears roll freely down her cheeks. " How can that happen ? How can it...but it was fine at the ultrasound...I still feel pregnant..." And then a distant stare, numb despair. I talk.

I tell her it isn't her fault. No cause is usually found. She will have to tell people what has happened. They will try to console her. If you haven't had a miscarriage it seems kind to point out the good things - young and healthy, can try again, already have lovely child. To a woman who has just lost a pregnancy(I know I have said this before) this sounds like " Don't stress. You may have been careless, but you've still got one left and you can always try again so you should stop worrying about it." People will imply that she will 'get over' it, or even 'find closure'. I warn her that this will happen and that people (well, women really - what man would talk to her about the loss of a pregnancy ?) really mean well and just cannot understand unless it has happened to them.
 I tell her she is not supposed to get over it. She will never forget the brief  deeply affecting life of her lost child. Whenever she thinks of it she will be upset all over again and that is how it should be.No one can make her pretend she no longer cares - because when people ( women ) console her it sounds as though she is expected to give up the precious memory, when that is all she has left of her pregnancy. It is a relief to know she can keep at least this much.

She says it is too awful. I agree.

I tell her that she will probably think of little else for some time. Then small gaps will appear in the relentless sadness before she remembers and then feels guilty for forgetting for a short time. Longer gaps will appear. She will laugh without remembering to feel guilty.One day she might feel the urge to make plans. She can't give up her life forever but there is no strict time limit for grief.

She shouldn't be surprised if her partner/husband reacts differently. Men don't usually want to talk over emotionally painful events but it doesn't mean they don't care. It isn't a criticism or a judgement of her, although she could ask him to simply listen even if he doesn't want to talk. Painful but shared experiences should bring a couple closer together. The irrational guilt that we all feel when something bad happens should be understood and not allowed to cause disharmony.

She asks when she can try for another pregnancy. It is tempting to try to get pregnant at once, to try to fool the emotions into believing that nothing was lost. However, there is a higher likelihood of a significant postnatal depression if that path is taken. In fact, overall, the incidence of depression is just as high after a miscarriage as after a stillbirth. This seems surprising if you think that an embryo is too small to have had as much emotional impact as a later pregnancy, but it has already had a large effect. To the mother it isn't an embryo but a baby. She knows when it will be born, what year it will start school, which of her friends will have a child which will be born at the same time of year and grow up at the same time. Names have been dreamed of for years. New rooms may be needed, even a new car. No other child can ever be born at that time. It cannot be replaced. It is unique. Its life must be mourned properly. I am prepared to answer her question.

She can try to conceive another baby when she feels she can cope with another miscarriage.

Plans are made. A possible curette discussed. But she has not even had time to tell her husband. She will talk with him, her friends and family then call me with a decision. She leaves to pick up her other child from the creche before going home to go through it all again.

The medical student has been quiet but supportive. She says that this was the last clinic of her term and she didn't expect anything like this. She had a tutorial on miscarriage the previous week and no one had described how upsetting it was. Tears glisten in her eyes.

I am an only child. My mother had ten miscarriages after me, as late as twenty four weeks. She is eighty five years old and I know she hasn't forgotten any of them.When I am alone I sit for a while and think of her.