You can usually taste the excitement in the air during a first visit for pregnancy. It’s palpable. And the evidence for it is everywhere: the nervous fidgeting of hands. Do you place them on your lap or not-so-casually at your side? Paper drape sheet typically is balled up into tiny handfuls for better “grip” on this one-ply provider of modesty. And the quick glances back and forth between soon-to-be parents as I walk into the room, as if to size me up. For the next 30 minutes, I get to be to one to officially open this new chapter on their lives.

We start with the typical chit-chat. Where are you from? How did you hear about us? How are you feeling so far? Are you excited? Russia. Google. Nauseous. Very. I’ve learned that asking more questions beyond this or diving into some educational nonsense gets completely forgotten if you dig deeper because they are here for one thing: the ultrasound. Cue the funny, but expected, joke from Dad about how he’s glad he is a man and doesn’t have to go through anything like this. Then, I flick my magic wand’s power button on and start the ultrasound. Drumroll, please.

No heartbeat at 10 weeks

There’s no easy way to ever deliver this news. I take a few still pictures, leave one on the screen, replace the ultrasound wand, and say the words in the kindest way I know. Even tone, soft eyes, just above a whisper. “I’m sorry, but your baby has no heartbeat and has passed away.”

I spend the next 30 minutes or so helping them navigate the early stages of their grief and disbelief. She cries easily, and he is quiet and contemplative, as if unable to fully process what I’m saying. I’ve learned that the most important thing that they understand today is that they were not culpable in any way. “This is not your fault. It wasn’t the food you ate, the glass of wine you had before you knew you were pregnant, the argument you had with someone, or anything under your control. This was never your fault.” I pause a lot to allow this to sink in.

This heartbroken couple then asks me something I’ve never been asked to do before: break the news to their family, who was waiting in the waiting room. All five of them. I glance quickly at the clock, knowing that I am already a half hour behind, and my kids need to be picked up from school soon. “Of course, I can.” I walk into the waiting room and see a small cluster of people look up at me. They are the only people still in the building at this hour. I bring them back to my grieving patient’s room and give them the terrible news as well. There simply weren’t enough tissues in the building that day for all of the tears they collectively shed. Would-be grandparents demoted back to parent status. Auntie is now sister again. Reviewed the ultrasound pictures with everyone in tow. “Are you sure?” they ask. I was.

Over the next 45 minutes, I juggle the conversation of why and what next with the buzzing of my phone in my pocket. It’s my kids’ school making sure they don’t have to call CPS on me because I’ve left my kids after school after sunset. I also become acutely good at math as I start to multiply the per-minute late fees I am accumulating by leaving them there. After-care now has my credit card on file for exactly this reason. Ultimately, though, I make the decision that this isn’t something I can pull away from and am emotionally invested now. At a little before 6 p.m., I escort the family to the door and let them know when they are ready to take the next steps to surgically remove the miscarriage with a procedure called a D&C.

A few days later, I get a message from my office manager about this couple. Thinking she wants to ask me about a day I can schedule the procedure, I plop myself down into her chair and grab my calendar. She proceeds to play a voicemail that the husband had left for her.

“Uh, hi. We saw Dr. Lipton this week for pregnancy and she told us that the baby had no heartbeat. She was really nice and all. We need to schedule our D&C. But I need to tell you that we are upset that she charged us a copay for our visit. We came into the office for pregnancy, and aren’t really pregnant with a good baby. We don’t think it’s fair that she charged us $40 for her to tell us that our baby died. No one should make money off this. No one should have to pay in a situation like this. We don’t appreciate it at all and don’t think it’s really fair that she charges us for such a sad day. My wife is ready to schedule her procedure now, and we want a Tuesday or Wednesday as early as possible, maybe tomorrow? Can you also have Dr. Lipton call us because we have a few more questions for her.”

After the message ended, I was quiet. Which is unusual for anyone who knows me well. And then I start tearing up. My office manager comes over and places an arm over my shoulder and gives me a warm hug. I take a moment, collect myself. I go into the bathroom and try to put cool water on my splotchy cheeks and chest. Then I walk down the hall and finish my patient schedule.

That night, once my kids were home from school, I decide to splurge on the fancy pizza from the coal-fired oven place down the street. While a $40 copay won’t solve much, it will satisfy the hunger pangs of two growing kids, and mine. But what it will never “pay” for is the little sliver of me that I carve off for so many patients. That sliver is manifested in the way I blink away the tears when I broke the news to them, the way I hold hands and meet the gaze of devastated women. Most importantly, it is the sharp point of my kids asking, “Where have you been?” as I picked them up from school at nearly 6 p.m. because I ran late yet again.

So, tonight we ate $40 pizza, and paid the per-minute childcare bill times two. Turns out, there’s no way to quantify the feeling of missing the mark at both home and in the office. Shame.

Alexis Lipton is an obstetrician-gynecologist.