Author Archives: jill.n.donald@gmail.com

Stories of Strength: Marcy’s Story

Marcy is well-known to everyone in the Abbyloopers community. Here is the story of her beautifully imperfect TAC journey leading to her perfect TAC miracles (cross posted from Abbyloopers).

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

 

Marcy 1

 

Marcy 2

 

Just to forewarn you all, my story is very long and complicated, lol. This is the very first time I’ve ever written it out. My “TAC journey” is not picture perfect, but it did result in my sweet boys. It begins with my 1st born son Joshua, back in 1998. It’s before I knew what a cervix was, and just how important and critical it is. I got pregnant with my first baby within 3 months of TTC, and assumed I’d have a normal pregnancy, like everyone else I knew had. Little did I know that my whole life would soon drastically change.

During the entire pregnancy, I had bright red bleeding and spotting. I saw my doctor several times, only to be blown off. At one point, the doctor filling in for him even went as far as to tell me that “my uterus had too much blood in it and this is why I was bleeding, to get it out of there.” I know, crazy! I knew that didn’t sound right, but it was my first pregnancy and I didn’t know any different. We didn’t have the internet as a resource back then.
So fast forward into 2nd trimester. In addition to all the bleeding and spotting, I was also having knife-like stabbing pains in my abdomen. This happened every day and would literally stop me in my tracks for a few minutes each time it happened. I told my doctor about it, but again was blown off. Later, I would find out that this was all due to my placenta slowly abrupting.

After my first ultrasound scan at 20 weeks, I decided to switch doctors. I didn’t feel like I was being taken seriously with my pregnancy. Just 2 weeks later at 22+0 weeks, I woke up with what seemed like a full-on period. It scared me to death, I knew something was very wrong! I called my new OB. He said to come in immediately. Of course the weather was bad. I had to clear the mountain of snow off my car and get gas on the way (I was on empty with the light on). Then once at the hospital, the only parking spot I could find was in the very back of the lot, so I had to walk quite a ways to get there. When it rains, it pours. Finally, at my new OB’s office, he examined me. A look of panic and shock came over his face. He told me that I was dilated between 6-7cm, with membranes bulging through. I thought he was joking, but he said he was not.

They rushed me into a room downstairs and started steroid shots for baby’s lungs right away, and also got an IV started. They also called my husband, and he sped from work (an hour away) as fast as he could to the hospital. A neonatologist from another hospital came to talk with us before we were ambulanced over there, where they had a Level III NICU. We were told it was too late to try to place an emergency cerclage. I had dilated too much. We were devastated. We were also told that our son had NO hope, that he would be born within the hour, and he would not survive. They even went so far as to tell us if he were born and they didn’t feel he could survive, they would not try to help him . . . even if we wanted them to help him. They also told us if by some miracle he did survive birth, then he would have a lot of problems. They gave him a 50% chance of possibly surviving birth, and only a 9% chance of surviving without big preemie issues. All I can say is thank the Lord that He intervened when the doctors had no more options and no good answers for us!

After I was ambulanced to the other hospital, they found that I had dilated the rest of the way to 10cm, just on the way there. No contractions, just cervix falling apart. They admitted me on SHB (bedpans, head down – feet up, etc.), put me on IV antibiotics to help protect me from infection, and they STOPPED the steroid shots for my son. They said the shots were not effective that early at just 22 weeks. I have to say looking back, I really appreciated my new OB’s response when everything fell apart. He didn’t know if the steroids would work that early or not, but told me if there was even the smallest chance that they would work, he would start them. So fast forward, at 24+0 weeks, the nurse came to check on me and found that I was hemmoraging. So even though I was still dilated to 10cm, it was off to the OR for an emergency c-section, classical incision since I was having him so prematurely. Amazingly and miraculously, my water-bag never broke, I never got ascending infection, my son DID survive, being born at 24+0 weeks, weighing 1 lb. 4 oz. and 12.5” long. God protected him and brought him through everything during his 3.5 month NICU stay. He went from being the sickest, most critical baby in the unit, to actually surviving and coming home! And he miraculously fell into that 9% of preemies who survive without big preemie issues! We know beyond a shadow of a doubt that our son is only here because of God bringing him through it all. My son Joshua is a healthy, strong 19-year-old young man today!

On to my 2nd pregnancy. We decided to start TTC 3 years later. We struggled with secondary infertility for over 3 years. After having a laparoscopy surgery to remove endometriosis / scar tissue / adhesions, we finally conceived! We were so thrilled! We really didn’t think it would ever happen again. My OB sent me to a high-risk perinatologist in town, and I was given a preventative McDonald transvaginal cerclage (TVC) at 12 weeks. After it was placed, the peri asked me if I had ever had surgery on my cervix before because it was very short and looked damaged. At that point, I had never had any surgery on my cervix, and my CL was 3.0cm. In spite of bedrest and P17 shots, I was funneled to my TVC by 15/16 weeks and was leaking amniotic fluid. Then at 19+3 weeks, I kept feeling like I had to have a BM, but nothing would come. This progressed into horrible back labor. My husband drove me to ER. He ended up carrying me in because the pain was so bad that I wasn’t able to walk. This was the beginning of our nightmare. Once examined, it was discovered that my TVC had failed, my water-bag had fallen halfway through, and I was dilated between 2–3cm, with pPROM and infection (chorioamnionitis). One of the nurses in the room had to excuse herself to go throw up. She left the room crying after seeing what was happening. She came back later and apologized. I wasn’t upset with her at all. We were all devastated. We tried to hang on with SHB and IV antibiotics. But by 20+3 weeks, all my amniotic fluid had finally leaked out completely, and I was bleeding due to the TVC tearing my cervix apart. We had to deliver him, there was no choice. It was an experience I can’t even put into words, just too deep . . . too much heartbreak and devastation. Our worlds were completely and utterly shattered. Our precious baby boy, Philip, was born at 20+3 weeks, and lived for 1hr 50min. We never got to see him alive, which haunts me most. We were told he passed away after he was born . . . he never even got his momma when he needed me the most. This was our little miracle baby that we had TTC for soooo long. Our son was finally going to get a little sibling to grow up with. But instead, we lost him and we were all left trying to pick up the pieces of our hearts. The hardest part of it was not knowing what happened, why my TVC failed, and why we lost our son. He was healthy and strong, so how in the world could this have happened?

Thankfully, 2 weeks after we buried our precious son, I found Abbyloopers on the internet. I had NO idea how much this would change our lives. I know this might sound silly, but I started reading all of the files, and following some of the girls’ TAC pregnancies, just waiting for them to get into their “critical CI weeks,” and wondering if they were going to lose their baby, like I had with my TVC. Oh my goodness, to my amazement, they stayed pregnant!! Their cervix did NOT give in. The TAC was actually holding strong and keeping them pregnant, and beyond those critical weeks! After I saw this happen over and over, I decided to set up a consult with a surgeon listed in the Doctor List.

At that time, I think Dr. Mason was the only TAC surgeon listed in Michigan. I consulted with him and he was so kind and compassionate. He reviewed all of my medical records. He agreed that my cervix was a mess. After examining it, he found that it was permanently dilated between 1-2cm in a NON pregnant state, and that half of my external cervix was missing and flush—badly damaged from my failed TVC. But he also wondered if I had more going on in addition to my cervix. Red flags for him were my placenta abruption with my 1st son, and then the pathology report with my 2nd son showing the placenta being all clotted up. After running many labs, he found that I had 2 clotting issues going on and said I would need to be on blood thinners for future pregnancies. I ended up also setting up a phone consult with Dr. Haney. After much confusion and feeling so torn emotionally, I finally decided to go to Chicago and have Dr. Haney do my TAC, pre-pregnancy. After making this decision, it was the 1st time in months that my husband and I felt peace in what we needed to do.

My TAC surgery went well, no complications. Dr. Haney also checked my tubes and for any possible endometriosis / adhesions, and everything was clear. My husband and I had decided that we would start TTC in 6 months following my TAC surgery, mostly because we were still grieving terribly. To be honest, we wanted another baby SO much, one to raise on this earth, but we really didn’t believe it could happen for us. We were looking at the TAC as a “safety net,” just in case we ever got pregnant again. And to our shock, we unexpectedly conceived just 6 weeks after my TAC surgery, with our 1st TAC baby!! It was a complete surprise, since we had struggled for so many years with secondary infertility. When I took the HPT, I remember we were both so focused on the “negative” window that neither one of us noticed the BFP staring us in the face, LOL.

The pregnancy, though complicated, went better than my other 2 pregnancies. I actually stayed pregnant through my “critical CI weeks” and ventured into UN-charted territory for the first time in my life! And even though my cervix shrank quite a bit at 18 weeks, my TAC held rock solid. I never funneled through it. Starting at 23/24 weeks, I began struggling with contractions. At this point, my MFM put me on tocolytics and moderate bedrest to try and help keep things calm. The contractions complicated things with my previous classical scar on my uterus. At 29+5 weeks, my MFM wanted me to come down for a “mag wash,” (magnesium sulfate) so I would be “re-sensitized” and hopefully start responding better to my tocolytics. When I arrived, my contractions kicked in out of nowhere, and were just minutes apart, so it became trying to stop them. After a combo of meds (and a round of steroids for baby’s lungs), the contractions finally stopped and I was sent home on tocolytics again. Just 2 weeks later, contractions got the better of me, minutes apart again, and my MFM decided to deliver my son. He was worried about possible uterine rupture with my scar, and the fact that I did not respond well to the magnesium sulfate last time. Ryan was born at 31+5 weeks, weighing 3 lbs. 10 oz. He spent 5.5 weeks in the NICU and did really well. He is a healthy, smart 12-year-old today.

Fast forward almost 7 years, and after having a 2nd lap surgery for endometriosis / adhesions, we had a surprise pregnancy. This was our 2nd TAC baby. I was 39 years old this time. It was a complicated and difficult pregnancy, mostly because of contractions—again. Only this time, they began earlier with a couple each day starting at 15 weeks. At 16 weeks, I funneled to the level of my TAC. I was really scared at first, but then, after messaging Dr. Haney and talking to my MFM about it, I felt better. They were not surprised and said they expected that to happen with true CI and that it only proved that I needed my TAC. As long as I didn’t funnel through my TAC, then I was in good shape! For the contractions, I was put on P17 shots again, and started on tocolytics at 20 weeks as needed, and was on moderate bedrest. By 23/24 weeks, contractions were pretty bad as I was having 2 an hour, almost every hour. In spite of all my contractions and my short cervix length (averaged 2.2cm but had measurements as low as 1.7cm), my TAC held rock solid for a 2nd time. I was given a round of steroids for baby’s lungs at 24 weeks this time, given my preterm delivery history.

At 30+5 weeks (on Christmas morning!), my contractions got really bad again. They came on quickly and were 3 minutes apart. My MFM admitted me to do a 2nd round of steroids for baby, and to put me on magnesium sulfate. He wanted to do the mag for the contractions, and also for baby – just in case baby came early (neuro-protection). My contractions slowed down significantly, so the plan was to keep me in the hospital to buy more time for baby. However, the next day, they decided to deliver baby because they found that he was having heart decels on the monitor and was not recovering well from them. This was the first time I had ever seen the look of panic on my MFM’s face. He told me that if they didn’t deliver baby now, we would lose him. They thought the cord was around his neck. We were so upset and so scared for our baby. So off to the OR we went. To my MFM’s surprise, once he had me opened up, he could see my son’s face through my uterus. It had become paper thin and I was on the brink of uterine rupture. And they also found that the heart decels were not due to the cord being around his neck. Instead my placenta was partially abrupting. My MFM thinks it was because I had an anterior placenta (on the front wall), and it had implanted on my classical scar. My little Roman was born at 30+6 weeks, weighing 3 lbs. 12 oz. He did really well in the NICU, and is a healthy little 4-year-old today.

I know my story may scare some people, and it’s definitely not “picture perfect.” But I know without a doubt that without the TAC, my last 2 miracles would not be here today. I’m so thankful to the Lord for leading me to Abbyloopers! It brought our wonderful Dr. Haney, the TAC, my amazing MFM, and my Abbysisters into our lives. And most importantly it helped us get our precious little miracles here. My oldest son was able to have the gift of getting 2 little siblings to grow up with. I will forever be thankful to Abbyloopers, for helping me through the most devastating time in my life when we lost our son, and for giving me hope in being able to possibly have another baby with the TAC.

Marcy

Marcy 3
 

TAC Surgeon Map Beta Edition Published

I put together a preliminary version of a map that lists all the doctors worldwide that do the TAC surgery, along with the contact information I have for them. I have not verified most of this information. Thanks to Abbyloopers for putting together and maintaining the list this is based on.

The page will live at https://tacinformation.com/tac-surgeon-map/, but I’m putting up this blog post to announce it. The map is below – it will get updated occasionally as I have time and as I get better information.

If you find any information that you know is wrong, please let me know at tac.information@gmail.com.

A Note on “Funneling”

This is just a really quick note on a topic that is confusing for a lot of women: funneling. Many of us hear the word “funneling” and start to panic, but it’s a word that has some very different meanings.

What we women with cervical insufficiency need to worry about is funneling of the cervix, which often precedes premature dilation. You can funnel from the top down, or from the bottom up. With a TAC, it is possible to have a narrow funnel through the TAC (narrow because you should only be able to dilate up to about one centimeter with a properly placed TAC), but not common. It also doesn’t necessarily mean that your TAC will fail or that anything will happen to your baby; it’s just something that your doctor will have to keep an eye on.

A lot of times, you might hear a woman say that she “funneled to the TAC,” but not below. This is something that some doctors or ultrasound techs say, but it’s confusing. There is NO cervix above a TAC, just uterus. When a doctor tells a woman that she has funneled to her TAC, it’s a terminology problem, not an anatomy problem. It simply means that the lower uterine segment is beginning to expand, which always happens as the baby gains weight, and is a normal part of any pregnancy.* By itself, it is NOT a concern in a TAC pregnancy or any other pregnancy, although it’s possible that it might happen earlier in a woman with cervical insufficiency (I don’t know, and I’m not a doctor, that’s just a guess). Sometimes doctors say that means that you really did need a TAC, which I feel adds to the confusion, as the expansion of the lower uterine segment is only an indication that the baby is growing.

So if you hear that you, or any woman, has funneled “to the TAC,” know that it’s normal and probably not something to worry about. We have plenty to worry about already. Your doctor should be on the lookout for funneling through or below the TAC, which certainly can indicate a potential problem.

*This is also the reason that c-sections done before mid-late second trimester usually require a classical vertical incision. The lower uterine segment has not expanded enough for a low-transverse incision between the uterine arteries.

Stories of Strength: Brynn’s Story

Brynn shares her story* from over the rainbow. Despite a short NICU stay, her TAC twins, Aislyn and Grayson, are happy healthy 6 month olds. Women often wonder if the TAC is effective for twins. As Brynn and many others know first hand, this “magic band” can handle multiples.

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

Nothing about our journey to parenthood has been easy. After years of fertility treatments and losing our angel twins, getting to 37 weeks with our rainbow twins felt like such a blessing. Little did we know we were in for another roller coaster ride.

As we neared the birth of our twins, it began to come up that I had hired a birth photographer. I got a lot of weird looks and awkward questions. To ensure a safe pregnancy, I had surgery to place magic bands around my cervix, necessitating a C-section. I know people were thinking, “Who wants pictures of a C-section?!” I am very thankful that Neely was able to participate in our journey. I trusted her to take pictures of everything and the pictures are tasteful and beautiful.

Our birth experience did not go as planned, but that makes me even more grateful for these amazing pictures. (PSA to other mamas-if you go into labor hours before your scheduled c-section and go to the hospital early hoping they will give you drugs, they won’t. No matter how many times you ask!)

For any parent the words “We have to take your baby to the NICU” is devastating. For us, those words created a nauseating sense of deja vu. Less than two years before, we lost twins at 23 weeks and the NICU was the scariest place on Earth. My whole pregnancy, I told people my goal was healthy babies and to never set foot in the NICU again.

Our NICU journey was cathartic in so many ways. We had amazing doctors and nurses who have such a heart for the tiniest babies. They kept us sane, answered a million questions, didn’t laugh at our attempts to dress the munchkins and were just as excited as we were at each milestone towards getting released.

Because a c-section is major surgery, I had to remain in the OR while the babies were whisked away to the NICU. Seeing the slideshow Neely compiled, showed me so many beautiful moments that I missed due to the c-section. Words cannot express how grateful I am to have these moments captured.

Our journey to have a family has been a walk of faith. Aislyn and Grayson are an answer to many prayers. We are so blessed to have these rainbow babies; Isaiah 61:3, they are truly beauty for ashes.

*This was first published on Ker-Fox Photography.

TAC Variations

When you think of a procedure like the TAC (transabdominal cerclage), you may think that it is a standardized operation. In fact, each surgeon has his or her own techniques, informed by their teachers and developed over their years of experience. So while there are some basics that are common to all TACs, the procedure itself can actually vary quite a bit.

So what are the defining characteristics of a TAC? What makes a TAC a TAC? Technically, there’s only one:

A TAC must be placed via an abdominal incision. If a surgeon tells you a TAC can be placed vaginally, he/she is either misleading you or very much mistaken. Either way, steer clear. A TAC is a transABDOMINAL cerclage, and can only be placed through an abdominal incision.

For the record, when I say “TAC” throughout this blog, I mean a cerclage that is placed via an abdominal incision and tied as a band around the internal os of the cervix at the cervicoisthmic junction. This has been proven to be the most effective form of TAC so far, although any cerclage that is placed through an abdominal incision is technically a TAC.

There are several areas where TACs differ:

Incision

Remember, this incision is NOT on your uterus, only on the outside. We’ve established that all TACs must be placed abdominally. Traditionally, this has meant through an open incision in the abdomen (laparotomy). Most of the time the incision is a low transverse incision — a horizontal line at about the level of your pubic hairline. Sometimes, however, there might be a reason for a vertical incision. If a surgeon does all of his placements vertically by default, I personally might consider seeing somebody else, as that type of incision makes recovery more difficult (in addition to creating a nasty scar). Sometimes a Pfannenstiel type incision has been used, but that is not as popular these days. Alternately, many surgeons now place TACs laparoscopically, or via several tiny incisions in the abdomen. This can be done with or without the DaVinci robot, but the incisions should be about the same regardless.

Here are a few examples of incisions:

Jill Donald Davis in-preg traditional almost 3 yrs

This is my scar, on my soft, stretch-marked 3 pregnancy belly. Dr. Davis in-pregnancy traditional TAC, September 2012. This scar has been used for TAC placement and 2 c-sections. 3 years post-TAC, 2.5 years post c-section #1, and 6 months post c-section #2.

Haney pre preg almost 2 months

This is a Dr. Haney traditional pre-pregnancy TAC at about 2 months post-op.

Haney 4 weeks

This is a traditional Dr. Haney TAC at 4 weeks post-op. Dr. Haney is able to make a very small incision for pre-pregnancy TACs and TACs on smaller women, but keep in mind that your OB will very likely use the same incision for your c-section, so it will be bigger anyway.

Davis pre preg traditional 1 month

This is a traditional Dr. Davis TAC at 1 month post-op.

Paraiso RoboTAC 3 months

This is a Dr. Paraiso RoboTAC, 3 months post-op. She has older scars as well; the arrows point to the TAC scars.

Scibetta in-preg lap TAC 3 yrs

Dr. Scibetta lap TAC, 3 years post-op. After 3 years and 2 c-sections, she says this scar on her right side is the only incision you can still see.

Material

There are three possibilities here:

    • 5 mm mersilene tape. This is probably the most common option. Mersilene is a nonabsorbable braided polyester suture. It is sterile, inert, and nonreactive, so it should be able to stay in your body indefinitely without causing any problems. It’s incredibly strong, and could essentially support the weight of a grown man jumping on it.
Mersilene Tape In Situ

5 mm mersilene tape in situ. From http://www.kjkhospital.com/CaseStudyDetails.aspx?nid=24

    • Neonatal/IV tubing. I only know of this being used in Australia. Tubing — either neonatal tubing or IV tubing — is used the same way as mersilene tape. As far as I know, success rates are similar.
Dr. Alexander Neonatal Tubing TAC

A TAC placed by Dr. Alexander in Brisbane using neonatal tubing.

  • Nylon suture material. This is not recommended. It is strong, but much more likely to erode into the tissue of your cervix.

Suture Type/ Knot Placement

Some surgeons use curved needles to thread the band behind the cervix, but some prefer to use a more blunt instrument like clamps. Most surgeons placing a TAC traditionally tie the knot posteriorly (behind the cervix), I believe, to avoid problems with bladder adhesions and irritation. (One paper I read said tying the knot posteriorly allows the TAC to be removed, theoretically, through the vagina in a procedure called a culdotomy, in which the vaginal wall is cut in order to access the knot via the rectouterine pouch. I have never heard of this being done.) However, the knot is sometimes anterior (in front of the cervix) when placed laparoscopically without the DaVinci robot. The knot is usually a square knot, but surgeons may have their own variations.

Most variations here are minor and don’t make a lot of difference. There are a couple, though, that potentially make a big difference.

  • I have heard of surgeons tying the band lateral to the uterine arteries, instead of medial to them, but that is a mistake (as opposed to a preference), and can lead to erosion into the arteries and bleeding.
  • Some surgeons don’t tie a band around the cervix at all, but instead stitch through the cervix. One example is a surgeon who makes an abdominal incision and places a modified Shirodkar stitch at the internal os. This, in my opinion, should not be done, as it is more susceptible to problems with erosion and more likely to cause damage to the cervix, and ultimately, more likely to fail. If you’re going to undergo major surgery, you might as well have the best, safest solution, which is a band tied around the internal os of your cervix.

Method

This encompasses all the other variations that might exist between surgeons. Some prefer only in-pregnancy, while some only do pre-pregnancy. Some have a strong preference for traditional, laparoscopic, or robotic laparoscopic. There are a lot of different approaches to anesthesia and pain management. Some doctors prefer spinal anesthesia in pregnancy, some always place the TAC under general anesthesia. Some prescribe ibuprofen for pain management, while others tell you never to take ibuprofen in pregnancy. There isn’t a clearly right way to do most of these things, and very experienced, very successful doctors have different opinions. Do your own research and decide who you want to trust based on that.

A Note About TAC Surgeons

When you start looking into a TAC, you will quickly realize that there are a few surgeons who are much more frequently mentioned than others. In the US, those are Dr. Haney, Dr. Davis, and Dr. Sumners (see The Big Three for contact info). When I got my TAC in 2012, all three were equally popular. Since then, Dr. Davis has semi-retired, and more women are seeing Dr. Haney, so the commentary is very much skewed toward Dr. Haney at the moment. While these three doctors have some differing opinions, they are all essentially equally experienced, and all have the same very high success rates. As far as the Big Three go, you’re in good hands all around, but I’ve been hearing some disturbing comments to the effect that Dr. Davis (or Dr. Sumners, or any other doctor) does it “wrong,” and therefore their TACs fail more often. That’s pure nonsense, so if you hear such a thing, don’t let it worry you.

My real point here is that there is no “right” or “best” surgeon, only the best one for you. If you have time, shop around. See who your insurance covers, and figure out if you can or want to travel. There are a lot of things to consider when you choose your surgeon. Here are a few:

  • How far are you willing to travel?
  • Does he or she accept your insurance?
  • How much experience does he or she have?
  • Does he or she prefer laparoscopic, traditional, or robotic assisted laparoscopic? (If you have a preference.)
  • What type of material does he or she prefer to use?
  • What are his or her stats? Success rate?
  • How comfortable are you with him or her?
  • Will he or she be available to answer questions after surgery/during pregnancy? Will he or she consult with your OB/MFM/perinatologist?
  • Does he or she offer an out-of-pocket rate? (if your insurance will not cover the procedure, you may save money by traveling cross country or even out of country to a doctor who offers an at-cost option)

These are all questions you’ll need to ask yourself and your doctor. As far as experience goes, you’ll have to remember that not all doctors can have 20+ years of experience placing TACs. Some of them will be less experienced, and that’s okay. With several of our beloved TAC doctors nearing retirement, more and more women will have to see these less experienced surgeons, which, of course, is how they gain experience. Also, no two doctors do any procedure the exact same way. They each put their own spin on it, and are constantly trying to improve their own performance. Some use mersilene, some use neonatal tubing. Some place one band, some place more. There are a hundred variations, and no “right” version. We all want the very best doctor when our baby’s lives are at risk, but placing a TAC is actually a relatively simple procedure. If you find yourself in a situation where it makes sense to you to see a surgeon with less experience, there might be some additional things to think about. Personally, if I were going to have my TAC placed by a newer surgeon, I would want 1) a traditional open placement, and 2) an in-pregnancy placement. Here’s my reasoning: 1) a traditional placement allows an inexperienced surgeon a more open field and better visualization. He or she can feel the tension of the band and the knot. 2) This one seems counter-intuitive, but according to at least one study, it’s more difficult to get the correct tension on the band when placing it on a non-pregnant cervix. Since the cervix swells during pregnancy, placing it in-pregnancy means that you already know what size it will be. Placing it before than can lead to the band being too loose or too tight, both of which can cause the TAC to fail. These are probably more cautious than necessary, and if your convenient local doctor only does pre-pregnancy lap-TACs, you will do just fine. Going with the method your doctor feels most comfortable performing is probably more important than any specific type of placement. If you have any questions, please feel free to email me (Jill) at tac.questions@gmail.com.

Happy 3rd Birthday, Lucy

I started writing this days ago, and meant to publish on her birthday, but I couldn’t finish it. I can’t imagine why it felt so much harder this year.

Dear Lucy,

Happy third birthday, sweetheart. It’s hard to believe you would have been such a big girl by now. Time keeps passing, but you’re still just a baby. It’s so wrong and heartbreaking that you don’t get to grow up. What would you be doing now? Would you be an outgoing little chatterbox? That’s how I imagine you. I see you as a little adventurer. You would have loved to go exploring with William, I think. He loves to be outside, and he’s not afraid of anything. You two would have scared me during your explorations. You would have loved your little brothers. I have two little brothers too, and although we fought a lot growing up, I love them very much. Would you have been a daddy’s girl? I suspect so. You had your daddy wrapped around your tiny finger from the moment he first saw you.

As we enter the season of your life, I feel like I’m in limbo. For these next two months, my mind will flit back and forth between two alternate realities – the one we live in now, without you, and one where you are alive. Every day, I look at pictures of you from that day and try to remember what we were doing. Easter – the day you had to have steroids, and we missed Easter dinner with a nice family who’d invited us over because I couldn’t stop crying. Every memory I have with you is a memory that I cherish, but so many of them are sad or scary. I try to focus on the others: May 3, the day I first held you, my beautiful girl. April 18, the day we first got to take down the walls of the isolette and give you kisses and nuzzle your neck. April 19, the day you looked at me and I knew you saw me, and I knew that I would die for you.

A month ago, you got a new little brother, Andrew. Maybe you already knew him. Maybe you chose him to be your little brother, because you knew he’d be the perfect fit for our family. If so, you were right, he is the perfect fit. Sometimes he looks just like William, but somehow he reminds me more of you. While I was pregnant with Andrew, I couldn’t think about you the way I wanted to. When the memories got hard and I cried, I got really sick and my contractions got out of hand. So, to protect Andrew, I had to stop thinking about you so much. It felt like a betrayal, and I’m sorry. After Andrew was born, it all came crashing down, and I’ve done a lot of crying. It seems strange to cry so much at such a happy time, but Spring will always be bittersweet for me. When I see the grass greening and the wildflowers blooming, I think of you. The daffodils remind me of your short bright life. When the magnolias start to bloom, I’ll know we’re nearing the end, and my heart will break all over again.

Lucy, your mommy and daddy and brothers have a beautiful life together, but we’ll always miss you. Now that we have Andrew, I keep thinking that maybe if we have a girl, our family will feel complete. Then I realize that our family will never ever feel complete without you. We’ll just do our best to keep you with us, and hope that it will be enough. Darling girl, your light and beauty changed us forever.

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For your birthday, we took William and Andrew for a picnic in the mountains, like we wanted to do with you. When we came home, we had Matilda cake and sang happy birthday. William sings “happy to LeeLee,” which is very cute.

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First cuddles:

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The last picture of happy, hopeful times with Lucy:

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Loving and missing you, baby girl.