The Unexpected

Chapter 1

Prepare Yourself

There are many technical things to do to prepare for another pregnancy after one that was complicated: collect medical records, decide about doctor changes, perhaps undergo additional testing. We'll talk about all of that in depth in the next chapter. Before any of this, though, you need to do perhaps the most important thing: prepare yourself emotionally.

So, what does that mean?

Very broadly, it means looking back on what happened before, trying to process it, and thinking deliberately about your steps going forward. It sounds straightforward in theory, but it can be anything but.

What this means for you will depend tremendously on what happened. Complicated pregnancies take many forms, and both the medical and the emotional experience will inform what comes next.

What is obvious to most people is that your history will influence the medical choices in a later pregnancy. What may be less obvious but equally important is the recognition that the life choices you make may be affected by this history. More specifically: it may make sense to engage in detailed planning for a possible repeat of complications in a later pregnancy even if there is nothing to do medically.

Many of the people I spoke with for this book hadn't been encouraged to think about this step.

Consider one woman who suffered from hyperemesis gravidarum (severe nausea and vomiting):

One year after our son was born, we began the discussion of a second. We talked through the cost of child care, impacts to our careers (both were taking off), desired age gap between children, and the belief in our ability to handle two children. The discussion of my experience with HG never came up . . .

In this case, HG did return during her second pregnancy, and the experience was extremely challenging for the entire family. It is not clear that her choice to conceive again would have been impacted by this risk, but if they had grappled with it from the beginning, they would have been able to put more support in place. They could have had a more concrete plan for backup childcare. She could have had a conversation with her employer about how her team could have prepared to adapt if necessary. There are a variety of ways this might have made the experience at least somewhat easier than the previous.

One reason I think people avoid these questions is that we require acknowledgment of things we wish were not true. Acknowledging the fact that this debilitating pregnancy condition might return in a later pregnancy forces us to live with that uncomfortable reality-past, present, and future. In the moment, it's easier to live with the hope that it won't happen again. Of course, doing so may leave us unprepared. Hard as this is, I urge you not to skip this ultimately healing step.

A second problem is that it can be hard to know how to approach what comes next. Sometimes, it's hard to even know what you're trying to think about or prepare for. Is your key question whether to have another child? Is it how to prepare for that? Is it both? The issues raised by complicated pregnancies are large and varied, and it can be difficult to know where to start. Process can help.

When the questions are uncertain and hard, it is easy for your experience to drag on without resolution. It is almost impossible to know if you are making the right decision, which makes it tempting to make no decision at all. Ultimately, you'll be better prepared for whatever decision you make, though, if you commit to making it deliberately.

In my book The Family Firm, I talk through a structured process-the Four Fs-to approach big decisions. I think this provides a useful starting point in deciding whether to try getting pregnant again and for many of the other decisions we'll address in this book.

Step 1: Frame the Question

You cannot make plans or prepare without clarifying what you are trying to decide or to accomplish. The first step, then, is to frame the question.

After a complicated pregnancy, for many, the question is simply whether to try for another child. This is an example of a question where it is very important to be explicit about alternatives. It's easy to state this question as "Should we try for another pregnancy or not?" That framing isn't explicit enough about what "or not" means. There are other ways to grow a family-adoption, surrogacy-that may be a possibility for some people. "Or not" does not allow for the nuances of timing. Are you really asking whether you should have another pregnancy now or never? Or is it now versus waiting a year, or two, or waiting x amount of time and then reconsidering at that point?

For other people, the choice to have another pregnancy may be an obvious one, and the question may be about timing. After a miscarriage, for example, people often struggle with the question of whether to try again right away or to wait. The question "Should we try again now?" might be better framed as "Should we try again now or revisit the timing in three months?" Because this framing is explicit about the choice-it's not "now or never" but "now or in the relatively near future"-it may make it easier to recognize the need to wait.

Or the appropriate question may be about support. "What support systems should we have in place before trying again? Should we invite my mother to live with us in the event that the pregnancy is complicated?"

This question framing is an opportunity to clarify priorities. Are all family members committed to having more children? And if so, are you emotionally ready to consider trying again, especially after loss? It is reasonable-common-for people to differ on these questions, even people who are building a life together. They are often not questions we confront when we first start trying for a family. This moment is an opportunity to confront them, to figure out what decision we need to make about going forward.

Step 2: Fact Find

Get all the information you can in order to be prepared for whatever may come next.

For example, imagine your first pregnancy was complicated by preeclampsia at 25 weeks, followed by seven weeks of in-hospital bed rest and then six weeks in the NICU with your baby. When considering another pregnancy, your first question will probably be how likely this is to happen again. Should you expect a repeat experience? You'll probably also ask what might be done to reduce the risk of recurrence or to improve the outcome. For many of the complications we discuss throughout this book, it isn't possible to prevent them. But knowing the possible risks allows you and your provider to treat the condition better and have a better outcome.

When considering another pregnancy you should also take into account how your family would approach the situation. What supports could you have in place to take care of your existing child if you had to be hospitalized again? If you are working, what preparations might you make professionally? Of course, we can vehemently hope that the condition will not recur, in which case these questions would have been unnecessary. But confronting how you would deal with these complications again should be a part of both preparing and, possibly, of making your decision about moving forward.

This step may take some time; in many cases, it will make sense to speak with your medical provider. In the particular case above, you might raise the question of alternatives to bed rest. This is an opportunity to talk about whether that's something that the provider would insist on if it happened again, or whether there would be options that might be a better fit for your family.

The goal of this step is to get the information you need-all of it-to make the decision you're facing, whatever it is.

Steps 3 and 4:
Final Decision and Follow-Up

Having asked a specific question and collected the information you need, you can come together to make a final decision.

We've intentionally left space for deliberate follow-up in some of these decisions. The decision you may make is the decision to wait. Rather than trying to conceive immediately, you may decide to wait and see how things look in three months (or six months, or a year). When you explicitly decide to wait, you can then also set a time when you'll revisit the decision.

The combination of these approaches-to commit to a decision and then to commit to a follow-up time, if appropriate-may help some people move forward. If you've had two miscarriages in rapid succession and the past months have been a devastating period of back-to-back losses, it may help to say, simply, "We are not going to think about this for another six months." Sometimes, self-care is the only, and best, possible goal.