When Is It Right To Let Your Unborn Baby Die?
I faced a choice: Deliver early or risk a stillbirth.
Still, the likelihood that something is legally permissible doesn’t make it ethical, or the right choice for an individual woman, and so I kept puzzling. My ob indicated that at Mass General, doctors would usually not recommend intervening on behalf of a fetus in our situation until 26 weeks, but that for our priorities, a suggested target might be 28 weeks and a birth weight of 750 grams. My husband and I were inclined to later targets—myself 30 weeks, he 32. But making it that far along, we were warned, was a long shot. My ob guessed that our baby had maybe a 25 percent chance of surviving to 28 weeks, but when pushed by my husband for a probability of making it to 32, wordlessly shook his head. Given the severity of our baby’s IUGR—she was at the third percentile, meaning that she was smaller than 97 percent of all fetuses, and the slowdown in her growth had begun already by week 18—the doctors expected that by 26 weeks, the amniotic fluid around her would be gone, and the end-diastolic blood flow in the umbilical cord would be absent or have reversed, halting growth and leading to signs of fetal distress such as heart-rate decelerations. It would be possible, my ob said, to monitor me closely over the next few weeks and follow that decline, delivering when reversed flow or fetal distress was seen.
I went with a different plan, along the lines outlined by Gyamfi, going without close or even weekly monitoring until after 30 weeks, my original delivery target. In the meantime, believing the prognosis, I started making practical arrangements for the stillbirth, which in Massachusetts would be recognized with a death certificate after 24 weeks. And yet, my baby kept kicking. When I went in for an ultrasound at 28 weeks, I was told that her weight was still less than even the ob’s suggested target of 750 grams, but that contrary to expectations there had been some growth, the fluid levels had recovered, and the blood flow through the cord, fetal movements, and heartbeat looked fine. The ultrasound doctor said something like, “It’s like you were 10 points behind in the first quarter and now you’re level in the second. It’s a totally different ball game.” My ob said that it was now more likely than not that there would be a live baby—even given our targets. On the way home in the car, my husband and I restarted a discussion we had suspended months earlier, about names.
There’s no sugar-coating a decision to wait. For all the cases in which it turns out the doctors have been overly pessimistic, there are many others with tragic outcomes. One woman who did respond to an interview request about losing her baby was Lindy Whitson, an Ohio schoolteacher whose son Elijah had IUGR and was stillborn in 2011. When reversed end-diastolic flow was first seen by ultrasound, Whitson says she was offered an induction of labor, even though the baby was too small to have a chance of survival, the idea being that if she delivered, she might meet him alive, and that comfort care could be offered until he died. She decided against that option, both because she felt it would be more painful for him than passing on the inside, and because of her hope, unlikely as she understood it was, that he might not miscarry as predicted and survive to an estimated size of more than 450 gram, her delivery target. She went for regular ultrasounds to check on him until 26 weeks, when no heartbeat showed on the scan, and she was admitted to have him born still. “As horrible as it was, I still think we made the best of it,” she says.
My story has a very different ending. I hit my 30 week goal and then was monitored weekly, and then biweekly for fetal distress. By 33 weeks, none had shown, but I noticed a period of reduced fetal movement, and ultrasound showed that my baby now measured down below the first percentile (meaning, she was smaller than 99 percent of fetuses of that gestation). In the office appointment, my ob put the case for delivery urgently, and when I agreed, handed me paperwork for a C-section that he had already scheduled before the conversation to save time. Our daughter was born at 34 weeks, breathed on her own, and was transferred to a special-care nursery for five weeks to gain weight. Because of her breathing and relatively advanced gestation, she did not need to be admitted to the NICU. Five months later, she is an amazingly happy baby who is doing well at home.
This past June, a mother in Pennsylvania who had already lost a preemie baby after an early delivery and who was developing similar complications the second time around asked on Inspire whether women who had delivered early would in the future choose to deliver at 24 weeks when faced with an imminent stillbirth. Dozens weighed in, and, on balance, the mothers who had delivered early themselves expressed respect for women who opted to wait. One of the responses was from a California woman who had been waiting out an expected stillbirth from IUGR when she went into labor at 27 weeks and unexpectedly had her baby alive; she said whatever choice the woman makes is the best decision for her family.
To rest the question there, on a woman’s right to choose, may sound like an iteration of the abortion debate, but there are important differences, as I came to realize. Unlike a termination, neither a choice to deliver nor a choice to miscarry has a definite outcome, so women are dependent on counseling from their doctors to understand evidence or medical nuances that might tip them one way or the other. Given uncertainty, many obstetricians counsel in favor of delivery because—as Dr. Jay Iams of Ohio State University Medical Center says—stillbirth is the one option that isn’t treatable. Still, several experts I spoke to said that evidence-based guidelines for obstetricians who discuss stillbirth as a valid alternative to an early delivery would help women make more informed choices and standardize practice across the country, as might more public awareness of the existence of early-delivery dilemmas. I made my decision to take that very high risk of stillbirth on the information available to me at the time, without knowing how things would turn out. Some situations don’t present any right choices, but at least for me, interrupting a pregnancy with a delivery so early that my baby was not very likely to have a good outcome would have been the wrong one.
Eugenie Samuel Reich is a science journalist in Cambridge, Mass.