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A Voice in Ramah (Welcome to Holland)

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The pain comes first, knife-like and deep, and then the blood, made of heat, life, and misspent hope. She is lucky to be at home when it happens. She wouldn't have known what to do if it happened at work. At home, she can be alone with her forehead between her knees, cursing softly, rubbing stinging tears from her eyes, and breathing through the stabbing contractions.

When the bleeding stops, she takes a shower so hot it scalds her skin, leaving her pink and raw. Then she crawls into bed and remains there, dry-eyed, until sleep overtakes her.

The next time, House knows she's pregnant before she does--but House always assumes she's pregnant, so she doesn't give his jokes and double entendres much credit. She hasn't told him that she's still trying, or even that she miscarried, and he never asks, so there's no reason to assume that he has a clue. When the second urine test comes back positive, though, she starts to wonder.

"I'm pregnant," she confesses to him on Monday in her office.

He immediately starts shouting, comically, managing to sound somehow bored and outraged at the same time. "Well, of course you're--"

"I don't want anyone to know."

He considers her, eyes raking up and down her body. "That's going to be a problem, given what a huge heifer--"

"I lost the last one."

She would like to say that he is immediately sorry, but if there is one thing at which House takes his time, it's contrition. He doesn't meet her eyes when he asks, "How long?"

She tells him she was at eight weeks when it happened, and that this pregnancy will hit the six week mark tomorrow. Defensive, she fights the urge to tell him that the miscarriage doesn't have to mean anything, that lots of pregnancies simply don't take; he already knows, and he already knows that that's not the full story. A miscarriage doesn't have to mean anything, but she's already forty-one. She doesn't have that many chances left.

He doesn't apologize, but she doesn't really expect him to.

She is a doctor, an endocrinologist, Dean of Medicine at one of the country's most prestigious teaching hospitals. She understands the science of conception, gestation, and spontaneous abortion. She understands blighted ova and missed implantations. She knows that intrauterine insemination, as her doctor had warned repeatedly, rarely works in women over forty. She knows that this is the chemistry of her body and that there is nothing she or anyone else could have done to make those early attempts take, or to save that first pregnancy.

Still, it is a struggle not to think of this pregnancy as a fragile piece of art, a blown glass figurine, a hollow painted eggshell inside her. She replaces her morning runs with less strenuous exercise. Sometimes she catches herself slipping unconsciously into some superstitious practice: avoiding cracks in the sidewalk, ducking away from her neighbor's black cat. Picking pennies off the ground for good luck.

Sometimes she feels joy at the subtle changes her body is already starting to undergo: the swelling of her breasts, the tone of her skin, the hunger cravings that assail her without warning. Triumph, that her body has defied the averages, proven its resilience: shown that it can bring life into the world on its own. Quiet pride at what she knows is nothing more than basic biology and maybe—maybe—an ounce of luck.

At other times, though, the trepidation is like a pillow pressed over her face, suffocating the happiness she wants so badly to feel. She is pregnant, but she's not out of the woods yet; in fact, she's barely even entered the woods, and there are long, dark pathways ahead, tangled with thorny underbrush, traversed by yellow-eyed wolves.

At eight weeks, everything is normal and everything is quiet. She has her first prenatal exam—at Princeton General—with a white-haired obstetrician named Dwivedi, who reassures her that the embryo is still there, right where it should be, heart beating furiously fast. It's earlier than one would normally have an ultrasound, but in her case, that's to be expected.

House seems to have held his tongue, for which she is grateful, although part of her fears that he's just biding his time and waiting for the right moment to spring. In the meantime, nobody at work looks at her differently or treats her with exaggerated caution.

Walking around Princeton one Sunday afternoon, she passes a baby clothing boutique. Its magnetic pull is too strong for her to fight. She has told herself again and again, endlessly, that she isn't going to buy anything until she can say with relative certainty that she'll have a baby at the end of this journey. That won't be for several more months. She doesn't really believe it's bad luck; she's more practical than that. She just doesn't want to have to look at a collection of tiny baby things she'll never get the chance to use.

But all her willpower crumbles inside the shop, and a few minutes later she walks out with a tiny brown knit cap with bear ears sewn on. She can't stop herself from reaching into the paper bag and stroking its velvet-soft material.

She doesn't remove the tag. On the way home, she tries to think if she knows anyone who might be having a baby sometime soon.

In week ten, she finds a dozen white roses on her desk in her office with James Wilson's name on the card. She sighs, purses her lips, and then decides that she's surprised House didn't tell him sooner.

Wilson comes by the office around lunchtime, looking far too anxious for someone whose only involvement in this pregnancy was being dismissed as a potential donor. She almost feels a pang of regret. He might have been a good father.

He congratulates her, but cautiously--she doesn't employ fools.

For all he knows, the flowers could have been for sympathy.

He wants her to know that if there's anything she needs, all she has to do is ask for it. She smiles wryly, despite herself, imagining. Contemplates asking him, just to mess with his head. He's a good friend, so she lets it go and simply thanks him.

Maybe he can help her assemble a crib down the road--if it turns out she needs one. If everything turns out all right.

She stopped dating when she started thinking about getting pregnant. Closed the accounts she wouldn't admit to having at various matchmaker sites. What kind of guy would want to date a woman pregnant with another man's child--even if that other man was nothing more to her than an anonymous list of statistics on a file at a sperm bank? Pregnancy fetishists, maybe, and she didn't miss sex that much. And when the baby came, when she became the new, single mother of a young child ... well, she knew what she was giving up by traveling this road. She knew the risks and the sacrifices, and she made her choice.

Yet even as she closed her profiles there was still a part of her that thought, This is not how it's supposed to be. It's the part of her that expects at any moment to meet him, the one, the faceless man in the tuxedo standing next to her as she gleams in her crisp white gown in all the photographs that exist only in fantasy. She's imagined him ever since she was a little girl, off and on as a teenager and in college when she'd decided that marriage was a farce, and less and less as the years slipped away. Occasionally she tried out the faces of men she's known, to see if any of them fit: her first boyfriend Mike, her college near-fiance Nate, a few of the lovers she's had since--once, unconsciously, even House.

Now there is no face, no catalogue-model smile supplanted over the hazy mystery, no blue/green/brown/gray/hazel eyes shining at her on their picturesque spring wedding day: just a question mark, fading into obsolescence, turning into smoke. Time moves too quickly now, and too slowly--her temporal paradox.

Twelve weeks. She's scheduled for a first trimester screen: only a screening test, not a diagnostic. She reminds herself that this is normal. That the results are not definitive.

At Princeton General, her blood is drawn by a silent lab tech. Later the ultrasound technician smoothes gel onto her flat belly and rolls the wand over her baby-to-be.

The gray and white image on the screen looks like nothing more than television static at first glance, but a moment later it resolves itself into the silhouette of a human fetus. Her child.

Her breath catches in her throat.

She stares and stares at the ultrasound screen, full of longing, hypnotized by the slight jerking movements, the visible limbs. Its heartbeat.

She completely forgets to notice the ultrasound tech's silence.

"Okay, Lisa," the tech finally says, as the ultrasound screen freezes on an image of the fetus mid-twitch. "You can get cleaned up and dressed now."

"What is it?" she asks, snapping back to the present so quickly she feels she'll have whiplash.

The tech busies herself with putting the wand aside and removing her gloves. "It'll take a few days for the doctor to look these over, but we'll get back to you as soon as we can."

"You can't tell me …?"

"I'm not qualified," the tech explains, but Lisa knows she's not imagining that the woman is leaving something unsaid. "The doctor will look at the ultrasound and give you a call in a few days."

The tech sweeps out of the room before she can object. Dazed, she looks back at the screen, at the frozen image displayed. Nothing looks out of the ordinary to her, but she's untrained--this is not her area.

The silhouette on the screen offers no suggestions.

In the early days, she thought about adopting.

She did research on domestic and international agencies, public and private, open adoptions and closed adoptions, infants and foster kids.

What she learned: it takes years. It takes money--as much as in-vitro fertilization, and certainly more than intrauterine insemination. If she went outside the U.S., she'd have to spend weeks in the child's home country; if she went the domestic route, she'd save money and travel, but the odds of her being able to adopt a child under age two were slim. And no matter what she chose to do, she'd spend weeks and months and years having strangers pry into her personal life, evaluating her, judging her ability to parent based on everything from her job to her weight to her sex life.

Expensive, invasive, inexorably slow, and at the end of the battle, she may have had nothing to show for it but the battle scars.

She went to the fertility specialist instead. And even now, knowing what she knows and fearing what she fears, all she has to do is put a hand over her swelling middle and she fills with warmth and thinks: mine.

It's three days later that Dwivedi brings her back to Princeton General to recommend more tests.

"The nuchal translucency test indicated some potential abnormalities," Dwivedi explains in his precise, lightly accented syllables. "It is important to understand that a result like this is far from definitive. It only means that we should discuss further testing."

"The combined accuracy rate of a first-trimester screen is eighty-five percent," Cuddy says quietly.

"Please, Lisa--you mustn't be anxious."

She stares back at him and thinks that he has never been pregnant.

"As you know, you and the fetus are at increased risk for certain conditions, due to your age," Dwivedi continues. "Our options now are chorionic villus sampling, which can be performed right away, or waiting a few weeks to do amniocentesis. There is a risk of miscarriage with both procedures. The risk is slightly higher with CVS, but both procedures are extremely safe."

"What's the risk?"

Dwivedi looks at her. "Approximately one in a hundred pregnancies are miscarried."

"And with amnio?"

"One in four hundred." When she didn't respond, he continued, "These numbers are taken from national studies. I can guarantee that the success rate at Princeton General is excellent--well above average. I have personally performed CVS and amniocentesis hundreds of times.

"I know you had a miscarriage once," he adds, in a softer voice than before. "It's natural to be afraid."

Cuddy nods, but she isn't listening. "Are there other differences I should consider?"

Dwivedi pulls up a rolling chair and sits in it. "Well, as I mentioned, amniocentesis cannot be done until later in the pregnancy, which gives you less time to … consider the results." He clears his throat, a thin, rasping sound. "Amniocentesis can also be used to test for neural tube defects, such as spina bifida, which CVS cannot. But--"

"But you're not looking for spina bifida," Cuddy finishes.

"No. I'm not."

She looks down at the ultrasound printout in her hands. The limbs are barely visible in this one; the fetus appears to be nothing more than a round little head and a slightly larger elliptical torso. It looks, like every human ultrasound, like an alien. It could be an ultrasound of anything.

"What is your recommendation?" she asks Dwivedi.

"Chorionic villus sampling. It's better to know sooner rather than later."

She looks at the ultrasound again and then puts it back inside her bag and asks, "How soon can you fit me in?"

He can fit her in on Monday.

She takes the morning off and comes to his office, bladder full, as instructed. In the exam room, she strips below the waist and lies on the table, her feet in the stirrups.

Dwivedi, female assistant looking on, guides a catheter inside her while another ultrasound tech--not the one from her first visit--slides the wand through the slick gel on her abdomen.

She looks down and sees the top of Dwivedi's head bent between her knees. Then she looks sideways at the screen. Sees the fetus, the placenta. The catheter, moving towards its target.

"Stop," she says, struggling to sit up, "stop."

"What's wrong?" the female assistant asks.

"I changed my mind," she says frantically. "I want to wait."

"Lisa," Dwivedi says heavily, and then sighs. "It will only be another minute to collect the cells we need …"

"I don't care," she says firmly. "I want to stop. I want to wait and do the amnio."

The assistant and the ultrasound tech both look to Dwivedi for instruction. The old man sighs again and then withdraws the catheter. Cuddy winces and then sags with relief as the speculum is removed.

"You are nervous, Lisa," Dwivedi says. "It is normal. But you must use your head."

"I'm waiting," she tells him, lifting her legs out of the stirrups and sitting up straight. "I feel better waiting."

"We will not be able to do the amniocentesis until the eighteenth week," he warns. "That will not leave you with much time."

He leaves the rest of the sentence unspoken. None of them need to hear it.

She dresses in private, and then allows him to listen to the fetal heart rate and to check her own blood pressure. As expected, it's elevated, but Dwivedi is not concerned.

She has mild cramps for the next few hours, but that's all. She drives back to Princeton-Plainsboro with her hand over her abdomen. There's no way she could feel it kicking this early, but she keeps her hand there just the same.

She has a quad screen. Back in the lab, a different nurse draws vials of blood from her arm, which is still purple and blue from the last test. She's not the least bit surprised when she gets a call two days later, asking her to make an amniocentesis appointment.

Most women who have an abnormal result from a screening test deliver healthy babies, the nurse at Dwivedi's had told her. A result like this only indicates that we need to do more tests.

She wonders what they would do if she simply refused.

But she doesn't: she makes the appointment, and sixteen weeks after her last period, she tugs down her pants and lies back on another exam table while another ultrasound technician rubs a wand through the gel on her abdomen. The image on the screen is clear. Two arms. Two legs. One head.

Dwivedi inserts the needle through her abdomen and into her uterus. It's uncomfortable, even with a local anesthetic. She shuts her eyes. She doesn't need them open to know what's going on. Dwivedi is very good at what he does. House, maniac that he is, had figured out who she was seeing and done a background check.

"Okay, Lisa, we're all done here," the ultrasound tech says.

She opens her eyes and sees the vial--an ounce at most--of amniotic fluid. Dwivedi lets her look.

"That's all we need," he says, trying to be reassuring, and then he tells her she should go home, take the afternoon off, and rest.

She goes home, but resting is the very last thing on her mind. She tries lying down, but almost as soon as she does, she's up again, wandering aimlessly through her empty house, looking for things that need to be put away or cleaned or moved.

She stops in the room she's prepared--started to prepare--for the baby. The walls are a pale green, the color of new spring. She's bought no furniture, no diapers, no clothes. The idea of having this baby still seems implausible somehow.

No, not somehow--she knows exactly why she can't be sure that she'll be bringing a child into this home.

She goes back to her bedroom and lies on her side, arms wrapped around her middle, wide awake with her eyes open.

She's starting to show.

She's been needlessly self-conscious about it, but now she can tell by the curious glances from her staff that the bulge is not all in her head. She's already put on weight, and it's possible that people just think she's got a gut now--long hours at the office, more time sitting behind a desk than moving around--it happens, especially at her age. Yet the bump is undeniably there.

On top of that--literally--her breasts have swollen to nearly two whole cup sizes above normal. She knows for a fact that people have noticed that little change, even without House making loud commentary about her bustline in the middle of the clinic on a daily basis. She's caught several in the act of staring.

She knows that they're gossiping. That eventually, the truth will come out. And right now, that prospect fills her with dread.

Dwivedi walks back into the room and shuts the door behind him. She tenses immediately. She has been hyper-aware of other people's emotions lately, able to tell instantly when someone is trying to conceal sorrow or sickness--or when House is lying to her, which is pretty much always. She likes to think it's the pregnancy that's doing it, bringing her new insight and wisdom, putting her in touch with some part of humanity that she never knew she was missing.

Dwivedi's expression is fixed and somber, and he regards her with pity in his eyes for a moment before speaking. It makes her fingers clench.

"Lisa," he says. "There is no easy way to say this. The test came back positive for Trisomy 21."

She doesn't even blink. For a moment, she's angry, wondering why he doesn't just say it. Why he doesn't just say the words Down syndrome. She focuses on his delivery of the verdict more than the verdict itself. If I were giving this news, she thinks, How would I say it? Would I say the word, the dreaded D word that every pregnant woman over forty fears? Would I couch it strictly in genetic terms? Would I be calm and professional, or warm and sympathetic?

"As I am sure you know," Dwivedi continues, "there have been remarkable advances in this field over the last several decades. Developments in pediatric heart surgery have greatly reduced the cardiovascular problems that children with Down syndrome suffered in the past. Down patients are living longer, fuller lives than ever before. It is nothing like it was twenty, ten--even five years ago."

She thinks about twenty, ten, five years ago. If she'd been pregnant twenty, ten, or five years ago, would this have happened to her? Would she have had this conversation with Dwivedi or another doctor then, when she was twenty-one, thirty-one, thirty-six? Before her chromosomes and ova and her whole body began to fall apart?

"Of course, termination is also an option that many women choose. You have time," Dwivedi is saying, somewhere. "Not a great deal of time, but you do not have to rush into any decisions. I can give you referrals if you like. Specialists. Parents of children with this condition."

Dwivedi frowns at her and she realizes she hasn't spoken since he entered the room. "Lisa. You will be all right. Is there someone here who can drive you home?"

She blinks. Her eyes are dry.

"I'll be fine," she lies.

She has her assistant cancel her appointments for the rest of the day, and then she goes home.

She stands in the center of the empty, pale green room as the late afternoon sun streams through the sheer window curtains.

She's not surprised by the diagnosis. At her age, the risk is one in sixty. It's hardly unheard of. And in a way, she's always known--since even before that first ultrasound, when the technician must have observed the thick layer of fluid in the nuchal folds behind the baby's neck and known the truth, even if she wasn't "qualified" to explain what she'd seen.

Lisa Cuddy sits down in the green room and wonders if she'll ever have the strength to get up again.

"You should terminate," House says.

Wilson looks like he's just eaten something sour. His eyes shoot daggers at House. "She should make the choice that's right for her," he says, pointedly.

"Over ninety percent of women whose pregnancies are diagnosed with Down syndrome opt to terminate," House says.

"If ninety percent of women with Down syndrome pregnancies jumped off a cliff, would you tell her to do that, too?"

"That doesn't even make any sense--"

"Shut up," Cuddy says. "Both of you. Out. Now." She points to the front door of her office to make herself as clear as possible. She doesn't know why she let them in here and told them in the first place. Temporary insanity--or maybe she really is just that alone.

It's already week eighteen, and she still feels nothing but helpless confusion when she thinks of the choice she has to make.

Wilson looks appropriately ashamed. "I'm so sorry, Lisa," he says, but she bristles; it's not the disturbance in her office he's sorry about. "If there's anything I can do--"

She meets his eyes. It's not the same offer as last time: moving some furniture, painting a nursery, maybe a backrub, maybe more. Now, it's more like a ride to and from the clinic.

She shakes her head and points again at the door, and miraculously, they both leave, House giving her an indecipherable look as he makes his exit. She locks the doors behind them and sits at her desk with her forehead in her hand. She won't cry at work. She's done it only once, and she won't do it again.

She waits until she's at home, in her kitchen with the phone pressed to her ear. "Mom," she manages to say before her throat closes up like a bloom in a freeze. There's no warning, just a flood of tears breaking from her eyes, and she can feel her mouth twisting into an ugly shape as she tries and fails to speak.

"Lisa. Oh, Lisa," her mother says, comforting and gentle even though she must be anticipating the worst. Right now, Lisa can't imagine what could be worse than this. "Honey," her mom says. "What's the matter?"

"It's Down syndrome," she blurts.

"What's Down syndrome?" her mother asks.

"Mom," she says thickly, "I'm pregnant."

She takes a breath, trying to calm herself. Her voice keeps hitching, and she's not even sure that what she just said was understandable. Her mom hadn't known, of course. She hadn't told anybody except the one person who had to know--her doctor--and the one who would have figured it out on his own, anyway.

She doesn't see her mother that often. She'd been planning to make the announcement when she was sure--sure that she wouldn't lose this baby. But even after she was well into the pregnancy, well past the point of most miscarriages, she still didn't tell. Because she had known even then, hadn't she? There was no such thing as surety here. No guarantees.

"I didn't even know you were seeing someone," her mother finally says, her voice infused with that strange mixture of warmth and reprobation that only moms can do.

"I'm not," Lisa explains, trying to ignore the guilt she knows she shouldn't be feeling. "I used a donor. An anonymous donor."

"I don't understand," her mother says. "Why didn't you say something? How long has this been going on?"

Lisa hesitates, wondering how to answer these questions. How long has this been going on? How long has she known about the Down, how long has she known about the pregnancy, how long has she been trying, how many years has she longed?

"I don't know what to do," she says instead. "I feel--paralyzed."

After a long period of silence, her mother speaks again in a low voice. "I don't know what to tell you. This is all so much. I didn't even think you wanted children …"


"I waited for years for you to find someone and settle down, and your sisters got married and had kids, and I thought that maybe it just wasn't in the stars for you."

She covers the phone's mouthpiece with her hand and sobs into the other. The side of the counter provides a solid surface to lean against as she lets herself slide to the kitchen floor, knees drawn up to her chest.

"And with your job keeping you so busy … Lisa, I'm so proud of you. You've done so much with your career, accomplished so many things that women in my generation would never have dreamed of--"

Her mother's misguided praise drifts into the ear still pressed against the speaker, but Lisa's only half listening. Her eyes drift around the kitchen, pausing on the open electrical outlets, the cabinet below the sink full of cleaning supplies. This place is a baby death trap. How could she have ever thought …?

But her mom is still talking, murmuring anxious assurances that somehow ring hollow this time, no matter how many times she's heard them before.

"You've got a lot to be proud of," her mom says. "My daughter. My doctor. I always knew you'd go places, even when you were just a little girl … and if you don't have kids, you'll still be perfect to me."

Lisa has to cover the mouthpiece again. She grits her teeth and tries not to scream.

"I had an abortion," Stacy says one afternoon, when they meet for tea halfway between Princeton and Spring Hill.

Lisa glances up, surprised. "I didn't know."

"It was in my first year of law school. The condom broke." Stacy is warm when she looks Lisa in the eye. "It wasn't easy, but it was the right decision. I wasn't ready to be a parent. I'm still not ready to be a parent."

"I'm ready," Lisa says. "I've been ready for so long. But not--" Her throat is suddenly constricted again.

Stacy's hand is a safe weight on her knee. "Nobody asks for this. Nobody is ever ready for this."

"I used to dream of having kids," she blurts, unable to stop herself. "When I was younger, I mean. I used to dream that I'd grow up and become a doctor and marry another doctor and have two perfect, beautiful children." She laughs once, or at least makes a sound that passes for a laugh. She knows that whatever expression she's wearing, it's not a smile. "I guess that sounds ridiculous. But even later on, I always thought--I mean, I always thought--that it would be easy."

"Oh, sweetheart," Stacy says. "Everyone thinks it's going to be easy. If people knew what it was really like, nobody would ever get pregnant. The whole human race would die out."

This time, the laughter feels more genuine, though no less tinged with bitterness.

"I don't know what to do," she admits again. It's starting to become a familiar refrain.

Stacy gives her an even look. "You don't have any … moral qualms with abortion, do you?"

"No, of course not," she answers shortly. "It's not like I've never had a close call and wondered--but this is different." Stacy nods, but Lisa just charges ahead. "I wanted this. This is … my last chance."

"You don't know that," Stacy says, trying to be reassuring, but she meets Lisa's eyes and smiles weakly, letting the argument go. She knows as well as Lisa that there won't be any more tries after this one, that even if she could still have a healthy pregnancy, this is the end of the road.

In week twenty, she goes back for a fetal echocardiogram.

Up to 50% of children with Down syndrome are born with congenital heart defects, Dwivedi had said, parroting what Lisa had already read in every piece of literature she could find on the subject. The echocardiogram is to determine if there are any major heart malformations.

Dwivedi doesn't ask her whether she's made a decision; Lisa knows that it's obvious she hasn't. She's worked hard to conceal this at work, but at the old man's office, she can let her guard down a little. She has nothing to hide from these people.

There are times in the middle of all the tests and exams that she feels like a piece of meat, a stuck pig, a broodmare: an object to be poked and prodded as needed. She has only rarely been sick, and aside from a broken arm in junior high, she's never been a patient at a hospital--only a doctor. She's not used to being subjected to such intense medical scrutiny. She resents it a little, feeling like an object in the one place where she's always felt that she was in control.

She submits to having her swollen belly covered with gel again, to the transducer smoothing through the cool, slick mess.

Dwivedi tells her that there are no visible defects, but that some minor issues are not detectable prenatally and won't become evident until after birth.

He also reminds her that Down syndrome pregnancies have a higher chance of spontaneous abortion than normal pregnancies, so even if she chooses to have this baby, the choice might still be snatched away from her. Dwivedi doesn't say the last part; that, she adds herself.

Then Dwivedi asks her if she wants to know the sex.

She sucks a breath through her teeth. She says yes.

Dwivedi is quiet for a long moment before he tells her that it's a girl.

Dwivedi gives her a phone number, a woman who heads a local support group for parents of kids with Down syndrome. She takes the piece of paper, folds it into quarters, and puts it in her purse.

Later, at the office, before she can talk herself out of it, she dials the number and talks to Nancy, whose three-year-old was diagnosed prenatally. Nancy offers to meet her over lunch, near the hospital, and Cuddy agrees.

Nancy is more or less what she expects: a suburban soccer mom, slightly frazzled, on the heavier side, with a purse larger than some of Lisa's suitcases.

She's not expecting Brandon.

Nancy starts apologizing as soon as she introduces herself, saying that her usual sitter was busy, but that Brandon is very well behaved in public. As it turns out, Nancy is telling the truth: the little boy may be the best-behaved child Lisa's ever seen in a restaurant. She thinks that Nancy herself might have a lot to do with that; she pulls a box of crayons and a pad of blank paper from her oversized handbag and sets Brandon to work writing the alphabet and drawing pictures to go with each letter. Lisa sees him scrawl a red circle next to the letter A and fill it in with deep concentration.

"We started early intervention classes as soon as possible," Nancy says, watching Lisa watching Brandon. "It's like all-purpose therapy for kids with Down syndrome. And we got to meet other families like ours, which is how I got involved with the support group. What are you drawing, Brandon?" When she speaks to him, the pitch of her voice rises only slightly.

Brandon puts down his crayon, brings a fist to his mouth, and twists his wrist.

"Apple," Nancy says with approval. "Very good." To Lisa, she explains, "Baby sign language was a part of the intervention therapy. He can speak--he's just shy about it."

As if to disprove this, Brandon turns to Lisa and holds out three fingers. "I'm three years old," he informs her, only in his child's voice, it sounds like fwee.

Lisa smiles weakly, feeling like her heart is on the verge of breaking.

"When did you find out?" Nancy asks.

"Three weeks ago. That was--eighteen weeks," Lisa explains, fumbling with the words she's not saying. But Nancy just smiles gently.

"I won't lie to you," she says. "I cried a lot when I first found out. I still do from time to time. This choice--it's not for everyone."

Lisa feels her face heating and a guilty nausea creeping over her. "I'm sorry--I just never planned for this, and I don't even know if I can raise a healthy child now, let alone--"

"I'm not from the pro-life brute squad," Nancy says quietly. "I'm not here to guilt you into making a decision that'll make you unhappy. That's why I was sorry to have to bring Brandon. It's not fair to you."

"He's a beautiful child," Lisa says truthfully.

"Light of my life," Nancy agrees. "But there's nothing I wouldn't have given for him to have been born healthy. He may yet have to have another heart surgery. And now we have to look into schools--there's never an end to it. His older brother is a big help."

"How did you decide?" Lisa says, the words coming out before she can stop them. "I mean, how did you know that you were making the right choice?"

"I didn't," Nancy says. "Know I was making the right choice, I mean. Not until I met him. When I first saw him, first held him--it was indescribable." She looked back at Lisa and her face softened. "Hey, look. You want to know what you should do? Forget everything you thought you know about Down syndrome. Forget all the stereotypes. Then start reading, start learning. Meet other people with Down syndrome. Meet parents of kids with Down syndrome. You might be surprised. This thing has come a long way. And then, when you're really informed and educated about it--then you make your decision."

"Just like that," Lisa said.

"Well, that's the thing about pregnancy--if you don't make a decision yourself, at a certain point, the decision kind of gets made for you."

She gets a card from her mom in the mail. A sympathy card. She reads it and then throws it away without giving it another thought.

She looks up every piece of literature she can find on Down syndrome, medical and otherwise. She reads for hours every evening after work, poring over research until after midnight, until her eyes start to burn, like she's cramming for exams in med school all over again.

House comes to her office every other day and tries to pry. She tells him, with all the authority she can muster, that she will not discuss this at work.

In the twenty-fourth week, he shows up on her front doorstep.

He has some flimsy excuse about needing her permission to administer completely unethical treatment to a new patient she's pretty sure doesn't even exist. Her suspicions are confirmed when he drops the issue almost immediately after she says no.

But he lingers, staring at her, his eyes boring into her, blue as a newborn's, and she sighs. "I don't know what to do," she says.

"Twenty-four weeks," House says, and of course, of course he was tracking her pregnancy. "Time's up."

"Do you know what the average lifespan of a person with Down syndrome is?" she asks him, fighting the panic that threatens to take over her voice. "It's fifty-five years. And rising. Adults with Down syndrome need supervision and care all their lives. I'm already forty-one. What happens when I die? What happens when I'm not able to take care of her anymore? Does she go into a home? Some sort of nursing home? Or what if something happens to me before then? My mother couldn't take her, my sisters all have kids of their own--anything could happen. I could die in five years."

"Right," House says. "In fact, you could get hit by a bus and die next week. Probably better to just quit everything now, so nobody's left in the lurch. I'll help you with your resignation letter. And I'm totally down with desperate near-death sex, by the way."

She frowns. "Are you … encouraging me to keep it?"

"I'm mocking the gaping holes in what passes for logic in your world. Don't make it out to be anything else."

"There are so many reasons not to have this baby," she says, looking away from him. "I'll spend the rest of my life worrying--how she'll do in school, whether people will make fun of her for being different, whether she can get a job and some sort of independence …" She stops herself before she can say the rest of what she's been thinking. As fewer children are born with Down syndrome each and every year, how will this baby make friends? How will she find people who look like her and who act like her and who understand her? How will she fall in love? How will she not be crippled by loneliness?

"How many reasons are there to have it?" House asks.

"Just one." She looks up at him. "I've never wanted anything as much as I want this."

He gazes at her, perfectly inscrutable, for a long moment. "Congratulations."

In spite of herself, she feels a smile on her face. "Thank you."

He leaves without a goodbye, as is his usual. After locking the door behind him, she lies down on the living room sofa and sleeps for six hours.

The next few weeks pass breathtakingly fast, a whirlwind of preparations. She buys a bassinet, a crib, and a changing table. A cabinet for baby supplies, a chest for baby toys, shelves for baby books. Nobody else is going to do this for her.

At twenty-eight weeks, she has another ultrasound. Dwivedi says that the fetus is continuing to develop well. She takes a black-and-white printout capture of the ultrasound home with her and sticks it on her refrigerator.

She calls Nancy again and gets invited to a dinner party where she meets two other women from Nancy's group, and their children, ten and six. She watches them playing together and sees her future--her daughter's future--and thinks that it's brighter than she imagined.

She informs the board and puts in for maternity leave at work. She does not tell them that the baby has Down syndrome. They'll find out on their own eventually. She plans to stay right up until the birth, but she's entitled to twelve weeks afterward, plus whatever personal time she's accrued, and she already knows she's going to need every bit of it.

Everything is about to change.

She tells her mother and her sisters. Unlike her hospital colleagues, they get the full story. Unlike her hospital colleagues, they can't judge her decision to have this baby, or even to become pregnant in the first place. They can't look at her askance for--just this once--choosing herself over her job. They send a car seat, a diaper bag, gift certificates to chic baby boutiques. Their cards are stilted and awkward; none of them know quite what to say to her.

She thinks that when Greg House is the only person who knows exactly the right thing to say, the world is in serious trouble.

Wilson brings her more flowers. Foreman, who surely knows by now what kind of child she's expecting, sends a gift basket with no message on the card. It's so him--that alone makes her smile.

House, for his part, acts like nothing out of the ordinary is going on. He continues to antagonize her at work and occasionally at home, silently and (for him) stealthily appraising her for any signs of distress. He never asks directly about the baby. It's not endearing. In fact, it borders on creepy--but then everything about this experience has been eerily invasive. House, who is eerily invasive by default, is no different.

"No," she tells him soundly in Week 39, when he barges into her office, ready to bully her into giving him permission for some bizarre, life-threatening treatment for a patient who may or may not have what House thinks he has.

"When's your replacement coming again?" House asks, annoyed. "I can wait."

"Interim replacement," she says, "and I've already asked that all requests from you be routed straight through to me."

"Can't get enough of me? I don't blame you." He changes subject. "This is the right treatment. If your brain wasn't addled by late-stage parasitism, you'd realize that."

"Screw you," she says serenely. "My brain is fine. I'm getting plenty of sleep, and I am more than capable of doing my job."

At that moment, Cameron bursts through the office doors. Cuddy spares a moment to wonder if anyone knows how to knock anymore. "Biopsy was negative," Cameron says. "It's not Whipple's."

"It's Whipple's," House says.

"Not according to your patient's small intestine," Cuddy says. "Go treat for--"

She stands and stops midsentence, her mouth still open on the next word.

The warm wetness gushing from between her legs this time isn't blood.

Wilson, naturally, is the one who meets her at Princeton General. He doesn't agree with her decision, or possibly even support it, but his magnetic attraction to "women in need" is as strong as ever.

If he wants to think she needs him, or anyone, that's okay with her.

"You know, there's a perfectly good maternity ward one floor up from your office," Wilson says when he arrives.

She groans her way through another contraction. "I'm wearing a hospital gown that leaves nothing to the imagination, and I'm about to push a small human out of my vagina. I do not need my entire staff witnessing this. Especially not certain department heads."

"Point taken," Wilson says. "I hope I'm not included in that last part?"

"Just stay up here and away from my crotch," she answers.

He does, except for when he goes to fetch her ice chips and to answer the occasional call from PPTH. She feels like she should reprimand him for taking time off for this, but as the contractions start to come faster, she gradually metamorphoses from a dean and administrator to a woman in labor, and Wilson, who's a good friend but only incidental to what's happening to her, fades from her mind.

Dwivedi comes and goes, checking the dilation of her cervix and telling her that she's doing well, that the baby is fine. She paces the room because walking helps, and perches awkwardly on the birthing ball, which doesn't. She has no love for labor pains, but under the circumstances, she wants to meet her daughter--and her daughter to meet the world--as lucid and cognizant as possible.

She rides out the contractions until it's finally time to push. She doesn't lie flat, but rather braces herself, still standing, letting gravity do its thing. She's dimly aware of Wilson, who's only ever witnessed this as a med student, standing out of the way with no idea what to do with himself.

"Push, Lisa," a nurse says, and she does.

"She's perfect," Lisa says, her voice rasping a little, when the baby is placed in her arms. Lisa has only a few moments to hold her before the nurses will whisk her off for tests and measurements, and through the chaos, she studies the baby intently, her heart pounding in her chest.

She's not perfect. She has a heart defect that will require at least one surgery. She will be at a greater than normal risk for many other conditions as she grows. She will learn more slowly than other children. She will need special therapy to help her gain strength. She may never be able to live independently. She may always be lonely.

These are things that Lisa Cuddy, the doctor, will take note of later. She will understand them and grieve, and then she will be a professional. She will make plans and contingencies for her daughter's life. For her daughter's happiness.

Right now, Lisa Cuddy is a mother. All she sees is her child's tiny fingers and tiny nose. The baby has a full head of thick, dark hair and bright blue eyes.

This is not the child she dreamed of, but that doesn't mean she can't still dream. This is not the life she dreamed of, but it's still her life.

And it is perfect.



End note: you can read Emily Perl Kingsley's short essay "Welcome to Holland," from which this story got its working and parenthetical titles, at the NDSC.