The Birth Plan

I was 37 weeks pregnant and had just completed a busy Monday in the OR, my last scheduled shift before maternity leave. While relaxing in front of the TV that night, I found my fetal kick count to be significantly lower than normal. I spoke with the on-call OB team, and after going back and forth, we decided it was best if I go to the hospital for further monitoring. I threw on my slippers and jacket (was already in pajamas) and said, "See you in an hour or so," to my husband. I never made it home that night, and six days later I brought my baby girl home from the hospital!

The fetal non-stress test showed that she was ironically doing well, but my blood pressures and urine sample showed that I had developed preeclampsia. My leg swelling was increasing over those last few weeks, but things just got real. My husband dutifully showed up with my pre-packed bag and birth plan. Yes, I had a birth plan - but not the long, detailed essay that some women present to eye-rolling hospital staff, replete with all sorts of unrealistic demands involving birthing balls, hot tubs, candles and music. As an anesthesia resident on the obstetric service, we used to joke that those women with the most detailed and rigid birth plans would inevitably be the women who ended up with "emergency" epidurals at 3 AM, or worse in the OR for a crash C-section.

Instead, what I provided was a one-page sheet with an outline of my complicated medical history and a few important preferences for my care. Because I have adrenal insufficiency and am steroid-dependent, it included a regimen for stress-dose steroids from my endocrinologist. I made it clear that I desired an epidural and that I was ok with all monitoring and testing deemed necessary. I listed a few if-then decision statements regarding vaginal birth vs. C-section. For instance, if I had a vaginal delivery I wanted immediate skin-to-skin contact and delayed cord clamping... if baby is stable.

The feedback I got from nursing and on-call staff about my birth plan was good; they seemed appreciative of the precise and explicit set of preferences that could be passed on through numerous shift changes. I will say, however, that even with my minimal birth plan as a "good luck charm", things still didn't go the way we had originally hoped. And yet, once my daughter was born, none of that mattered one bit. Meconium was present on delivery so she was handed off for resuscitation instead of immediately placed on my chest as I had hoped, we couldn't do delayed cord clamping, etc. But she was healthy! I was lucky to have a smooth albeit slow induction with no complications and a quick period of active labor (only 45 minutes of pushing). We didn't have to go to the OR. I only needed two stitches post-delivery. Again, she was alive and she was healthy! After experiencing a pregnancy loss, I admit that a fear had persisted deep inside me even into the late months of gestation that I would lose her without getting to see her face.

Nothing went exactly as expected, and yet everything turned out fine. Nothing went exactly as expected, and yet everything turned out fine. This is my new mantra, and it would be a good one for all pregnant women to adopt. Because in the instances of labor and childbirth, resistance and rigidity pose potential risks to both mother and baby.

Have you had an experience with a birth plan, either yours or a patient's?

The Great Many Juxtapositions that are My Life as an OB/GYN

It was 9:35 pm and I found myself staring longingly at a trash can, salivating at the beautiful sandwich perched precariously on its rim. My hands were trembling from hunger. If you would have checked my blood sugar at that moment, it would have likely been critically low.

My day had started at 6am with a 5 mile run and I hadn't stopped moving since. I got paged for a stat delivery while I was in the shower and the day had seemed to go down hill quickly. A full office and multiple laboring patients awaited me. My emergency protein bar served as my lunch and during the cafeteria's dinner hours, I was in the OR on a hemorrhaging ectopic pregnancy. I was so tired I could feel every muscle in my body, and each one throbbed in their own unique way.

Clearly the sandwich is above the rim.

That is how I found myself in my real life Seinfeldian dilemma. After realizing the cafeteria was closed I had went back to my office in hopes of grabbing a leftover sandwich out of the refrigerator only to realize in horror that someone had thrown the precious salted meats in the trash. However one specimen had perched itself slightly above the rim, still on its original plastic tray.

Do I eat refuse or trek across campus to the doctors lounge for a poptart? If it is above the rim is it technically garbage?  Not to me in that moment. I wolfed down the cold cuts and said a little prayer against listeria and all other types of food poisoning. It tasted divine.

I thought about how very strange my life was, as I sat back and patted my full belly. A mere two weeks earlier I was dining at leisurely at cafes in Paris, now I was George Constanza eating out of the trash.

Beautiful gourmet meal in Paris.

The next day  I ran into a casual acquaintance who remarked how glamorous my life seemed on social media. I laughed and told her my trash eating story. The incident made me think of the many other strange juxtapositions of my life.

There was the time I found myself in one of the messiest deliveries of my life a couple of hours before the hospital Christmas party. While birth is a beautiful moment of life, sometimes it can also be a giant hot mess. During this rather difficult birth I was initially pooped on quite extensively. Then as the baby delivered, I was hit with a tsunami wave of amniotic fluid that soaked me to the core, making a mockery of my 'protective gear'. The patient then began hemorrhaging, so I performed an internal uterine massage to help stop the bleeding, which equals me inserting my entire arm into her uterus, making me feel a little bit like a large animal vet. The only bodily fluid missing from the event  was vomit. Hours later after a "Silkwood  shower" and a quick makeup application, I find myself at a country club in a little black dress having small talk about the weather.

Many times I've been at the playground with my kids only to sneak away a few steps to answer a call from the hospital about a STD or other topic that is definitely not a 'playground friendly'. Bedtime stories or games of 'hide and seek' have often been interrupted with stat pages to the hospital. I've gone from reading Dr. Seuss to performing an emergency C-section in moments.

The worst juxtaposition is dealing with loss in the middle of a regular day. While OB/GYN is often a happy specialty, when it is sad it is heartbreakingly awful. I often have to deliver the worst of news: miscarriage, infidelity, cancer, infertility. There have been days where I have went from placing a lifeless baby in a mothers arms and with barely a moment to catch my breath and dry my eyes, to seeing a patient for a new pregnancy right down the hall. Death and life with only moments in between; the roller coaster of emotions is so strange.

I'm not complaining about my job. I'm well adjusted to the bodily fluids and tumultuous schedule. I simply find it intriguing how my life can go from one extreme to another so very quickly. I'm sure most other doctors would have similar stories (well maybe not the trash). Also this serves as a good reminder that if you see me looking semi-fancy in a picture, the special ingredient that made my hair extra shiny, might just have been amniotic fluid.

Cross posted @ drheatherrupe.com

The Three Mentors You Need

A lot has been written about mentorship. In medicine, we are often assigned mentors based on our clinical or research interests.  Sometimes we get guidance on how to cultivate these relationships, sometimes we don’t. 

In 2013, the author and expert on gender and workplace issues wrote a book called “Forget a Mentor, Find a Sponsor” where she argued that in the workplace we don’t need mentors who just give us advice but we need sponsors who will pull us up, get our names out, and have our backs. 

I whole-heartedly agree that everyone in medicine, especially working moms in medicine, need sponsors but I have also found that we need more than that.   Over the course of my career I have found that three mentorship groups make a huge difference in my career and my life. 

Here’s what I have:

1. A  Sponsorship Team

I spent some time last year formally identifying sponsors and now have a team of them.  This team includes people who traditionally fill the role of a mentor such as more senior faculty at my institution but also come from outside this traditional role.  For example, I identified someone who has a career path that I admire and contacted him.  In some settings, there is a formal process to meet with your sponsorship team as a group but often the meetings are one-on-one and casual.  The key component is knowing who your sponsors are so that you can cultivate long-term relationships.

2. Peer Mentors

I can’t overestimate the value of peer mentors.  A few years ago, a colleague and I started organizing monthly peer mentorship lunches where we discussed topics that were relevant to us.  It was a safe environment and a huge success. The format was informal: one person picked a topic and everyone chimed in. Topics ranged from delegating tasks to staff to negotiating better pay to saying "no" when you have too much on your plate. The connections I made from this group are amazing and very valuable to me professionally and personally.

3. Outsider Mentors

I have a group of family and friends who don’t practice medicine and aren’t in academics but know me as a person. I’ve often discussed career challenges with them.  For example, I have a group of college friends in different industries that gets together periodically to do life assessments.  I am so close to these women and value their opinions tremendously. They are the people to whom I turn to when I need a reality check from someone outside my industry or when I am thinking about change.  I find that the outside perspective helps me keep things in perspective.

That’s it! These are three (groups of) mentors who have helped me.  Keeping up with these groups may sound daunting but often the maintenance of these relationships can be weaved into your lives and often they bring tremendous value to your career.

Not a Soccer Mom

For years, my older daughter has done dance as her extracurricular. It was easy. Every Saturday afternoon, I would take both kids over to the dance studio, and my younger daughter would play while my older daughter would dance.

My husband has been talking about how he would like her to do a team sport, and my daughter has been talking more and more about how much she loves basketball at school, so this year I signed her up for basketball. And ever since, have been filled with regret.

At the end of a workday in which my pedometer usually tells me I walked about 3 miles, the last thing I want to do at 6 o'clock is drive my daughter over to another school, and either try to entertain my younger daughter or drag myself out to go back an hour later to pick her up, all in the freezing cold and snow. Then race everyone through dinner before bedtime half an hour later.

And the games are all super early on Saturday. There's no decent parking, so we have to walk pretty far to get there. And my younger daughter won't sit through them, and my husband doesn't want to watch her while I leave her behind.

Last night, I had my second argument with my husband in one week over basketball, and I couldn't take it anymore. This is not school, this is an extracurricular activity. It seems like if it's causing me this much stress, the answer is obvious:

Quit.

I feel bad about it, because she really does like basketball. But I'm not a soccer mom. I work hard all day, and evening activities are difficult. I can't run myself ragged for an extracurricular activity.

Now I just have to find a way to tell her…

Conversations with My Daughter

This morning as she read the newspaper report of yet another shooting death.

Why does this keep happening, Mom?

It's complicated.

After all those kids were killed in Newtown, you'd think someone would do something. And black kids get killed all the time - way more often than white kids.

Yes.

Can't the President do something to fix this? To stop this? Can he make guns illegal?

You learned about checks and balances in the Constitution, right? The President can't act on his own.

So Congress needs to make a law?

Yes. And the National Rifle Association spends a lot of money to make sure they don't pass laws limiting access to guns.

Do you think we should do something?

Yes. Your dad and I do what we can to support politicians who would pass reasonable controls - to treat a gun like a car. Before you can get a driver's license, you'll need to pass two tests and practice for at least 65 hours, and we need to have insurance.

I guess criminals will always be able to get guns. They can steal them.

Yes. I don't think we'll completely stop gun-related crime. I do think we can reduce the number of accidental shootings and suicides by gun, though, and I think we should.

Well, the way it is just isn't right.

Saying their names

I don’t have a television but your story flashes across my Facebook feed, my friends tell me about you, my husband the Anthropologist tells me about you, and I look you up online.

You were bullied for being a cheerleader and you took your life (Ronin Shimizu). You went out for a pack of Skittles, a stranger chased you, you were shot and killed (Trayvon Martin). You were selling cigarettes on the streets of New York and you were choked to death as you screamed “I can’t breathe” (Eric Garner). You were playing with your big brother and he accidentally shot and killed you with a gun you found (9 month old in Missouri whose name will not be released). You were born a girl but your birth body was that of a boy, you tried to be your true self but took your own life after not being accepted by your parents (Leelah Alcorn). You were misunderstood, you were playing with a toy gun in the park and you were killed (Tamir Rice). You were with your friends listening to music in your car at a convenience store when a stranger approached you and began arguing with you about your music, he shot you and you died and he went back to his hotel room, walked his dog, and had dinner and drinks (Jordan Davis).

I honor your legacy with my tears. I think about your family. I snuggle my little one more tightly knowing this world is both a beautiful and dangerous place. I honor you with this post; I apologize it has taken me months to find the courage to say your name in this space. This space that is sacred to me but after my last post about Trayvon Martin received some insensitive comments I was hesitant to share some of my deeper feelings since I don’t see much social commentary here at MiM. Why is that? We are mothers and we are providers and don’t we see how unique our vantage point is? We can talk about the intersection of life and policy, public health and personal life from a place most others cannot. I struggle to find the time to read anything besides mindless fashion blogs when I’m not balancing my own needs with full-time medical practice, my husband’s needs and those of my four year old let alone to allow myself the freedom to reflect on society’s transgressions and tragedies.

I thought of you today while looking at my ever growing to do list. And because your life matters to me I put away other thoughts and wrote your name, I am saying your name.

#BlackLivesMatter #ProudLGBTQAlly #MothersInMedicine #2016LivingMyTruth