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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.

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.

Announcement

Hi Everyone! It’s been a very long time since I posted anything here, and I’m sorry about that. I have a lot of plans for the blog and lots of useful information coming, but I’ve had a lot on my mind lately. Here’s the reason I’ve been so preoccupied:

IMG_7001

IMG_7002

Introducing our newest little one, Andrew. He’s wonderful, but it was a long, difficult pregnancy, and I had a hard time concentrating on anything else. Hopefully I’ll be able to get back to work pretty soon. In the meantime, thank god for the TAC and new babies.

A Note on Contractions and Preterm Labor

This is just a brief post to mention a tip that I hope will be helpful to anyone suffering from contractions or irritable uterus during pregnancy. I have had contractions/irritable uterus/preterm labor in all of my three pregnancies. In the last two, with my TAC I was able to endure the contractions and make it to full term, despite starting to contract at 22 weeks and 16 weeks respectively. There are many ways of dealing with preterm contractions that have varying degrees of success. I will go over all of those methods in more detail later, but there’s one method that helped me immensely, and it’s one that I haven’t read about anywhere else. Ready for this?

A maternity support belt.

That’s it. It’s simple, cheap, and (for me at least), incredibly effective. Wearing a basic maternity support belt helped control my contractions more than any other method I have tried. Once I started contracting, I wore it 24 hours a day, 7 days a week, only taking it off to wash it or to bathe. When I did take it off, my contractions immediately worsened, and they immediately calmed when I put it back on. It’s a big part of the reason I was able to stay pregnant to term, in my opinion.

I have no medical basis for this, and I can only make educated guesses about why it works. I know it probably won’t work for everyone. I just wanted to put this trick out there in case it might help anyone else the way it helped me. I’d love to know if you try it and whether it helps you.

Belt up, ladies.

Dear Doctor

An open letter to all doctors who provide care to women with cervical insufficiency.

Dear Doctor,

Here in the US, there is a lot of heated discussion about abortion. That’s not what I want to talk about, though, because while we as a country focus on that, there is another, quieter epidemic: extreme prematurity caused by cervical insufficiency (CI). Every day, women are losing babies that they love and want due to CI. It’s supposed to affect about 1% of pregnancies. In the US in 2012, there were almost 4,000,000 births, which means that at least 40,000 that year were affected by CI. Not all of the babies born too early will die, but most will, as women with CI tend to deliver their babies before medical viability (24 weeks). That’s a lot of babies lost, but that’s not even the whole story. CI is vastly under-diagnosed, and many second-trimester deliveries attributed to other things (infection and preterm labor, for example) are actually caused by a weak cervix. I get it; CI is notoriously difficult to diagnose. It’s impossible to screen for it, and you can’t be certain that the weak cervix was to blame unless you catch it in the act, or a woman has had multiple second-trimester deliveries (sadly, many women do). Still, as soon as you dive into the CI community, it becomes apparent that the incidence of CI-caused second trimester deliveries is under-reported. Who really knows how many babies are lost to cervical insufficiency every year? Too many, certainly.

I have congenital CI. I didn’t know – couldn’t have known – until it was too late, and I was delivering my first child, my daughter Lucy, at 23 weeks exactly. Too early! It was too early for my little one to be born. She was beautiful, and healthy, and despite not being “viable,” she defied the odds and lived. She lived and lived, struggled and grew, and constantly amazed her adoring mama and daddy. Unfortunately, almost two months later, an infection took her from us, and our world crashed down around us.

You told us what we would do next time. You said we would try it, and “if it doesn’t work, you can always try again.” Those words haunted me. Try again? If it doesn’t work? I’m still trying to figure out how I’m going to go on living after losing one child. If it doesn’t work, I don’t know how I’ll ever survive. If I was going to try again – and I desperately wanted to – I needed to know that I wasn’t going to be condemning another innocent baby to death, or months in the NICU and potentially a lifetime of problems. What I found wasn’t very encouraging. A 75% chance that my baby will make it to 24 weeks? No, not good enough. But I found another option. It’s called a transabdominal cerclage, and while it entails a surgery for me, it also nearly guarantees me a full term baby (95% chance of making it to term when placed correctly). Those are very good odds. In fact, they’re nearly identical to a woman who does not have CI.

So why didn’t you tell me about this option? Why don’t you tell women that they have this choice? I know, you think it’s too extreme. You think my loss was a fluke, or that we’ll “wait and see,” or that we’ll place a vaginal cerclage early in the pregnancy and it will probably work. I know, I’m your patient, not my baby, and you want the most minimally invasive and least risky procedure for me. You say “what if that’s not the problem?” So what if it’s not? I will have had an unnecessary surgery, but I will never regret having fought for my babies. But what if it is? If I found out, for certain, that CI is my problem by losing another child, I would never forgive myself. I would always regret not doing everything possible to prevent it. I know that sometimes you distance yourself from pregnancies that don’t end well, but that means you end up treating my baby as a commodity that can be replaced. I know you’re a good doctor, and you’re trying to do your best for me. But you’re missing something important here. I’m a whole package, and my physical health depends not only on my physical well-being, but also on my mental well-being. After my daughter died, like many other bereaved parents, I thought maybe it would be better to just join her. Just trying again (and again, and again) is not an option for me. So while you want to minimize risk to me, I want to minimize the risk to my heart and soul, and that means doing whatever I can to keep my child safe.

And here’s the thing: it’s not your choice. The way I see it, it’s your job as my doctor to give me a run down of treatment options. You tell me their pros and cons, as you see them, and you tell me which one you recommend and why. Then I decide. It’s important that you tell me about all the options, though, because your priorities are not always the same as mine. When you leave out an option that you don’t think is a good one for me, you’re making the choice for me, because you don’t think I’m capable of making the “right” choice. You might find that I won’t make the same choice you would make for me, but you’d better believe that I will consider all my options and choose the one that is right for me and my family. So please, stop treating us like children, and let us decide for ourselves.

Please stop treating me like I’m crazy to go through an extra surgery to help guarantee my child a healthy start. Don’t you understand that I’m already a mother? What mother wouldn’t do that for her baby if she could? Please don’t act like I’m being unreasonable and extreme. Do you know what’s extreme? Holding your child as she breathes her last breaths, her skin growing cold beneath your tears and kisses. I’ve done that, and I would have endured a hundred surgeries to prevent it. If you’re a parent, you already know. I would have died for her. Don’t tell me that a surgery with less risk than a c-section is too extreme.

Doctor, I love and respect you. You’ve spent years educating and training yourself. You have a hard job, and I know you’re doing your best. But please, please trust us enough to give us this choice. And please, above all, stop telling us that we can “always try again.” Even if we have the physical, emotional, and financial wherewithal to try again, nobody can replace the baby we’ve already lost. That baby is not a fetus, or a “product of conception,” or a miscarriage – she was my heart, and my love, unique and beautiful and completely irreplaceable.

Love,
Jill

DSC00356
This is Lucy. This is what a victim of CI looks like.

The Big Three

Here’s the most basic contact information for the big three TAC doctors in the US. I’ll keep updating this post as I get new information. If you are specifically looking for a doctor in California, I keep a list of all of the doctors I know of who do TAC/TVCIC in the state, and everything I know about them. Email me at tac.questions@gmail.com for more information.

Arthur Haney
Pre-pregnancy and in-pregnancy TAC, placed traditionally (laparatomy, no laparoscopy)

Currently practicing in Chicago.

ahaney@babies.bsd.uchicago.edu

Center for Reproductive Medicine and Fertility
333 S. Desplaines Street
Suite 201
Chicago, IL 60661
Office: (773) 702-6127
Appointments: (773) 702-5161

The University of Chicago Medicine
5841 S. Maryland Avenue, MC 2050
Chicago, IL 60637

George Davis
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Dr. Davis has retired, sadly, and is no longer practicing in either New Jersey or Tennessee.

askdrdavis@aol.com

 

 

James Sumners
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Currently practicing in Indianapolis.

james_sumners@yahoo.com
FB: https://www.facebook.com/DrJamesSumners

Center for Prenatal Diagnosis
8081 Township Line Rd, Indianapolis, IN 46260
(317) 415-8070

Keep in mind, there are other very good surgeons who place the TAC and TVCIC. These three have the most experience of them all, but that doesn’t mean you have to see one of them. Also, please remember that all three of these surgeons are incredibly busy. I have no idea how they do all the work that they do, let alone have a life. They save hundreds of babies every year, so don’t get too frustrated if they don’t get back to you immediately, or even if you don’t get a response. It’s not because they don’t care. They care so much and they help such a huge number of women that sometimes emails or phone calls slip through the cracks. I promise you, they’re doing their best. If it’s critical that you reach them as soon as possible, usually calling is a better option.

Today’s Grief

Grief looked different to me today. Usually I’m sad. I cry, I miss my little girl, I think about what could have been.

But today it looked different. Today I was cranky, moody, and impatient with others. I was tired, and didn’t feel well. Not sick, just not . . . well. I didn’t feel like getting dressed. I didn’t feel like helping people, or trying to make a difference.

Today, on my second Infant and Pregnancy Loss Awareness Day, my grief was ugly, and I didn’t even recognize it. It wasn’t inspirational, it was selfish.

That’s just how grief is sometimes.

My TAC Experience

If you have questions, or would like to contact me privately, please email tac.questions@gmail.com.

Well it turns out that it’s difficult to do things like write blog posts with a new baby. There are people who are much better at it than I am, but the fact is that I’m not very good at it. It’s hard enough to stay on top of the house work when I just want to spend all day cuddling my little boy. I thought my next blog post would be a picture-heavy run-through of William’s first several weeks, but instead it’s going to be about how he got here. No no, not that, get your mind out of the gutter.

If you’ve already lost interest, that’s fine. This is really for all the women who find this blog looking for information about incompetent cervix and the Transabdominal Cerclage (TAC). This is my experience with the TAC surgery and how it’s held up since. But I have to start at the beginning. Feel free to skim – as you know, I’m a talker.

The day that Lucy died, as we were driving home from Bakersfield, David and I looked at each other through our shock and grief and agreed that we’d still like another child. This may not seem like a big deal, but you can’t understand what that decision feels like right after you’ve lost your baby (unless, of course, you’ve lost your baby, in which case I’m so sorry and I’m sure you do understand). But we knew even then that we wanted Lucy to have a little brother or sister, as she would have had she lived. So it didn’t take long – maybe a few weeks – for me to start researching my condition. It was easier for me to start than it is for many women, because the doctor who delivered Lucy had diagnosed me with incompetent cervix. This, unfortunately, is not the case for the majority of women who lose a child to IC. Doctors are reluctant to diagnose IC as it is not a straightforward or easy diagnosis. Sadly, this sometimes means a woman will lose more than one baby before she figures out what the problem is. As I said, this was not the case for me, so a few weeks after Lucy’s memorial service I sat at my computer googling “incompetent cervix.” It didn’t take me long to find the most common solution, which is what my doctors had suggested for next time – the simple TVC (transvaginal cerclage). I then found a group of women who had taken it one step further with the TAC. I won’t get into all the differences and pros and cons here. If you’d like to read about that, I wrote about it here.

After reading the posts of the Abbyloopers (on the web here and on Facebook here) women for a week or so and researching the TAC extensively, David and I decided it was the only way for us to go. If we were going to try to have another baby, we were going to give it the best chance we could. I contacted Dr. Davis in New Jersey and Dr. Haney in Chicago. They, along with Dr. Sumners in Indianapolis are the experts on the TAC in the US, and perform the most surgeries in the US as far as I know (although rumor has it Dr. Davis is nearing his retirement). I discussed my case with both of them (by email and by phone), and they agreed that it sounded like a classic case of IC and suggested I have the TAC surgery. I started checking into insurance coverage for a pre-pregnancy TAC. Then, out of the blue, I found out I was pregnant. I had always had irregular cycles, and it took us so long to get pregnant with Lucy that I didn’t think anything of it when my period was one week late, then two. When I finally took a pregnancy test and got my positive result, I was already 7 weeks pregnant. As in-pregnancy TACs are usually placed between 10 and 14 weeks, I hit full panic mode. How was I supposed to schedule a cross-country trip and clear everything with my insurance that quickly? I originally intended to fly to Chicago to have the TAC placed by Dr. Haney, but after two weeks of trying to get in touch with his assistant she finally told me he would be on vacation during the time I needed to have the surgery. Now I really panicked. Here I was, 9 weeks pregnant and without anything scheduled. Fortunately I was able to get in with Dr. Davis, and we planned our trip from Southern California to New Jersey. And because of Lucy’s time in the NICU, we’d already hit our catastrophic limit with our insurance and didn’t end up paying a thing for the surgery, which was covered without incident (again, many women are not so lucky, so I count myself very fortunate). Dr. Davis is outstanding at getting insurance to cover the procedure, and he usually takes care of everything. If you don’t have insurance, or they won’t cover a TAC, Dr. Davis is the only doctor I know of who offers an out-of-pocket option at cost. It runs about $4500-$6000, I think.

I planned for our trip through my morning sickness, which completely disappeared the day before we were scheduled to fly out (hallelujah!). We flew into Philadelphia (PHL) on Wednesday, which is definitely the closest airport to Kennedy Hospital. We got a rental car and settled into our hotel, the Hampton Inn in Turnersville. We got the federal employee rate, and the hotel was nice, clean, had a decent breakfast, and was pretty close to Kennedy Hospital. Next door is a Friendly’s, and there are many other (mostly chain) restaurants very close by. Be warned if you’re not from the area: New Jersey has these really weird left turns called jug handles. You go right and loop around to make a left, and it’s strange to get used to. There’s at least one close to the Hampton Inn, so you’ll probably see what I mean.

The next morning I had a consultation with Dr. Davis, then later met my friend Ruth and her wonderful family for dinner. The morning consultation was easy – a quick vaginal exam to check my cervix, an abdominal ultrasound to check out the baby (then almost 13 weeks and measuring large), and a question and answer session. I had him take me through what would happen during the surgery (he had a handy Powerpoint presentation to show me) and we asked a bunch of questions about safety of the baby and other things. He didn’t rush us at all, and he let us get all of our questions out. He has a dry sense of humor, and he’s easy to get along with. The truth is, Dr. Davis is a bit of a talker too, which is actually nice when you’re used to doctors rushing you out. We also discussed food – I asked him where we should eat, and he had a lot of ideas. We wanted the quintessential New Jersey experience, so he recommended a diner that we enjoyed for lunch. We were there for over an hour and left feeling very reassured. Oh, after we left his office I went down to the lab to do my pre-op bloodwork also.

After dinner with Ruth’s family we went back to our hotel to relax. I wasn’t to eat or drink after midnight, and we had to be at the hospital at 7:00 am to get registered. Both our consultation and the surgery took place at Kennedy, by the way, although Dr. Davis also has offices elsewhere. We got to the hospital, registered, then waited and waited and waited because they were running a little behind. I didn’t mind too much, but I was hungry and thirsty of course. Finally they brought me back to the pre-op room without my husband where I dressed in a gown, met the anesthesiologist, got my IV, briefly met with Dr. Davis, then waited some more. At some point David was allowed to come back and sit with me.

Since I was pregnant and wanted the least medication possible going to my baby, I opted to be awake for the surgery with a spinal, just like for most cesarean sections. I’d had surgery before, but never awake, and that part was a little scary. Finally (after noon by this time – I was starving and so thirsty!) I said goodbye to David and they wheeled me back to the operating room. The anesthesiologist placed the spinal, which was weird and hard for me to deal with (needle issues), but it was actually nice when I felt it moving down my legs because I’d been so cold, and then only my top half was cold. Oh, there was a really nice nurse, a handsome Marine, holding me steady and keeping me calm while the spinal was placed. They then put up the curtain and flipped up my gown. By the way, when you’re awake for a pelvic surgery, you have to just let go of any dignity you thought you had. Actually, just get used to it, because it only gets worse when you actually have the baby. I chose to have the TAC placed with a traditional open incision – the same kind they use for c-sections. They gave me a quick shave where the incision was going to go. I normally might have been pretty embarrassed by that, but when you’re numb from the chest down and you can’t see it, it’s like it’s happening to someone else. Oh, at some point in here they pushed some antibiotics through the IV in my hand, which was incredibly painful. In fact, that was the most painful part of the whole surgery I think. It burned, and it made my wrist feel like it was breaking. The anesthesiologist was really nice though and brought me warm blankets for the top of me that was still cold. I mentioned that it might be cool to watch the surgery on the TV screen they had in there, and they would have let me except I didn’t have my glasses. So if you’d like to watch, ask them to let you bring your glasses back if you need them.

I remember wondering when they were going to start, and then I smelled burning. I wondered what it was for a second, then realized oh, hey, that’s my burning flesh as they cauterize the incision. It was a bit weird feeling a lot of pulling and tugging and not knowing what was going on – I kind of wish they’d say “ok, this is what we’re doing now.” But Dr. Davis was just chatting with everyone in the room, and at one point started quizzing people: “how many cups in a pint?” and “how many feet in a mile?” Then he asked “how many two cent pieces in a dozen?” Trick question of course, and his assistant surgeon fell for it: “umm, 6?” “Nope. Anyone?” Nobody answered, so finally I said “12. There are always 12 in a dozen.” Everybody stopped, then Dr. Davis leaned over the curtain to look at me and said “Yes, Jill is correct.” Haha. Anyway, the surgery was progressing fine, and it didn’t hurt at all, but it did feel like they were trying to pull my lungs out through my belly. Partway through they put me into a steep Trendelenburg position, which means that they tip you head down. I had to lay like that the whole time I was in labor with Lucy, but this was a steeper angle and they did it so quickly it felt like I was going to slide off the operating table. When he was finished placing the TAC he did an ultrasound directly on my uterus, and I got to see my healthy squirmy little baby looking fantastic.

After what felt like kind of a long time, they finished up and cleared out really quickly, wrapped my torso up tightly with a binder, then I was wheeled back to recovery. They brought David back to see me, and he told me he’d received texts letting him know the surgery was going fine. I thought that was a nice touch. After a little while (not sure how long) they took me to my regular hospital room. I was happy and awake and felt pretty great. They gave me Duramorph – a morphine injection – through my spinal that lasted most of the next two days, and I didn’t need any other pain medication until I left the hospital. I was on a liquid diet (bummer) until the next morning, and I also had the catheter until the next morning. I HATE the catheter, but it wasn’t a big deal. After they took it out, they wanted me to get up to use the bathroom. It was a little tricky at first, but I managed fine and just held a pillow against my incision while I walked. The next morning they took off the binder and said my incision was all the way closed after 12 hours, and I could shower after 24 hours. (I showered back in the hotel before we left.)

Just an aside, and probably TMI, but this is a concern for many women having this surgery. Many, many women had trouble with constipation and painful bowel movements after the surgery. This was NOT a problem for me, but I think I’m in the minority. They give you Colace stool softener in the hospital, and you should definitely take it, but you should probably start it a few days before the surgery if you think you might have any trouble. Also try to eat foods high in fiber, and you should be fine.

The most important thing (as everyone will tell you) after the surgery for your recovery is to get walking as soon as possible. Right after the surgery, it will help your body get rid of extra gas caused by the surgery. This is a problem for every surgery, but is even worse for laparoscopic procedures, so keep that in mind. It’s scary, but walk as much as you comfortably can. Your incision will probably burn at first, but the more you move the better it will feel. Don’t overdo it, of course. In the long run it’s even more important to walk a lot right off the bat. If you don’t, you’re more likely to develop scar tissue, and I can tell you that it is not pleasant. As my pregnancy progressed it became apparent that I had some scar tissue (confirmed by ultrasound), and it was incredibly painful as the baby pressed against it. One of the most painful things I have EVER experienced, in fact. So walk. Just do it. This is probably even more important if you’re already pregnant when you get your TAC, especially if there’s any chance that you’ll end up on bed rest like I did. You want to be as active as possible while you can, and if you have a complicated or difficult pregnancy, you might have trouble with it later.

I was discharged from the hospital the next morning, less than 24 hours later (so it was an outpatient procedure, not requiring pre-authorization from our insurance). They took me in a wheelchair down to the car, and we drove straight to the pharmacy. I took other women’s advice and filled the pain-medicine prescription at a Walgreens near there. I’ve heard that you can’t fill it out of state (although that doesn’t make sense to me, so I don’t know), and that the hospital pharmacy takes a long time. Anyway, we picked up my Percocet and I took one since I knew I’d be moving more. We drove back to our hotel and hung out there the rest of the day (Saturday by now, surgery was on Friday). I slept a lot, and David went and got dinner and brought it back, then we got a sundae from Friendly’s. I took the Percocet the rest of that day and mostly stopped it by Sunday. On Sunday David and I took a drive out to the Pine Barrens to explore. On Monday we went back to Dr. Davis’ office. He removed the staples (he uses staples instead of dissolving stitches), which didn’t hurt at all. I couldn’t even feel it really. He covered the incision with steri-strips. He also did a vaginal ultrasound to check the TAC and take pictures to send to my OB. We saw the baby again, then sat with him while he wrote a letter to my OB. We thanked him and left the hospital, driving straight to the airport. Oh, not quite, we stopped for bagels.

Back at the airport in Philadelphia we got a wheelchair escort. I could have walked very slowly, but we were running a little late, and I knew I had a long day ahead of me. I’m a little paranoid about the full-body scans, so I opted out of that and the TSA agent very gently patted me down. The escort left me at our gate, and I realized I needed to use the restroom before we left, so I set out to find one. It took forever, it was way back out of the terminal. When I finally got back, people were asking David if I was going to be okay. It was nice that people were so concerned; you don’t normally think of strangers being that worried about you. The flight attendants offered to let me board first, and I did very gratefully. We had booked a nonstop flight, thinking it would be easier not to have to transfer. I had an aisle seat (definitely recommend to my fellow TAC mamas) because you need to get up and move during the flight. Unfortunately, it was a very turbulent flight, so the seatbelt light was on most of the time. I got up when I could, and was fine. Oh, you should also be drinking a LOT, and therefore will probably pee a lot. Try to get a seat near the bathroom if you can. I took the Percocet at regular intervals all day Monday, more because I wanted to stay on top of the pain than because I was actually in pain. We got back to LAX, where I didn’t use a wheelchair. We just walked slowly and took the shuttle back to our car. We had a 3 hour drive home still so we set off immediately. We stopped once to stretch and use the bathroom and got home pretty late.

I think I only took one Percocet after we got home because I felt fine really. I stayed mostly in bed for a couple of days and took a shower after a few days. The steri-strips mostly just fell off, and my incision healed really nicely. In fact, my OB used the same incision for my c-section, and 6 weeks post-op it is still just a thin, flat red line. David took really good care of me. Dr. Davis hadn’t given me any restrictions. He said I could do anything that felt okay whenever it felt okay. I asked about swimming and he said it was one of the best things I could do. He said sex was fine whenever we felt up to it. I was swimming very gentle laps a week after the surgery, driving myself to the dentist ten days after surgery, and feeling pretty much completely back to normal a week and a half after surgery. Again, probably TMI, but sex did happen pretty shortly after surgery and it was perfectly fine.

So that was my experience of the surgery. I had other complications of my pregnancy, and they may or may not have been related to the TAC. I will write about that at some point, but here’s the most important thing: the TAC held strong until I was full term (39 weeks) and had reached my scheduled c-section date. I have a delicious, wonderful, beautiful, perfectly healthy baby boy because of Dr. Davis and the TAC. I only wish I had known enough to have it done when I was pregnant with Lucy, because then I’d have my sweet little girl with me. Of course, if that had happened I never would have had William (he was conceived before Lucy’s due date).

Okay, I hope this is informational for women thinking of or planning on having the surgery.